Coronavirus (COVID-19): Press Conference with Michael Mina, 03/19/21

You’re listening to a press conference from the Harvard School of Public Health with Michael Mina, assistant professor of epidemiology and a faculty member in the Center for Communicable Disease Dynamics. This call was recorded at 1:00 p.m. Eastern Time on Friday, March 19th.


MICHAEL MINA: Well, I just wanted to take a moment for those of you who care, I suppose there is a lot of movement this week, just a ton, really, in terms of announcements from Biden’s administration, announcements from the CDC and from the FDA, all centered around screening and getting schools open and repeat screening tests using ideally rapid tests. So the just to walk through what happened this week, back at the beginning of the week, it feels like weeks ago at this point, the FDA announced new a new template and rubric that provides manufacturers of tests a new way to get an idea for screening. I think it’s a huge step in the right direction and at the very least suggests that the FDA is recognizing the utility and the benefit of speed of testing and frequency of testing. And they’re creating essentially a pathway to get to go from an EUA authorized test that is for symptomatic use only and not require those tests to be used off label anymore, but to actually give an opportunity for companies to get a screening claim. And so that’s a big sort of decision from the FDA to formally be supporting screening. I think There’s still a little bit more work to do in terms of, you know, declaring screening tests, not medical diagnostic tests that require prescriptions. That hasn’t happened yet. Oddly, now it’s still a screening test, will still require a prescription. But nevertheless, I think it was a show of interest.

Then the Biden administration, of course, announced 12 billion dollars towards testing to expand testing, specifically rapid testing, as well as a hub and spoke model of PCR labs for opening K through eight schools. And so that that kind of came the day after. I think the FDA’s decision to put the template out was probably recognizing that the Biden administration was going to be formally recommending screening the next day. And then on same time, the CDC released new guidance, finally, and I know Rochelle Walensky, I’m guessing, really worked very hard to get the CDC to write very well-crafted guidance about screening tests and the use of them in our communities, in our populations. This is the first time that the CDC has really suggested frequent testing as a way to mitigate spread and has given states guidance. So I’m really hoping that all of this combined, you have this 12 billion dollars that’s going to be distributed to states very quickly. States are going to say, this is great. What do we do with it? And then along with it came CDC guidance to help guide the states. There’s going to be lots of questions that states will have. They’re still going to be problems with access to tests because they still aren’t authorized for the most part. But this is all really good news that I think is at least helping us stay on the coattails of our peer nations. Many countries have moved forward already with getting these types of tests out all over the place. And I think that the US is probably recognizing that there’s a major benefit to this as well and is trying to get caught up and sort of stay relevant in this regard, especially in the context of mutations. And I think biometrics mutations are increasingly worrying. And so having other tools in our in our pocket to be able to mitigate spread if and when that’s needed if vaccines aren’t doing all that we’re hoping that they will. This is going to be increasingly helpful. I’ll stop there and I’ll take questions about whatever you want to ask about.

MODERATOR: Thank you, Dr. Mina. First question.

Q: Thank you, Dr. Mina. The word of the week seems to have been plateau. The number of cases in many states, including here in Massachusetts, was on the decline for several weeks. But over the past few weeks, we’ve seen just kind of a leveling off. Do you have any idea what’s driving this plateau and how concerned are you about it?

MICHAEL MINA: I mean, I want this to be a zero. And I think we have tools to help get us there, so I’m concerned about it. I think that, you know, is it the variants that are driving the plateau or is it just we’re kind of hitting we had this period of very high transmissibility. You know, the seasonality is is a real thing with this virus. And then seasonal force comes down and we hit a new equilibrium. And so that’s part of this. I think part of it is certainly potentially variance. But again, we have to look at what’s the like when we when we just throw out that word like, oh, this is because of variants. Why is that? It’s because at least B.1.1.7, for example, can transmit with a higher effective r value. For everyone person or for every hundred people that get infected in a certain context. You know, instead of infecting one hundred thirty, maybe it infects one hundred and sixty. So that means is that even if things if things are coming down, if B.1.1.7 is coming up a bit, we’re going to see that sort of could potentially push and keep r around one or r just above one rather than just below one. And that difference, when you’re skirting the edge of r being one, is the difference between exponential growth and exponential decay, unfortunately. And so this plateau around r one is which by definition is a plateau. And it is certainly concerning. It’s really difficult at this point to pass it out and say, oh, this is because of seasonality or this is because of increased people mingling together and increased transmission or mutants. It’s probably a little bit of all of them, to be honest, but it does beg the question, you know, it was I think that the questions will be asked, of course, are we accelerating? Vaccines are here. A lot of the vulnerable people in our communities are not vaccinated. I mean, that’s been by any metric a scientific miracle. I mean, it’s just been amazing. And that has led the pendulum to swing to say, OK, we can open up new regulations that nursing homes, if you’re vaccinated, you can mingle. You know, there’s all kinds of every state is opening up at an accelerated pace right now. And that does that does have its consequences. As we all know, we can’t go from staying very vigilant to not being vigilant and assume that that’s going to not have some impact. So it could also be just human behavior.

Q: Quick follow up to that, you mentioned the accelerated pace of states reopening, but at the same time Europe is closing down. New Lockdown’s announced today in France, Germany thinking about the same thing. Is it just a question of timing from one continent to the other?

