You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Barry Bloom, professor of immunology and infectious diseases and former dean of the school, and William Hanage, associate professor of epidemiology and faculty member in the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health. This call was recorded at 11:30 am Eastern Time on Wednesday, June 3.
Previous press conferences are linked at the bottom of this transcript.
MODERATOR: Dr. Bloom, do you have any opening remarks?
BARRY BLOOM: There’s lots of new things to talk about, particularly questions about serology, questions about hydroxychloroquine, and treatment and prevention. So I would look forward to trying to be helpful on any of the questions from the press.
MODERATOR: OK, great. Thank you. Dr. Hanage, do you have anything you’d like to say?
BILL HANAGE: I would like to say hi to everybody. Good morning. I would echo what Barry was just saying. And I will add that, of course, in my kind of customary almost-weather forecasting update, I will note that overall it appears that the reproductive number in the US is hovering around one. But there appear to be evidence of increasing cases slowly in California and Texas and indeed Virginia as well. It’s too early to see much evidence of anything that would happen from reopening. But I look forward to discussing what that might look like.
MODERATOR: Great. Thank you, Dr. Hanage. First question.
Q: Hi, thanks for doing the call. Can you just kind of describe where we’re at in the US in terms of the pandemic versus, say, mid-May? Are we at inflection point because of the opening of businesses? And also, you mentioned some trends in California, Texas and Virginia. Can you expound on that a little bit? Thank you.
BILL HANAGE: Sure. I think that sounds like it’s directed at me. So, yeah, I mean, the situation now in the United States is, and I sort of said this before, but it always bears repeating, to a large extent you don’t have one single pandemic. You have lots of lots of separate pandemics which are happening at different rates in different places. So early on, you saw this very big surge in the northeast, which is now finally beginning to sort of die down to levels which are still higher than many parts of the country, but which are obviously past a peak. I wouldn’t say the peak, but I will say a peak.
And that is the result of the interventions that were put in place. In other parts of the country, you can see evidence for a slower rate of increase. And I called out California, Texas and Virginia, because if you look at the apparent rates of reporting of cases and hospitalizations, it looks as if in those places there is a significant but slow increase in the amount of disease. But even in those places, it’s difficult to come up with an overall sort of one size fits all picture of what’s going on, because there’s a big difference between what you’re seeing in these metropolitan areas in which you’ve got to kind of, you know, what epidemiologists call almost deterministic process, because there’s a lot of people, there’s a reasonable amount of mixing, there’s no big effect of random chance. So those are increasing comparatively slowly.
But then I’m sure you’ve seen this already, if you think about communities like Amarillo in Texas up towards the panhandle, there have been really very high rates of local disease in some small and rural communities. So if I were to describe the pandemic in the United States overall now, it would be that there are slow embers burning within the metropolitan areas and there are a little sparking fires heading off all over the heartland. And that’s the situation as it is now. Numbers are hovering around steady, but we have to remember that that is reflecting a decrease in the northeast and a slow increase, which is replacing that elsewhere.
Q: Thanks and just for quick. Have you seen any major changes in demographics, whether age or racial groups, since a few weeks ago, or are things kind of staying the same in that regard?
BILL HANAGE: So far as I can see, I think things have stayed pretty much the same. I don’t think we’ve got any data suggests that there’s any major changes. I mean, the thing we have to remember is that that will to an extent reflect exactly when the pandemic is at that moment and the kind of folks who are living there.
Q: Thank you.
BARRY BLOOM: I would just add my usual caveat that what you see is not what’s there in the sense that with the relaxation of social distancing and reopening cities, if we’re going to see effects, they’re going to be two to four weeks from probably June 1. So that’s where I’ll be looking and most concerned about.
BILL HANAGE: Yes, I would agree with that. It may even be – we may get to this later, but it might, depending on exactly what happens, it could be that or the effects could be relatively small for a while, but they will change.
Q: Thank you.
MODERATOR: Next question.
Q: Thank you for taking my question. We’ve seen reports of testing site closures over the weekend and this week in response to protests in places like L.A., Chicago and elsewhere. Can you talk about how these testing site closures could affect efforts to contain the pandemic? Obviously, we don’t know yet if these testing closures are going to be permanent or just temporary or temporary just for a few days. And then my follow up question to that is, you know, what impact could this have on urban populations?
BILL HANAGE: Barry, do you want to take that or shall I?
BARRY BLOOM: Oh, you take it, Bill.
BILL HANAGE: So obviously, I mean, it depends very much upon the amount of testing that is being done that that is relevant to the local public health response. If it’s a major contributor to it, then you would expect there to be, you’d expect that to be knock on effects. One would hope that they will be able to be reopened or there will be an opportunity for backup testing. But, you know, it’s understandable that they have closed. As for the longer term effect upon those populations, we have to remember that those populations are at particular risk. And so we have to make efforts in order to maintain testing, keep it going, and, you know, remember that this is something that is going to be with us for quite a while. Because we’ve had to close things temporarily, we do have to come up with a way of solving that problem in the long run. And I believe that there was another question which I’m forgetting. Could you just quickly repeat it?
Q: Yes, I think you answered that. My follow up question was what impact could that have on urban populations who are already more at risk for, you know, getting the coronavirus?