MICHAEL MINA: You know, we could find ourselves there as well. I think that what we’re seeing in Europe is certainly partly due to more highly transmissible variants, like disrupting the balance, new equilibrium that we’re finding and there are differences, the US is more aggressive about getting everyone vaccinated than the whole of Europe. I mean, Israel obviously is the leader in this regard. But we bought a lot of vaccines. We just got a ton of them. And ideally, we’ll give our extras to the rest of the world. But we are pushing forward with that. And that is helping, I’m sure. But Europe, you know, I think that we should look at that as a little bit of foreshadowing or forewarning, rather, that, hey, we’re not out of the woods yet. We might want to be, but I don’t think we are. I think we’re going to see a massive difference, massive benefits from vaccines. But it doesn’t mean cases won’t arise. When we look at B1351 and we look at the vaccine or the protection in elderly from a natural infection, we’re seeing people over sixty-five are getting exposed at much higher rates than people under sixty-five, which isn’t surprising. We know that immunity starts to wane at around sixty-five, which is why people get shingles. And so I think we have to be very, very vigilant. I understand that everyone is extremely tired. I’m exhausted. Everyone in the world is exhausted by this virus. But we have to I think we have to really be careful when we swing the pendulum out because everyone’s vaccinated, that we don’t end up causing ourselves to close down. My personal feeling is we’ll probably end up locking down again, not as significantly, but this fall, I think we will probably struggle again.

Q: Thank you very much, Doctor, appreciate it.

MODERATOR: Next question.

Q: Hi, I wanted to go back to the testing and the rapid antigen testing. What is the state of how states or communities or businesses know which one to use? I mean, there just seem to be a lot out there. And I remember a while ago you had described something that came in the mail that was like a double packet, like two tests, so that one would confirm or, you know, serve as a backup to the other if you got a certain result. Could you just go over what the state of play is with the antigen testing and how it’s best used and how frequently?

MICHAEL MINA: Absolutely. Well, I wish that I could agree with you that there were a lot. There’s a lot of names in the space, but actually from the rapid antigen test perspective, the simple ones, those aren’t there’s very limited choice. Still, there’s BinaxNOW. And there’s I don’t have it here, this Quidel, those are the main two that you can actually get into the home still again with a prescription. So that really brings the cost up from these things, cost something like 70 cents to make. And they’re being sold for thirty dollars or twenty-five dollars because of their prescription. It’s a major barrier. There’s no reason to have a prescription. And then the other one is AccessBio. Those are the three that are in this form factor. None of the others have been authorized yet. There were two that also required instruments and those have been around for a while to be BD Veritor and the Quidel Sofia, those are like instrumented things that you only see a doctor using or some sort of official point of care instrument. But when it comes to these really simple ones, there’s unfortunately only three. There’s a lot of them that work really well. And I’ve evaluated them. Unfortunately, they haven’t been able to get through the FDA regulatory process. And so they’re not available to Americans right now. We’re running a big study with one of them with Citibank, and that’s the ANOVA test. But that’s not available. It’s only through because we’re doing this in an ethically approved study that we’re running it. That all said, we do have we’re seeing the BinaxNOW available. We’re going to see major investments in BinaxNOW in quite well, I’m sure, especially in light of the 12 billion. My guess is tons of money is going to get thrown towards quite and Abbott as a result, because they’re the only two really that are scalable, that are around. They’re not necessarily the best.

Abbott’s the best, and I would say that some of them are better than the Quidel that aren’t yet approved. The best way to use these is to really bank on the fact that they are rapid. And see, you asked about what? About having to package together. There have been a lot of concerns early on about false positives. And so that made me talk a lot about, hey, you know, you could confirm a positive with a second rapid test. So let’s say you’re using a BinaxNOW at your home and you get positive on this. Then you can use another rapid test right away. You package ten of these with one of these or whatever it might be, so that if you’re positive on one of these, you take this and your false positive rate plummets. That being said, many of these are already showing exceedingly low false positive rates. They’ve gotten a lot better. The BD Veritor and the Quidel Sofia had high false positive rates, those instrumented ones. But now this ANOVA test and the AccessBio test, they’re extremely specific, you know, less than point one percent false positive rate. So as far as specific as PCR, so in some ways you don’t even necessarily need the second test because you’re not going to get a lot of false positives. They’re best used frequently, they are only going to be positive when you’re when you’re infectious, so only then both PCR and rapid tests, if your goal is to stop transmission frequency is the key. If you’re not doing it frequently, then you start transmitting and you don’t even know it yet. And because these are so inexpensive, when they’re not prescription and because they’re able to be produced at tens of millions per day, if we had all the companies that could make them, making them, we could create policy and strategy around them. We could say, hey, you can open your schools. We know that kids are going to go and hang out and we know that they’re not great at wearing masks, et cetera. We know that they’re not getting vaccines. But what we can do is have them spend 30 seconds each morning and take a test. Super simple. That’s the beauty of tests. Every other strategy we have is very consuming. Distancing is a very it disrupts life. Wearing a mask is an all-day process. All of these things shutting down is horribly disruptive. Taking a test is. So I think of it as like a bio mask. It’s really not disruptive, but it’s 30 seconds in the morning and it greatly reduces the chances that you’re spreading that day. It just makes too much sense not to be using it right now. And other countries are now really getting to push forward with frequent testing. The CDC and the Biden administration really want to. That’s become apparent. And so I’m hoping that they will have the tools available to them, that these tools will get authorized and get through the FDA soon so that the by the administration and the CDC can actually create strategy. Right now, they’re kind of having to contort their strategy to create more PCR testing because we don’t have the rapid tests. But I think we should probably start seeing them. I hope, you know, eventually, because they’re working very, very well.

Q: So currently, like what the White House uses or use, that’s an antigen test? Like when you say Rapid, 15 minutes, what exists now, or antigen as opposed to like a fast PCR?

MICHAEL MINA: Well, the Trump administration is using the Abbott ID now. And that’s a fast molecular RNA test. It’s the one that was a box. And then this is an antigen. But then you have these new tests like this looks kind of like an antigen. It’s got a paper strip there. But this is a molecular rapid test, a rapid molecular RNA test. So we’re starting to see the lines blur. As you know, a year ago, I would not have thought that this kind of thing was going to become available in a year, but I did know that rapid antigen test would be. So now we’re actually starting to see rapid molecular tests become available. And that’s going to also create a whole new approach to rapid testing that could potentially sort of supplant the need for PCR. Get the sensitivity of PCR, but the speed of a rapid test. So the lines are getting blurred. But to be clear, at the moment, the only ones that are authorized are really good, they and the two antigens are the ones that without any instrument.

Q: OK, great.

MODERATOR: Next question.

Q: Hi, thanks for doing this call. And this is kind of a follow up on just what you’re speaking about, testing in schools. What kinds of policy decisions would you like to see implemented? I mean, you have schools dealing with things like CLIA waivers when they’re trying to do testing. And it seems like schools are all over the map on this right now. But there are really no policies for at home testing for students, staff and teachers. And, you know, as the CDC and potentially the FDA work through these things, what would you like to see?

MICHAEL MINA: Well, I would really like to see in terms of in terms of screening, you know, there are so many ways to do frequent screening to keep our schools and businesses and offices safe. The reason why we’re doing this study with Citibank is because Citibank looked at the landscape of what was available to them and they said, how are we going to open up all of our branches, you know, we can’t get a PCR test every day? And besides, even if we get a PCR test, if it takes two days to return, it’s practically useless to stop transmission. And that’s unfortunately true. So they looked around and said, what other options do we have? And they also said it’s really onerous for us to have to have employees line up when they get to work every day and take a test. And so we started this at home based program with Live Person. Live Person is a company that makes software for chatting, like if you go into a bank website and it says, Can I help you? And you can chat into it or talk to it. That’s this company, Live Person. And so we collaborated with Live Person and Citi to really bring this program forward by saying, hey, look, it is possible to actually ask people to do their test at home, distribute the labor, distribute the effort and do it at home three times a week, Monday, Wednesday and Friday. And if you have any issues at all, you have live person there to talk to. It’s an A.I. based app, but it also connects straight to humans if you need any help. And so, you know, bringing these technologies together has made reporting, if we’re not reporting in the study, because it’s a study with a authorized test for doing PCR stuff for the confirmatory testing, but it could enable reporting. It could enable sort of at home use very simply, very effectively. And that’s exactly what it’s doing. What I would like to see is that transition to schools. Is there a reason that schools that all the effort has to be on the schools, or could we ask schools to have most of their parents do the test for their kids or most of the test be done at home? Again, you brush your teeth and right afterwards you do a quick test, and it could take it really doesn’t take long once you do it once or twice. It is extremely simple after that. So 30 seconds at home and then you wait 10 minutes while you’re eating breakfast or whatever and you have your result and then you go to school. That’s what I would like to see. And we can do that every few days, even twice a week would be enough to stop spread, to stop future outbreaks from happening that would otherwise paralyze a school or cause a school to have to shut down. We just have to keep our below one in each of those environments. What that means is these tests don’t have to be perfect, we just have to make sure that if a case does get in, that it doesn’t continue to spread and and cause the school or the business to have to close down and to do that, all you have to do, if you had at a big scale, if you had one hundred people getting infected, you just have to get those hundreds to infect 90 if you can get one hundred people to just infect 90. That sounds to most of us like a failure. But that alone stops an outbreak from taking off. It keeps it in the exponential of the case. If you start to get an outbreak, it immediately burns itself out. That’s all we have to do with these tests, we just have to make sure that we’re keeping our below one. The moment it gets above one, which you can do very well, if we don’t have sort of a frequent testing program, then things can get out of control very quickly. And you’re closing down your schools, you’re closing down your businesses like we’re seeing in Europe again. So what I would like to see is America take a proactive stance here and say we are going to use tests every couple of days and we are going to use them in a way that keeps r below one. Even when outbreaks do start to emerge again, even with surges in cases, this environment here will keep r below one and we can keep businesses moving forward and schools moving forward. So that’s what I would really like to see. Does that answer the question?

Q: It does. Just to follow, schools are a lot of chefs in the kitchen with school boards and teachers’ unions and everything else, how does that complicate practical implementation?

MICHAEL MINA: Well, it’s part of the reason that I would like to see the testing be done at home, you know, and maybe we have to work to confirm this. With each of these tests have QR codes on them. So there’s ways to actually ensure that people are using the tests. There is a philosophy around sort of what your goals are. And I think the goal should be not stopping every single case but stopping every outbreak. That should have been our goal all along. And if we had that goal, we would have stopped the outbreaks. We would have got this test that a long time ago. But our goals have been stopping every case. And as a result, we haven’t stopped many cases because we’re trying to aim for perfection here in a in the wrong way. So I think but having these complex organizations, school boards, city administrators, parents, it is very complex. And I think that each place would have to, to a certain extent, take it. They would have to deal with the local environment. But this is also why CDC can get very clear guidance, which they’re trying to do now. The problem is, even if CDC wants to give really clear guidance, which they just did, there’s just no tests available for the schools to really be able to purchase. They can get some of the BinaxNOW, but BinaxNOW and Quidel aren’t going to be able to cut it. They’re not making enough. And so what this means is that most schools don’t have access to these tests and they need prescription. And there they need CLIA waivers like this should not be at this point in the pandemic, nobody, no American, especially school kids, should have to be prescribed a test by a physician and have extra cost added and complexity. We should just get rid of all that. I would like the president to make a presidential order that declares these tests as public health tools that don’t require prescription and then all of a sudden takes a big burden off of the schools. Right now, the schools have to go and apply for CLIA waivers and find physicians to write their prescriptions. And it’s a big mess. It makes it so hard. And so they’re just saying, screw it, we don’t want anything to do with this. And if we can make this much simpler and treat this as a public health crisis, which it continues to be, I think we could find that the schools would have a lot more latitude to move forward.