BILL HANAGE: Yeah, I mean, the the impact will be on the ability to tell exactly what is going on there and to enable to give people in place for what to be doing. And so the effect is as much as anything, a problem in our ability to be able to monitor the state of disease within them. If they are feeling sick, then obviously they should self-isolate and hopefully would be able to advise on contacts that they should limit their contacts.
MODERATOR: Do you have a follow up for that?
Q: No, that’s all, thank you.
BILL HANAGE: Thank you.
MODERATOR: Great. Next question.
Q: Hello. I have two question questions. One is, how do you feel about the researchers who deny the extreme danger of COVID-19 and still say that it’s similar to seasonal flu?
BILL HANAGE: Barry? Or shall I?
BARRY BLOOM: I couldn’t understand. Could you repeat the question?
Q: Yeah. So some of the researchers still deny that, you know, COVID-19, is dangerous and they still compared to seasonal flu. How relative is that?
BARRY BLOOM: It’s very different than seasonal flu in the following senses. It’s new. We don’t have prior experience or prior immune memory to it, whereas with influenza, people, almost everybody, has antibodies to some previous strain of influenza. So there’s a little bit of immunologic preparation. In flu, once again, there’s not a lot of shedding prior to people being sick. And really the driver, the unknown driver of this infection with coronavirus is that people are transmitting before they are known to be positive or ill, which means we’re having great difficulty finding all the sources of transmission.
So those are two major variables. And the third is flu comes back in a related but different form every year. This virus appears to be at least ideologically, relatively stable. We hope it stays that, so that if there were such a thing as a protective vaccine, we wouldn’t have to make it no different strain every year. It might be much more effective than the imperfect vaccines we have for influenza.
Q: Thank you.
BILL HANAGE: I would echo everything that Barry just said. I would add a couple of things. First, I would add that it’s absolutely correct that there’s a huge amount of pre-symptomatic transmission when it comes to SARS-CoV-2, the current pandemic virus. In work that I have been involved with, which is unpublished as of yet, so don’t run off with this, but it’s consistent with other published work, suggests that between 60 to 80 percent of transmission events happen at a pre-symptomatic stage of infection.
The other thing about it is the severity. Now we worry about the – it’s very difficult to estimate the infection fatality rate, which is the, you know, the numbers of people who die who are infected, which is different from the case fatality rate, because cases are the things that we can spot and we tend to spot more severe cases for obvious reasons. So people have been spending a lot of time trying to figure out the case fatality rate – sorry, the infection fatality rate from the case fatality rate. And we’re now finally being able to do that because of some pretty good serology, which is beginning to come out, which tells us how many people have been infected. Now taking together data from New York City, from Spain, France and the United Kingdom, I would say, we’re zeroing in on an infection fatality rate of about one in two hundred to one and one hundred.
Now, that is five to 10 times more than seasonal flu. So for each infection, it is five to 10 times more likely to kill you than seasonal flu is. And one final thing to get it through, it’s very interesting to note, if every single man, woman and child living in New York City had been infected with seasonal flu, you would expect the total number of dead people to be one in a thousand, so, we’re talking around eight thousand or so. And in fact, as we know, it’s much more than that. So in other words, we do not need, we should not need to be having the argument that it’s like seasonal flu. It’s much worse. And we know that.
Q: Well, thank you so much.
BILL HANAGE: Thank you.
MODERATOR: Next question.
Q: Hi. Thank you so much for doing this call and taking my question. I was hoping you could talk a little bit about super spreading and how, you know, we’re still learning more about how that is playing a role in transmission. And, on top of that, if you could talk a little bit about, you know, if this is becoming, is becoming clearer that this is a bigger problem, does it change any recommendations as states reopen social distancing measures that that would be helpful. Thank you so much.
BARRY BLOOM: Bill, why don’t you start.
BILL HANAGE: Sure. Thank you for the question. So, super spreading events are the consequence of what we call an over dispersed reproductive number, which is a way of pointing out the reproductive number is an average. It’s the average number of infections which are caused if you by one person who is infected by now. So it’s an average number of secondary infections from the case. It’s the basic reproductive number if there’s no immunity.
Now being an average, that doesn’t mean that it’s symmetrically distributed around at average. What that could be is that some people could do much, much more infecting. This is the so-called super spreading events. Now, we know from the study of the original SARS and the original – and also MERS, Middle East Respiratory Syndrome, that they have over-distributed R0, which means that a minority of cases cause the majority of onward infections. Now, a body of evidence which is coming together for COVID suggests that around 20 percent of infections are responsible for around 80 percent of onward infection events. So that means that it shifts the thing that we need to be worried about from thinking about cases to thinking about transmission events.
Now, the question then becomes, what should you do about that? Well, if we knew what made somebody a super spreader, then we’d be able to target that. But at the moment, we don’t. And it’s not clear whether or not it’s due to the features of the viral infection itself or if it’s just something to do with the number of contacts that some people happen to make. Perhaps there’s like a sweet spot where people shed a large amount of virus and if they happen to be in a situation where they’re shaking a lot of hands or, you know, at that point, giving it a lot of opportunities for transmission, it takes it. We don’t know that. So, however, the issue is that if this is the case, then it may be that we can perhaps come up with somewhat more, you know, some of the social distancing which we’re putting in place may be more important than others, because what the crucial thing is, is we limit the opportunity of the virus to spread to large numbers of other people.