MODERATOR: Next question.

Q: Hi, thanks for doing this. I’m wondering, so we’re seeing a lot of hesitancy out there. There’s a Washington Post story today talking about that even among health care workers, like 40 percent hadn’t been vaccinated yet. And of course, that’s going to change over time. But I wonder, like, if we’re not going to get to herd immunity, which seems kind of likely at this point, what does that mean? I mean, how does society operate when a lot of people are vaccinated but not everyone is vaccinated? Do we have to if we do have flare ups and things like that are vaccinated, people are going to go back and stay home and not work and not be able to go to restaurants. I mean, what is life look like in a world where we have a lot of vaccinated people but not enough vaccinated people?

MICHAEL MINA: Well, there’s a couple of answers to that, I think on the one hand, vaccines aren’t all. We’ve actually had a lot of infections and we’ve had probably something like one hundred and fifty million people have probably been infected. The CDC suggests something like a five-fold overall, that we’ve had a fivefold underreporting rate, we have 30 million people who have been reported as infected. So that brings us up to one hundred. You know, something around one hundred and fifty million people might have been infected at this point. Maybe it’s a little less. Maybe it’s a little more. It’s almost surely more than one hundred, because back in December, the estimate, based on serology and others from the CDC was it was eighty-five million or so. And we’ve had about a third or something of the cases have all happened since then. So one hundred and twenty thirty million. And that’s really without even testing the kids so much. So when we add that to vaccines, I think we are going to have a lot of protection, but regardless to your point, there are going to be a lots of people who aren’t getting vaccinated. I do think that number is going to keep shrinking, though. If we go back just two months ago, a lot of people are saying, I don’t want one of those vaccines, they’re dangerous. And then people started seeing their neighbors and their friends. And this gets into a cycle, a positive cycle, where you say, hey, you know, everyone around me has had a vaccine and they’re all doing just fine. And we’re going to keep seeing vaccines.

Vaccine receipt and acceptance begets vaccine received acceptance. And if it goes the other way, you know, like we’re seeing with AstraZeneca now, where it’s like a little bad news also tumbles into it and it snowballs. And so I think we’ll end up with a lot of people vaccinated. Do I think we’ll get herd immunity? I think we have to be really careful. We’ve seen that infection rates and the actual amount of viral load, rather decreases post vaccine. Not surprisingly, that is obvious. Like, we didn’t have to ask that question, but the question is, does it go to zero? And the answer appears no. So I think assuming that people will remain infectious. We’re going to have to be in this for a little bit of a long haul where we’re essentially waiting for enough people to get protected through both infections and vaccines that even if transmission is occurring, we start to see that hospitalizations aren’t ticking up. And that’s where I think we really need to step back today. I’ve said this a number of times now over the last few months that we need to decide now. We need to start getting ourselves conditioned for the question of what happens in multiple scenarios. If we get to the fall or the summer and there’s surges and there’s hospitalizations and we start to see hospitalizations creep up to a point that’s not sustainable, OK, we shut down again. But if we see cases and no hospitalizations, are we going to be OK with that? The populace is traumatized right now, and so I think we have to really ask the question, are we OK with cases if it’s not leading to hospitalizations by. And I think the answer, if we actually showed that it’s not leading to hospitalizations should certainly be. Yes, it’s a virus that maybe we can live with. But if we’re seeing instead that it is that reinfection with variants are actually potentially worse, whatever it might be. Then we should have a plan for that, too, and we have so far been reactive, and I think we have an opportunity, I’m hoping. But then again, I said it in April of last year. I said this exact same thing and that’s that we’re going to see cases come down. We’ll get a little bit of a reprieve from this virus. We’ll probably see cases come up again in October, November. And we can use this time right now in this lull of cases to say how are we going to react as a society and we can start having our officials come out with a game plan that says if cases are coming out, we don’t see hospitals tick up, then that is a fine thing. In some ways, getting reinfected. If you’re not if it’s not making you sick is a good thing. It boosts your immunity. But if it is making you sick, that’s a bad thing. And so we have to just be really cognizant. And I want to see a real plan ahead of time because it’s going to be a societal decision. It’s not a scientific one.

Q: Thank you.

MODERATOR: Next question.

Q: Hey, Michael, just to change the subject a little bit, but I think it’s important, interesting, I asked you months ago about why the Spanish flu, which still circulates, is no longer, you know, so bad in terrorizing us. I think I remember your response. In fact, I know I do. But I just wanted to hear you elaborate on that a little bit more, I understand is veers way off topic. But if it happened once, it could happen again. Whatever happened to that flu, which makes it no longer an issue? That was the flu that terrorized the world for two years and now it still circulates, but it is no longer an issue. So the question is why? What happened?

MICHAEL MINA: Well, that’s exactly what I think is going to happen with this. Well, first, the 1918 has changed. The 1918 strain the people enough to protein, which is a protein on at that and give some pathogenicity isn’t it’s not the same strain anymore. It’s similar for sure, but it’s not the exact same. And there are some reasons that people think that that’s, you know, a benefit to the new strain isn’t as lethal or pathogenic. But I think the same thing is going to happen here. We are going to age out of this virus. We’re accelerating that process because through vaccines, we’re accelerating it very quickly and but what I mean by aging out of it is kids are not impacted badly by this virus doesn’t mean that. You know, I know that there is a controversial piece in the Atlantic today or yesterday. I’m not sure on about kids and not getting vaccines and such, but it doesn’t mean that kids shouldn’t get vaccinated. Doesn’t any of that. But kids are much more protected naturally from this virus. And people after they’ve been exposed once or vaccinated, should have greater and greater protection. So as we start to see the population, either kids are getting exposed when they’re really little, they’re not getting disease or even 40 year old’s, they’re not getting much disease and they’re going to age up. And by the time they age up to a vulnerable state, say sixty-five, they’ve potentially seen the virus 15, 20, 30 times. And that’s kind of what happens in natural life. Kids are getting childhood infections repeatedly in early life. This is evolution like we’re programed to do this, and kids are getting there. They’re building up this big cushion of immunological memory. So then by the time they are 70 and they should be really vulnerable if they were naive to many childhood infections, they’ve actually already built up this massive amount of immunological memory that’s keeping with them for a long time and protecting them. But it’s also why pneumococcus is called old man’s best friend. It kills a lot of people. And that’s because immunity starts to wane with older age. And so how well we can age out of this is a big question. How well we’re going to. How will the vaccines allow the elderly to age out of this? I am very concerned that older people won’t be able to really build a good immunological memory. So they might just stay in this kind of purgatory where they’re never really protected except for the few months after each booster. We’ll see, I mean, there’ll be much more protected than not having a vaccine, but they won’t be 100 percent protected. What I mean, so I think it’s all about this sort of demographics of aging and the immunity that has led like H1N1 and such to not be so lethal anymore.

Q: That’s an interesting concept to aging out. Just real quick follow up, but see, so if the old one produced a variant of the Spanish flu, produced a variant, what happened to the original strain? It just disappeared. Why would that go away? Even if there’s less lethal?

MICHAEL MINA: You’re asking one of the big amazing, it’s one of the most impressive phenomena that happened in biology. I won’t go into detail about it, but you should just Google a map of the changes in the lineages of flu strains that happen over the years. They replace each other. They almost have always replaced each other. And one comes around and same way that variants of COVID will replace each other. These flu strains do in the most miraculous of ways where you just see this strain has just circulates across the whole globe at a lot of people get immune to it and then a new one pops up and just presses the other one out and it pushes it aside. Now, we have three and two in H1N1, but that’s likely because H1N1 came back onto the scene in two thousand nine. And before that, as a laboratory release of that, it was a mistake. And so now we have to and they haven’t. And actually, they’ve been living together and infecting. And every year we kind of have those plus flu B but traditionally we’ve seen just these massive replacements of flu strains, which has been, and they’ve been global. They’re very crisp.

Q: So the new one is less lethal, and it immunizes you against the old one and just blocks the old one out?

MICHAEL MINA: Yes. That’s generally the theme.

Q: OK, thank you. Thank you, Nicole.

MODERATOR: Next question.

MICHAEL MINA: Can I just respond to a question in the text? The question was Lucira and Ellume, why didn’t I list those? Lucira and Ellume, these are tests that are not scalable. We’ve done to hundreds of millions of dollars into these companies and they’re not scalable tests. They’re not going to make a dent from a public health perspective. We can’t reasonably get Q at three hundred dollars for the base station or something and to need a multiple of them. Q has to be done one at a time because you have this like little base station thing. Lucira is going to be something like fifty dollars and it’s still not on the market. Ellume is another, it’s an antigen test. It’s not you know, I would say Ellume is not as good as BinaxNOW, but it’s you know, it’s got all of this all of this stuff in it regardless. But it’s expensive. And so these are three tests that are expensive and they’re not scalable because of the complexity of their of their components, whereas a test like this is super scalable for public health. I don’t know if that helps.

MODERATOR: I haven’t heard, but she has her hand up for a question as well, so we can get to her directly in a bit, too.

Q: Thanks for taking the time, Dr. Mina. I am going to ask a question that kind of picks up on what’s a little bit, maybe a little bit blunt or crude, but why should somebody who is vaccinated and maybe has given it a couple of months, so let’s put us in July, why should it matter to them? And why should they care about herd immunity? Or the concept of it, if they are protected at that stage, they don’t have to?

MICHAEL MINA: That’s the cool thing about herd immunity. They’re already participating in it, whether they like it or not, and that’s the really nice thing about herd immunity, you don’t have to think about it. If you’re protected and if you’re vaccinated, it turns out the vaccines really do sufficiently stop transmission to a certain extent to even theoretically achieve the herd immunity. The nice thing is it’s a natural phenomenon. It is a population-based phenomenon that you don’t even have to try to participate in and you’re participating in it. So the average person doesn’t even have to be worried about it. The really nice thing about it is, you know, it’s great that the public is starting to understand it. But the cool thing about immunity is selfish. Well, I don’t mean this in a negative way, but like selfish behavior, if your selfish behavior is about keeping yourself safe and in so doing means that you have enough immunity so that you’re no longer able to transmit, then a whole lot of selfish behavior becomes a collective positive for the population at large. And so. It’s one of the beautiful things I think about herd immunity is it doesn’t require effort as long as it’s one of the nice things. If you can incentivize people to get a vaccine for their own health or their family’s health, they are naturally participating in population health as well.