And as I said earlier, it shifts the focus from a case to a transmission event. So when you identify – this as a thing for contact tracing as well – when you identify that transmission has occurred, it means you should redouble their efforts to be testing and looking around for them, because identifying one transmission means it’s more likely that there will be others if you go look for him.
BARRY BLOOM: I would just add to that we know from what turned out to be important medical anecdotes that the super spreading events can be quite triggered by a single individual. Korea had everything under enormous control, and there was a single visitor to the country who went to five bars in one evening and caused the flare up that caused about one hundred and sixty nine cases. Then there’s the case of a chorus, a church chorus in a rehearsal for two and a half hours, where one members of the 88 person chorus was not feeling well and was later found to get quite sick, about something like 59 people got sick. Two of them died. And to go back to Korea, the original super spreading event was a church event with an enormous number of people in close contact, and they dispersed all over the country and that’s what led to the spread of the epidemic there.
So the practical take home lessons are from Bill’s point, it’s very difficult to identify an individual super spreader. It is not difficult to identify events that bring a very large number of people together in a small, enclosed space. Again, the biotechnology company in Boston with one hundred and seventy five people attending a conference, two visitors from abroad, both healthy cost over one hundred cases in Boston. So one of the messages is to cut down the opportunities to bring very large numbers of people together for any considerable period of time in an enclosed space. And this has become contentious because, as we would learn from The New York Times today and earlier, in the original CDC new guidance on how to reduce the spread of the epidemic as we open up cities, one of the recommendations was to avoid many person events, including worship services.
And as you know, that was taken out of the report at the request of the White House. That is not good health, public health policy. Those are gatherings that really do need to be limited in size and duration for contact. And choruses do lead to singing, which gives more aerosolization of virus spread. So getting the public health and the politics on the same path has been challenging in this epidemic.
MODERATOR: Did you have a follow up question?
Q: No. Thank you so much. That’s helpful.
MODERATOR: Next question.
Q: I actually have a slightly related question to what Beth had asked. One of the things, or I guess I have two questions, but I’ll start with this one. What are the things that states should be looking at in terms of their readiness to reopen and lift restrictions? And is Massachusetts in particular, do you think, ready to move on to phase two, allowing things like in-store browsing, the opening of restaurants, hotels, some youth sports?
BARRY BLOOM: Bill, I’ll let you start.
BILL HANAGE: So, I’m afraid that I’m not actually sure I’m able to speak to Massachusetts at the moment because my focus on the last few days has not been Massachusetts. I’ve noticed that there have been some I will make the comment that there have been some apparent increases, but that’s actually due to starting to add together some presumed cases and deaths which have been occurring over the last few months.
I think that the most important thing for any state when it comes to reopening, I think, there are two things that need to be really addressed. The first is that the word reopening suggests that there will not be a reclosing. Now, when as the virus is given more opportunities to transmit, we can be pretty confident that it is going to take them. And if reopening leads to more opportunities for transmission, then we are going to see more cases in the future. So the question becomes, how ready are you to deal with that? And do you know what you are going to do?
So I think that for all states, not only Massachusetts, I mean, Massachusetts, I think has been comparatively clear on this, but it’s still very important that we come up with a set of metrics which you can see as triggers for prompting future action. And we can be clear, you know, we should educate the public right now about what that action might be. And I will not specify exactly what they are because they will depend on local conditions and they will depend on the local capacity for testing and things like that.
But you might suggest that a certain number of new cases, a certain number of new hospitalizations, the possibility of an increase in the effective reproductive number that I was talking about previously, or perhaps some increase in environmental surveillance of wastewater showing that there’s more virus being shed in stool, suggesting more community transmission. And what I think you need to do is, I mean, what we have been doing too much of is being reactive to the pandemic. We should be proactive, meaning that we should be trying to get out ahead of the virus, understanding that what we’re looking at now is, you know, we’re seeing sort of where it has been. We’re not seeing where it is transmitting right now and trying to anticipate that and be ready to take action in the future as it is necessary. And I think that’s true not just in Massachusetts, but basically everywhere around the world.
BARRY BLOOM: I would agree absolutely with everything that Bill said. I think there are couple parameters that one really has to keep one’s eyes on. In essence, the bending of the curve was designed to protect the hospital system so that there would be enough opportunities for high-level care for whatever number that one could have expected to come, in a way. And that’s the bottom line here. If there is an increase in cases due to reopening, for me, the limit would be to be absolutely certain there are sufficient beds and medical equipment to be able to handle whatever that is likely to be two and a half to three weeks in advance of that first number of cases.
Cases is too late to do it well, to do what Bill says, which is to get ahead of the curve. And that really requires testing and case finding and and tracking of cases. If we know the number of individuals in a given locates within the city, any city, but certainly this one, if their numbers are going up in Chelsea, for example, that’s where you would want to put an enormous amount of effort into contact tracing to be able to isolate people. And again, I think one of the things we’ve tried to emphasize this testing is not an intervention that prevents anything. It’s the isolation of those people identified that are positive, which is the intervention that blocks chains of transmission. So just counting cases or counting positives without isolating the people to prevent transmission is not going to change the numbers. So those are the two things. Carefully calibrating what’s expected two to three weeks now in advance or so in hospitals and looking for increases in cases in local areas that then could be contained by isolation.
BILL HANAGE: I think that’s very well said. I would add perhaps just one thing, because it’s something which is an opportunity to raise an issue which I haven’t seen raised enough, which is the – it is absolutely important, as Barry was saying, the crucial thing is that we want to preserve health care.
Now, in many places, people are stating that health care has been preserved and has not been overwhelmed. That’s actually a little bit disingenuous, because if you look at the way that that has been achieved in some places has been by basically stopping large parts of what health care does and turning over ICUs entirely to treating the pandemic. Now, we should remember that health care does a whole lot of other things as well, from cancer screening to treating people with heart attacks and so on and so forth. And it’s gonna be a very long time before we see the full consequences of the pandemic. But we should not be waiting until health care is pushed to the absolute limit. We should be trying to figure out action that we can take earlier on in order to manage things effectively. And that’s something which I haven’t seen in our discussion.
Q: The other thing I want to ask about is the serology tests that a lot of states are conducting now. I know that this is somewhat controversial. What are your thoughts on the validity of the serology test and how we should really be interpreting it?
BARRY BLOOM: So maybe I’ll start on that. Serology tests tells you at some level of specificity and sensitivity in principle that you’ve been infected with the coronavirus. And there are issues with both specificity and sensitivity. Because you are exposed to other coronaviruses, if the prevalence of infection in the community is low and the virus is not 100 percent specific for coronavirus 19, you will pick up a certain number, maybe one or two percent of reactions that say you’ve been infected. And in fact, they are probably cross reactive to some protein in one of the other coronaviruses. If you infer from that that because your test is positive, you’re immune, that would be a grave mistake at this point. And so the caution is it is very difficult to interpret it intelligently for what it means right now for the individual.
Another example, what makes the tests more sensitive is to include multiple different proteins from the virus. The Spike Protein is the one that we know neutralizing antibody reacts against and protects least infection in monkeys and in tissue culture. But it’s not the major antigen and the other two antigens that are in some of the diagnostic tests are more abundant in the virus and hence give you more positives. But an antibody to them, as far as we know, is unlikely to be protective and actually could be counter productive and lead to enhancement.
So just having an antibody, even if it’s specific, but it isn’t to part of the virus that we know neutralizes it, does not indicate, again, that you have an antibody that is protective. So my sense right now is, as Bill pointed out, epidemiologically, it’s very useful to know what parts of cities have had abundant infections. What parts of states like upper New York State has very low seropositivity. That gives you a very good idea of the abundance of infection within a community or at least past infections. Where I would be very cautious is drawing any conclusion that because you’re positive in one test that you’re ready to go back to work because you’re immune. And that’s the answer that everybody most wants. And that’s what I think, with all due respect, journalists have to be clearest on. A positive antibody could be helpful. But it isn’t a guarantee of protection to you or the companies or businesses that you will go to work in.
BILL HANAGE: That was excellent. Barry knows – I think Barry knows a lot more about immunology than I do. So, I mean, I will offer some more general comments on the value of these tests. As he said, there is a relatively high rate of false positives, which comes from confusion with the other kind of milquetoast coronaviruses which we see circulating every year. And if you are using a serological assay in a place where there is very, very low amounts of COVID infection, then you can completely, artificially inflate it because most of the signal will be the false positives.
The reasons why we are starting to get what we are thinking of as good serological data is because we’ve been starting to use it in places like Spain, France, the United Kingdom, New York City, where we have reason to think that that has been a lot of infection. And so whatever signal is coming from false positives is overwhelmed by the true signal. The other important thing to note about it is that it takes time for antibodies to develop and takes time for the different types of antibodies which are detected by the test to develop. And so you’re really only able to see if somebody was infected up to three weeks in the past. So anybody who is infected more recently like that may not have generated enough antibodies in order to be coming back as positive.
Finally, I want to reiterate, because there is a positive test, that doesn’t necessarily mean you are immune. There is emerging evidence, I think, that you get lower antibody titers if there’s less severe infection. So if you had a milder case, you may have lower antibody titers than if you had a more severe case. And as Barry indicated, there’s a thing called antibody dependent enhancement, which we know about from other viruses, which means that if some antibodies could actually make subsequent infections worse and we don’t know enough about this at the moment to be able to be absolutely clear on any of those things. And so it’s a space which we’re gonna have to watch pretty darn closely. But don’t think just because you put a positive antibody test back that you’re in the clear.
Q: Thank you. I don’t want to. Sorry. I don’t get too much time, but I would like my colleague who couldn’t be here today wanted me to ask this question. People who are particularly high risk for COVID, anyone who is elderly or an underlying medical condition, is there a different set of rules for them when it comes to feeling safe to venture back out? You know, what are those situations in which a family member might get to visit a relative in a nursing home given their current situation?