Q: I guess to follow up on that just a little bit, the way I’m thinking about this is let’s say that I don’t think we know what this will be, but let’s say we max out at like fifty-five or 60 percent uptake on vaccines and there are still restrictions in place, will vaccinating people have a reason to believe in those restrictions?

MICHAEL MINA: Not really, but so there’s two parts to that question. It’s an interesting question because let’s say it’s perfect. Let’s say you get vaccinated and you don’t transmit. In some ways, it doesn’t matter, though, if, you know, vaccinated people are the ones who aren’t caring and they’re kind of going out and about the world and they’re already vaccinated, they’re not going to be damaging herd immunity or impacting spread because they’re already theoretically protected. Now, if they’re not fully protected, meaning if people who are vaccinated can still spread and to get the herd immunity, we’re really banking on enough people being vaccinated, even if it’s not perfect, we’re getting everyone vaccinated and everyone has lower infectiousness as a result of being vaccinated. That, too, can lead to herd immunity. But if that’s the case, then absolutely. I mean, I think it’s a real issue. And I think that that’s probably the scenario we’re going to be in. Vaccines are not going to completely inhibit spread, not by a long shot. I think it will decrease spread, but especially in older individuals. We’re going to continue seeing we’ve already seen it. We can spot people and we see that there are viral loads in people and who have been vaccinated and infected. And so that means as we have to be really careful when we say everyone can go into a nursing home, it doesn’t mean that if you’re vaccinated that you can’t spread to somebody in a nursing home. I wish it did. I really do. And I think it’s going to really reduce the spread for sure. But what about after five or six or seven or eight months? Is it still after those plasma blasts have collapsed and you don’t have a billion cells producing antibodies, you have one hundred cells in your body producing a lot of antibodies? Maybe you won’t have enough antibodies to neutralize everything and you’re still going to get some viral replication happening in your nose. Then you’re vaccinated and you’re not caring about herd immunity and you’re not caring about transmission because you yourself are protected from hospitalization. That’s where things go awry. And, you know, I do think that we’ve been a little bit loose with this language in some ways. I think that the administration is recognizing in the US when it comes to policy setting, they’re recognizing that Americans are tired, and they want to give people weapons. And so right now there’s some wins in terms of saying, look, people have been vaccinated recently, we’re going to relax things for a while. Will that turn out to be the best option in the long run? I think there’s going to be opportunity, maybe even just a few months from now, where they say, hey, we’re finding out more information if we want to have people sort of settle down and wear masks again or something. And I do think that’s probably the direction we will go where we will see vaccinated people if they’re interacting with other vaccinated people, there’s very little chance that you might have a lot of ping ponging spread go on, but neither will go to the hospital. But the concern is when you have this person who’s been vaccinated, go to a party, get infected and then go to a nursing home or whatever it might be and not wear a mask there, that would be a potential bad outcome.

Q: This might be a long shot, but just one more I’ll throw on the on the lawn right now on the fire right now is do we have a sense yet for what would get us to herd immunity in terms of in terms of a number? I know that there’s been a lot of kind of back and forth on what that number could be from a percentage standpoint.

MICHAEL MINA: Well, it really depends a lot on the variants, and I mean, the back of the envelope calculation is you take the are not of the virus, which not they are t not that are effective, which it has been. You know, we’ve been measuring us recently of like one point three, but that’s in the context of lockdown’s and masks. So let’s say if you were to not have any mitigation of spread, let’s say if we go back to total normal behavior, the actual are of the virus are not as like three. Let’s just say the third. The threshold for herd immunity is one minus one r knot. So one minus one third is kind of the back of the envelope calculation. Sixty seven percent, that’s Marc Lipsitch got that number in a back on when he announced on 60 Minutes or something that 40 to 60 percent or 70 percent of the population will get infected with this. That’s based on the simple, simple back of the envelope calculation. So that’s if we were to go completely back to normal, we might have to get 60, 70 percent and that’s if protection is perfect. But if protection’s not perfect, which we know we don’t, I don’t think any of us really ever thought it would be perfect after vaccines, the vaccines are working much closer to much better than we expected from a symptomatic disease. But we’re still seeing that people do have virus in their nose afterwards. That means it has to be even higher. But the good thing about herd immunity is it’s not like you hit something and then and then everyone’s immune. It’s a continuum. It’s essentially you might have a growth rate that’s very high. And as you get closer and closer to that, it starts the growth rate of an epidemic starts to level out and then it comes down and burns itself out once you pass the threshold. But just getting towards that threshold is still really positive to slow spread. But it just means that the virus isn’t going to be depleted to zero over time. Eventually that will probably happen with this, especially as we keep vaccinating. But we’re probably going to get in this. I think we’re going to have a long, drawn out gray zone. We’re not going to see cases plummet to zero. That’s. Magical thinking for the most part, which is why I really think it’s important for us to take a step back as a society and just ask the question, what do cases mean? How are they going to impact us or are you going to keep taking cases and monitoring that? Or are we going to start monitoring hospitalizations? And those are the as we get more and more people vaccinated, maybe that’s really the key. But then we still are kind of going to be in this unfortunate space where if we’re OK with cases, we have to figure out how to keep the elderly and most vulnerable safe. And if they are not retaining immunity very well because you’re getting a vaccine at seventy-five. Then they might be very vulnerable, even if they’ve been vaccinated, say, seven months earlier, nine months earlier, and so maybe that’s where the boosters are going to really have their greatest benefit.