BILL HANAGE: I’ll have a stab at that. I think it’s an excellent question. So if you were to ask me what I would do if I had, I would visit and relative in a nursing home if I were confident that I had been practicing good social distancing and making it virtually very unlikely I myself was infected for a period of two weeks beforehand. I think that if that were the case, I’d be pretty comfortable going into the nursing home. I probably wouldn’t be comfortable going back until two weeks had elapsed in case I become infected while over there, while actually making the trip. When reopening, in all situations at risk populations should be protected as much as possible.
However, I want to point out that there is a tendency sometimes for people to say that you can kind of ring-fencing at risk populations and that they’re going to be, you know, you can preserve them in that way and that you could have the outbreak run riot, comparatively speaking, within younger age groups and preserve the old ones. That’s dangerous. And it’s dangerous because this is a respiratory virus for which there is not really significant population immunity, even in some of the places which are being most hard hit already, which can be, as we said, transmitted before symptoms to call apparent. Therefore, the only way to handle it is to assume that everybody is potentially infectious. And it’s very difficult, impossible to fully insulate those people who are at risk. And I think that states moving forward should really grapple with that situation and be directing resources in order to help them because of the fact that they are going to remain at risk for quite some time.
BARRY BLOOM: Let me just chirp in and add a question that wasn’t asked, but it’s related to the previous one that I’ve really pondered and don’t have good answers for. What we know from pneumococcal pneumonia is that it’s a big problem for elderly people. We know the immune response wanes in elderly people. And so there’s always been a concern. We now have vaccines that are given to elderly people, not as widely taken up as one would like. When the pneumococcal vaccines were developed, they were required as part of childhood immunization. And the great surprise that came from the first studies in California is as kids got vaccinated against pneumococcal pneumonia in schools, grandma and grandpa stop dying of pneumonia. What we learned then is that children, who in this context appear relatively refractory to the disease consequences of infection, appear to get infected at about the same rate as ordinary middle aged people.
They just don’t get sick, and I think it’s unclear why. And the question we don’t have an answer, at least I certainly don’t, is to what extent are kids who are infected, which show up in the studies that have been done and tested them for a virus, to what extent do they play a role in transmission of COVID in the same sense that they contribute to transmission of pneumococcal pneumonia, where adults and middle aged people, parental generations are likely to be relatively resistant but grandma and grandpa, the elderly people are at the highest level of vulnerability. And this has to be part of the considerations and the monitoring that will be done as schools are open. We’re a different country than many in that there are relatively small numbers of extended households where kids, parents and grandparents live in the exact same place. So it may not be as big a problem here as it is elsewhere, but it’s something that really, I think critically has to be monitored as schools open probably in the fall.
Q: Thank you.
MODERATOR: Next question, speaking of super spreading events – this goes back a little bit – do you believe that the ongoing nationwide protests over police killings are likely to become super spreading events?
BARRY BLOOM: I will introduce the subject, but really ask Bill to answer it. There is a factor in – I’m not a modeler and I look at models with puzzlement and wonder and admiration for the people like Bill who who does them. But there is a factor in the models called heterogeneity, and it is to reflect the variability of the ideal average circumstance of the R0 going into an empty room and how many people on a given day will be infected. And you can make calculations and they do for heterogeneity in the real world. I would challenge Bill to ask, how do you do heterogeneity when you have millions of people, mostly young people, out without masks in mass gatherings for hours of it time. How do you handle the heterogeneity factor there?
BILL HANAGE: I will give you the answer – with difficulty. So I’m going to, my response is going to take a couple of different angles. So the first thing is to note, obviously, the protests are directed against ongoing – I hesitate to call them problems because that seems to make it too small – the ongoing abuse of people of color by some police across the United States. This is a long problem and it’s been going on for a very long time. That’s what’s underlying them. That in itself is a public health crisis.
I will add to that the people of color have been disproportionately affected in the early stages of the pandemic for multiple reasons. It’s not clear how much of the disproportionate impacts is explained by exposure. It’s not clear how much the disproportionate impact is explained by various different other risk factors. But it’s without question. Just look at the amounts of disease in the outer boroughs of New York in comparison to Manhattan. Now it then comes the question of how should we feel about protests. There have been protests in Michigan against the lockdown and there have been protests across the country more recently against the, which have been initiated by more recent events, interactions between police forces and people of color.
Now, I will note that gatherings of people are always going to be problematic where infectious disease is concerned. Many of the people organizing protests have actually been quite responsible in terms of encouraging distancing. It cannot always be maintained, but encouraging mask use and distancing and most, if you look at the footage, you can see that a lot of people have been extremely responsible in doing that. It is also outdoors. And that matters because outdoors, the risk of transmission is much less than if you are indoors in a poorly ventilated space without a mask. And that is the concern I have which I have not heard articulated as much as I think it should be, which is that any protesters who are arrested or otherwise detained and held indoors in a poorly ventilated area without access to a mask are likely to be at a far higher risk of transmission from anybody who was detained along with them in the same states. And so those interacting things, which is, you know, this is a collision between different sorts of public health crises. And I think that we can expect it to have consequences. And exactly what parts of it are going to produce those consequences is really hard to predict in advance.
MODERATOR: I’ll ask you a follow up question. Could you please elaborate on your characterization of police brutality on members of the minority community as a public health crisis?
BILL HANAGE: I think that we know that any interaction between – if we have a situation where law enforcement has been interacting with a community in such a way that it is difficult to be able to work with them in order to achieve public health goals, than that is always going to be a problem. I’m not going to say that it’s true everywhere, because it’s just not. You can see a different type of interaction occurring in Denver, for instance, yesterday. But I don’t think, I think that I would probably suggest that it would be better to ask this question of one of my colleagues who works in social epidemiology like Nancy Krieger. I’m an infectious disease person.
MODERATOR: Thank you. Next question.
Q: Hi. Thanks so much for doing this. This is a vaccine question. Yes. Moderna came out with some early studies and sort of glowing headlines and got a lot of press. And then it turned out that maybe there was more there than met the eye originally. I’m curious what you think about sort of science by press release and whether these incomplete data releases and the accompanying accompanying surges of positive press and stock prices make it harder for regulators to do whatever it is they need to do down the line.
BARRY BLOOM: I feel that’s a terrifically important question and nobody could be more enthusiastic about the excitement around developing new platforms for vaccines. Moving the BARDA target was from any new pathogen that arose to have platforms that could produce candidate vaccines within 60 days. And the Moderna went from the DNA sequence in January to a candidate in 65 days when it went into humans for the first time. So a tremendous acceleration of the science has moved vaccines forward.
I was really disturbed by not just Moderna, but others as well. The Oxford Group as well, presenting a press release without data, without a scientific review, without knowing what the press release really was based on. And very positively enough to raise the stock prices so that the next two days later, the officials within the companies sold their stocks and made a whole lot of money, whether or not the vaccine works. People that I know that work on vaccines are dedicated to the fact of saving lives, not making money. In general, that vaccine part of the pharmaceutical and vaccine industry has been the least rewarding financially and probably among the most rewarding in terms of numbers of lives saved for the work being done.
I would, I don’t know how one controls that, but I think that there have been mechanisms to review science critically that given the speed of COVID have gone out the window of having peer reviewed stuff available to the public. Everybody wants to move the science as quickly as possible. But if you go into the archives, if you ignore those that don’t make a difference, probably half of what you read will not turn out to be true. So it’s a challenge to those in the field. And it’s a challenge to the press to be as accurate as possible in presenting the possibilities and the limitations and not be manipulated by people more interested in raising the price of the stock.
Q: Do you feel it’s a challenge to regulators as well who, you know, may have to be in the unenviable position of saying, nope, this doesn’t work after we all got excited about it?
BARRY BLOOM: No, I don’t think so. The common question that’s asked is in the acceleration of the research process on vaccines and with the rush to be able to accelerate the clinical trials, phase one studies morphing into phase two, which will then be if they turn out to be safe with signs of a protective correlates move smooth loosely or seamlessly into larger expansion trials, looking for effectiveness and safety.
I would be very, I would say I would like to be very confident that the regulators of FDA, who are not political appointees but are professionals, realize what’s at stake by rushing vaccines in a world with a lot of doubts about the safety of regular vaccines and a lot of people actively opposed to vaccines of letting anything out without reasonably good confidence that the adverse effects will be minimal and the protective value would overwhelm any small risks because all vaccines have some risks.
People are idiosyncratic how they react to any medical intervention. So I’d be confident that the regulators would hold on. And when a vaccine emerges and it may not be one of the front runners, that it would have gone through pretty critical scrutiny and large numbers to get a sense of adverse effects. So I would put my confidence in the people at FDA to do what they’re supposed to do.
Q: Thank you. And if it’s OK, can I ask one more quick one?
MODERATOR: Go ahead.
Q: Thank you. You mentioned the politics. I’ll make this quick. You mentioned the politics before. Do you think this sort of science by press release plays into the White House’s and the president’s tendency to go with his, quote, unquote, gut rather than the data?
BARRY BLOOM: I don’t know. I have no idea what information is picked up and jumped on by the White House. And I have no way to understand that. I would commend to your attention the original French paper on hydroxychloroquine, which if we assigned to a first year student the day they come before they have any training in epidemiology and if they couldn’t tear that paper to shreds, they shouldn’t be admitted into graduate school. It is a classic of what is not science by any criteria. So that’s what the original press releases and enthusiasm derived from. So I can’t answer the question of what sticks in terms of politically acceptable or favorable science. And that’s why we need to be as rigorous despite the urgency of getting the science right. There’s an enormous amount at stake, not least credibility in the scientific enterprise. And as, again, the Times story on the CDC points out, once you lose credibility with the public, it is very difficult to gain it back. And so we all have a lot to lose by not getting things right scientifically.
Q: Thank you.
BILL HANAGE: I would only add to that, I mean, I once said I want to remember everything that Barry said about vaccines because it was extremely educational. I thought was very well put and educational for me. When it comes to science by press release, we can see way too much of it. We have to remember that science and what’s going on here, what works and what doesn’t is going to be determined by nature. And nature cannot be fooled. So you will always remember nature cannot be fooled.
MODERATOR: OK. Next question.