Q: Thank you very much.

MODERATOR: Next question.

Q: Hi, could you comment a little bit more on what the school testing might look like and then if you have any advice for administrators at schools, you know what can they do to implement successful testing strategies with these funds that are now coming?

MICHAEL MINA: Well, every state is really going to be handling school testing very differently, and that’s kind of what’s happening now. In part, that’s because until just two days ago, there hasn’t been really good guidance from the CDC and nor like a really concerted position from the administration. And now, of course, you know, I feel like it’s been so long, but it’s only March 20th. So it’s been two months. And the administration is now and the new head of the CDC, they have put these plans in place, which has been great. And so I hope that that’s going to switch things. But at the moment, each state has really been thinking about this differently. Shauna has helped, a lot of policy has on this call. She and I have been meeting for almost a year, six months or something with her and me almost a year with governors of different state senators and Congress people to talk about these issues and everyone is doing it differently. Each state has their own HHS or some other public health authority that’s making decisions, and that does make it a complicated mix. The Biden administration is trying to come up with like a hub and spoke model for PCR laboratory testing to build up the PCR lab labs in the country and start to get the thirty-five or forty or fifty-five million K through 12 students testing on a repeat basis. But I don’t think that the PCR program is going to work. It’s really why we need these rapid tests to be authorized so that they can actually be used and strategy, a national strategy can be built around it. That’s one of the best things about these tests they can be. It’s something that a Biden administration could say, OK, we have 20 million tests per day, 20 million little tests per day that can be used at a state, state by state by state. And we can actually give a strategy to all of these states because it can be replicated across, because these things are dispensed, they can be distributed. But there’s barriers right now that are really affecting how states can respond to school testing.

CLIA waivers are still needed by every school and prescriptions are still needed. So how schools deal with those, some states are being aggressive. Texas, for example, just said we’re giving a blanket waiver to every to every school for asymptomatic testing. You know, that’s great. And essentially, that’s Texas’s way of getting around the FDA requirements as a whole state. Probably we should be looking at these requirements and wondering why is Texas having to do something like that? Is there something we could do nationally, maybe with a presidential order to take it off of FDA’s plate? They don’t want to set precedent. FDA is in a pretty tough spot because they don’t want to set a precedent that goes beyond this pandemic. So maybe the president can write an order that says, hey, clear waivers aren’t needed anymore. That would make simplifying testing in schools. It would really reduce some of the barriers essentially by keeping prescriptions and by keeping clear waivers in place. This is asking like, why are our schools asking to be called laboratories? Like schools are not laboratories. We can give them public health screening tools that don’t need prescriptions. That would be much better. But until we break those barriers, the short answer to your question is there isn’t really a strategy. There are not the tools. We don’t have the tools yet available to all Americans in an abundance for schools, for the president and the White House to make a strategy that everyone can use. So each state is kind of doing it on their own at the moment.

Q: And as far as you know, is there something where home testing could be taking place now in some place, like testing at home, testing in schools for students, certainly in California, for example, it doesn’t have to be at home.

MICHAEL MINA: Could be, creating really simple ways to use these at schools could also work. California’s using these for their schools, for regular school testing. There is definitely a process that these could be used at home and distributed much more widely. What I would like to see is maybe we don’t have to get into to an extended, you know, infinite time of using these every few days. One of the most powerful things about these types of tests is that we could turn them off and turn them on really quick. If everyone had these in their homes. Let’s say every household had a bag of 20 of these and you start to see cases pop up in your community or school, you get a text message that says, hey, cases are we just found in sewage wastewater surveillance that there’s COVID again somewhere. Just start using your tests and let’s keep our below one and we won’t even let the outbreak come back. Those are really smart strategies around these types of tests because we can just put them in everyone’s home, tell people to not use them anymore, tell people to use them, have people be able to replenish their supply of tests if they need to. Very easily. There are ways to do this. And had we done that back in August, we actually could have every American household had a bag of 20 of these or 10, we could have suppressed the outbreaks that we saw this fall and winter, we could have potentially saved or averted one hundred thousand or more deaths if everyone had these tests available. And we could still do that. We just have to distribute the right kinds of tests and get all the big logistics out of the way. And these tests really can do them.

Q: And is there anything that school districts can do or is it just too big? You know, it’s a larger problem than the individual district they can work with there right now?

MICHAEL MINA: I would say schools have to be they have to work closely with their state officials and their county officials and then their state officials to figure out what’s available. It’s really state by state and county by county. I know months ago I was working with Mayor Garcetti in Los Angeles to try to figure out, can L.A. do something like this? You know, I would say in a lot of the discussion has to go to the state and people schools are generally going to the state first and saying, hey, is there something the state can do to get rid of CLIA waivers and prescriptions, maybe write a blanket prescription for the whole state, which that’s what states are being forced to do, which is sort of an abuse of medicine and the purpose of a prescription. But that’s where we’re at. So states are maybe doing that and a school has to maybe say, can we do that in our state? And I think that with this with the new changes that are happening with FDA and CDC this week, I think that we’re going to start to see them really signal to states like how to get their answers to their questions. And what is the strategy this this week to me as a I as hopefully going to be a pivotal week. We’re going to see, you know, with three different sectors of government come out pretty hard around this issue this week. And I think over the coming weeks, we will see strategy and we’ll see instruction and we’ll see policy being built around this to help the schools figure out what to do.