Q: Hi. Thank you so much. My question has to do a little bit more about diagnostic testing now that it seems much easier to get a test across the US, what is your sense of the turnaround time for these tests and the availability and reliability of rapid testing? And then as a follow up to that, if a diagnostic test is taking up to 48 hours or 72 hours for results, what effect does that have on containment and efforts like contact tracing? Thank you.
BARRY BLOOM: I can talk a bit about the testing and then turn to Bill for the impact on useful lesson in public health. The test, as you know, is an expensive and complicated PCR test. And it’s pretty sensitive and it can be done in a massive scale only recently, but by a limited number of companies. And that takes transport time. And I see very little on the horizon for the existing tests that can speed the delivery of the tests from clinical center. I’m keen on the saliva tests. If we had more data on being pretty sure their sensitivity was as good as the nasal swab test, which is by itself somewhat prone to not getting accurate samples.
I don’t see how this can be speeded up unless every business and every company has a device that can test the people that they want to test. I have an interest in a new program at NIH that was launched by the director, Francis Collins and Tony Fauci a couple weeks ago, which I hadn’t seen anything like before, which is an RFA four applications with a very short turnaround time for a rapid, sensitive, inexpensive diagnostic test. The due date, I think, was the middle or end of May, and the funding would be provided starting in July and August with an aim to have a new, highly sensitive, inexpensive test without pre designing what it should measure. That would be as good and much more practical than the existing tests.
At the time this was announced, there was one application already in that is being funded. Again, nothing is published on this, but it is a test that could be done incredibly cheaply. We’re talking about somewhere between 20 cents and two dollars a test. And the question is they were sensitive and specific and didn’t require complicated equipment, this is the kind of thing that NIH is selecting for. And I am modestly hopeful something will emerge from that by the end of the summer. Bill?
BILL HANAGE: Thank you for that, Barry. That’s very interesting. I’ll note in passing that I should email you. I can think of a really good use for a very specific, not necessarily sensitive test that can be really handy. So I’ll email you about that.
In terms of the epidemiological impact of a slow turnaround, well, obviously, the quicker the better. So if you’re talking about a situation where you’re having to treat somebody and you’re trying to get if it’s a question about treating a patient and determining the appropriate treatment, you don’t want to be having to spend that much time not knowing. In terms of tracking it in the community, then that’s a period of time, you know, 24 hours, 48, no matter how many it is that the person in question may have been able to transmit to others. And obviously, when tests are done, people are told, you know, you should, they get counseled and told you should isolate until you’ve gotten the results back. You know, you should contact your friends and tell them that they should be isolating. But human beings are human beings and they may not do that. So it’s hard to quantify the exact results, the consequence of these relatively slow tests. But I think it’s very reasonable and it’s simply intuitive to understand that they will not help the contact tracing process.
Q: Thank you so much.
MODERATOR: Next question.
Q: Hi. Thank you for doing this. I wanted to follow up on the police protests again that we’ve been seeing across the country. You mentioned earlier that mass gatherings like that are always problematic from an infectious disease perspective, given that these protests are not really showing any sign of slowing down anytime soon. What do you think local authorities need to do, given these circumstances, to try to continue to slow the spread of the virus?
BILL HANAGE: Well, I think are a sort of two parts of it. One of them is not my area of expertise and there’s sort of social epidemiology here, which is a community outreach. That’s something which I think is important. But I would, you know, punt to an expert in terms of giving specifics about that. In terms of the protests continuing, I would hope that infection control is being practiced. And, you know, as much as possible throughout, understanding that all of the people you’re coming into contact with are potentially infectious. And you can you know, I know it’s slightly crazy to think that you should be doing physical distancing in situations like those we have observed.
But at any point, if you are traveling to it, if you are there, if, as I said, individuals who have been arrested or otherwise detained, if they can be held a distance apart from each other, continue still wearing masks and so on, that is something which is going to help protect them and also, incidentally, help protect the people are on all sides. Because the thing is, this virus doesn’t care. You know, this virus isn’t something that’s going to make distinctions between us in that way. It will transmit when given the opportunity. And I think that local public health authorities should be prepared and should be prepared to just give advice to all people involved and to be standing ready to help in order to limit transmission to all people involved.
MODERATOR: Dr. Bloom, did you have anything you’d like to add?
BARRY BLOOM: would share that and I guess most worrisome for me in the in the videos we’ve seen in the various protests have been that in almost no cases were the police or National Guard wearing masks. Some of them had plastic shields, mostly over their helmets. So I had real concern for them standing next to one another and straight lines facing angry crowds that were often yelling and screaming, putting our our police in a position of jeopardy that I find worrisome. And then, of course, there were many of the protesters wearing masks, which, as you know, are not perfect, but there were an awful lot that were not. And I would be surprised if there is not some bump in uptake of positives, if we had systematic testing. And the hope is that on both sides, most are young enough not to develop severe respiratory disease. That’s the best I can hope for.
MODERATOR: Did you have a follow up?
Q: Yes, sorry. I know we’ve gone over this a handful of times, but I guess I’m wondering what the – of course it’s hard to calculate, but we have been touching on what the consequences of these protests could be. If either of the professors could expand a little bit on what type of consequence we’re talking about here, though, I understand with the caveat that it’s hard to calculate exactly. Just touch a bit on what the consequences of repeated mass gatherings like this could be in terms of the coronavirus.