MODERATOR: OK, next question.

Q: Yes, this is a really good discussion, and it sounds like they thought that the testing strategy will have to continue to evolve as the disease evolves. So really interesting. But my question had to do with surveillance and the status of surveillance and whether it’s being held back. I know it’s been problematic in the US. And just any quick thoughts on that since we’re winding up?

MICHAEL MINA: Sure, did you hear my answer to your other question earlier, I just wanted to make sure?

Q: Yes.

MICHAEL MINA: About surveillance, surveillance is a huge issue. Obviously, we need surveillance to really know what’s going on. I think that there’s a few ways to do surveillance. On the one hand, we need to do genomic surveillance to know what strains exist. We should be taking every positive and we should be getting it to a site. If it’s there’s ways to do it, even rapid tests could be great tools for this. If you get a positive on a rapid test, maybe we have programs where we mail it in, just like we mail in swabs, just a very rapid test, has some sort of envelope or something that’s just paid by the government and says, OK, this is a rapid test, it’s from somebody who turned positive that you put in your biohazard bag and you mail it and just like we’re doing with swabs to get swabs processed in laboratories right now. That would be a great way to do genomic surveillance with rapid tests. We could do genomic surveillance with any positive that comes about. The more testing, we do, the better the surveillance can be. And the most testing we can do would be if we use these types of tests because they’re just so much more scalable. We could go from one or two million tests today to 20 million tons per day. And if we got even just a fraction of those back in sequence, that would be an amazing amount of genomic surveillance to make sure we’re keeping an eye on what the variants are doing. Surveillance, just to know what the cases are doing is also important. A lot of the critics have said that rapid tests can’t be used at home because you won’t ever get the value. So we’re showing in our Citibank’s study that you can we’re getting almost 100 percent reporting because we made it so easy. We’ve made it part of people’s morning that they use a rapid test and they’re plugging in their results anyway because they have to attest to not having symptoms to get into work. And they’re putting into it, was my rapid test positive or negative? And so we can still if we got even just a fraction of that across the country, if we scale these up to 20 million a day, we would have a lot more surveillance. So surveillance is going to keep being important.

I think we’re going to see wastewater surveillance is going to keep growing in importance. I think especially as cases go down, we’re going to want simpler ways for the long haul, monitoring sort of what I call peacetime surveillance. If it’s peacetime, you don’t have a lot of cases. You don’t want everyone to have to be testing every three days to catch one out of a million people or something. So you start going into peacetime surveillance, which is maybe very passive wastewater surveillance, keep an eye on hospitalizations. And then when you see cases start to tick up again, maybe RNA in the wastewater pick up again, then you can ramp up the frequent testing again at the individual level. So there’s going to be lots of ways and I think we have to just change our attitude around surveillance from just something that we’re getting, from numbers that we’re getting, from people going to the hospital or going to the drive thru testing site. Just something we’re very actively doing specifically for surveillance, and the US is really bad at this. The US has never been good at just doing surveillance for surveillance sake, for pathogens. Some countries do. They do it quite a bit. We could even use antibody-based testing as a surveillance tool. But the US were very hooked on just using hospitalization data and sort of clinical medical test data. But we could do things like the UK. The UK has this big study where they actually go to random selections of people’s homes and they just say, hey, can we test you as part of our survey like a census? And they’re just kind of routinely doing that sort of true surveillance testing all the time.

Q: Is there any surveillance that you think is being done, any project you can point to a surveillance that’s being done that’s effective now in the U.S.?

MICHAEL MINA: The wastewater. Nicole just put the Boston wastewater in. A series, surveillance can be very powerful, antibody-based surveillance. You keep monitoring, especially if you know who the people are that are donating, we could do surveillance with blood donors. There’s a large number of blood donations that come in. All of those blood donations get evaluated on a routine, regular basis very quickly for antibodies to other things and for HIV and such. We can do surveillance and it’s in my laboratories actually doing that. We get tens of thousands of samples a week from all across the country and we’re processing them for immunological signals to be able to monitor this virus in real time. So these tests, these approaches are coming on board, but they’re not particularly robust in the US and historically.

Q: Thank you.

MODERATOR: And last question for today, her question is, I’m working on a story regarding children and herd immunity. Every parent I have spoken to said they do not want to vaccinate their children. Would rapid testing school children be a good alternative?

MICHAEL MINA: Yeah, I think we’ve probably covered it, but absolutely, I mean if the goal is to stop outbreaks from happening in schools and to keep schools COVID-free, frequent testing and screening, testing for the K through eight and K through 12 can be extremely important to stop outbreaks from emerging in schools and keep people safe. I think it’s one of the best. We’ve seen great examples of it across all of the academic colleges and universities in the Northeast and a few others around the country. We have been able to use frequent testing alone, essentially, I mean, with some masks and other mitigating strategies. But even when there were lots of cases happen in the community, the universities and colleges, which should be the petri dishes for this virus, because you have all these young people mingling, they were protected. They were like these little havens with no cases. And that’s because of frequent testing. And so we know that frequent testing can stop outbreaks. We know it can keep places safe. And in the context of low vaccination rates in schools, this is a very good way to make sure that schools are staying safe and staying open, even if there are cases happening in the larger community.

MODERATOR: I think that’s it for today. Any other final thoughts you’d like to share?

MICHAEL MINA: No, I think that’s it. Thanks, everyone.

This concludes the March 19th press conference.

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