BILL HANAGE: Well, I think one of the answers – when asked to give very precise predictions about the course of the pandemic, I tend to shy away from. But I think we’re quite able to give some broad outlines, which I hope will be helpful. As we said, the virus appears to transmit in particular from a subset of individuals. About 20 percent of people caused about 80 percent of the infections. Now, that produces substantial stochasticity or randomness into what’s going on. And so it’s very hard to say definitively, oh, this protest is going to cause a large spike in cases, although I agree with Barry that if you were to do very, very good testing virtually everywhere, you would see that they were followed by some kind of increase within the community. But what we want to be concerned about is the potential for comparatively large increases.
If we have, I mean, like Barry said, there’s the South Korean nightclub led to infection of 90 people who then went on and infected 60 something more before they’re able to stamp on it as a result of something like forty thousand plus tests which were being done looking for all the people involved. So if that’s the situation which occurs there, it’s very easy to understand that there are going to be some – there are likely to be spikes and unpredictable flare ups following these protests. As I say, it’s not going to be clear whether they could have a protest or through other things which are connected with it, traveling to it, people have been arrested, detained and so on. And, you know, I think that there’s no question but that there will be a consequence.
MODERATOR: Dr. Bloom, do you have a comment?
BARRY BLOOM: No, I agree entirely.
MODERATOR: OK, great. Do you have any follow up questions or are you all set?
Q: I guess that was really the only thing I would add would be how soon until we find out the consequences of these protests?
BILL HANAGE: Well, that, sure. So actually, that’s gives me an opportunity to do a more general thing, which I think is important. So you’re not necessarily going to immediately know because of the fact that, as we were saying, we don’t actually have good population surveillance anywhere. So just I mean, it’s going to be playing catch up on this.
You’re not going to notice the consequences until people are falling ill and getting counted in a few weeks or so. It may be that you won’t see the consequences until community transmission leads to a burst of infections in care homes or something like that, which will be a few weeks away. However, I want to – Chris, if I can take you up to your question as an opportunity to raise an important point. We talk a lot about the reproductive number and whether or not it’s above one, and if it’s above one and you start entering a phase of exponential growth. Now, that is understood by a lot of people to mean that there’s basically a freight train coming at you fast.
That’s not true. If the reproductive number is only slightly above one, given the doubling time that gets given the period between subsequent infections and this, we don’t expect to see a large increase for some weeks. And as a result of that, it may not be apparent in particular with the lack of good surveillance in large parts of the country. So, if you’re looking for the consequences of this, you are very unlikely to be seeing them tomorrow. You’re quite unlikely to be seeing them next week. Two to three weeks from now, maybe you’ll be seeing them then. And one of the problems that we have had in the pandemic in general is that people take too long to respond to a virus which spreads silently among us and can infect large numbers before we realize that it’s actually in a community. And by the time that we’re able to respond, we are forced to take relatively draconian measures such as the shutdowns which have caused so much controversy.
BARRY BLOOM: Let me pick up on that, and I think it’s a really important point. When when we say, well, what are the consequences of transmitting infection in groups, it means that people in those groups, some of them three weeks from now, an unknown and probably very small number will develop symptoms of COVID or become COVID positive. We’re not going to see a spike until they amplify that small number by transmitting it exponentially to communities. And that’s going to take weeks, not days.
MODERATOR: And I’m just going to chime in here real quick. Would the age of the protesters effect how this could play out, because they’re, just from what I’ve seen in the media, quite a few of the protesters are relatively young, which I would think would mean they might be asymptomatic. So they may actually not be showing up as – so, could this even their age also be affecting?
BARRY BLOOM: That’s exactly right. Exactly what I was, if I was more articulate, could have said is that many of the people who get infected are not going to get sick. You’re not going to know that they’re spreading over until they spread it to people who do get sick. And that may only be after they amplify the infection throughout their communities. That’s exactly the point.
BILL HANAGE: Exactly what Barry said. It’s also true that if you look at serology from various other places, it looks as if the younger age group is actually very important in terms of contributing to the force of infection in communities. They do a lot of transmitting to each other. And so, you know, while some of them will get badly ill and hopefully very few, the knock on effects is what we need to be looking out for. That’s what makes infectious diseases so different from chronic diseases. It’s the fact that you have this feedback such that you end up with exponentials and stuff like.
MODERATOR: Great. Thanks. It looks like that’s our last question, Dr. Bloom, do you have any final words before we end the call?
BARRY BLOOM: No, I thank you for all the good questions and for not asking me about the Lancet paper on hydroxychloroquine. We’ll save that for our next occasion.
MODERATOR: All right, Dr. Hanage, do you have any final thoughts?
BILL HANAGE: Nothing other than to say it’s been a pleasure talking to you all and obviously pleasure talking to Barry, as usual. And I’ll echo his comments about hydroxychloroquine.
This concludes the June 3 press conference.
Michael Mina, assistant professor of epidemiology (June 1, 2020)
Bill Hanage, associate professor of epidemiology (May 29, 2020)