You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Michael Mina, assistant professor of epidemiology. This call was recorded at 11:30 am Eastern Time on Friday, May 8.
Previous press conferences are linked at the bottom of this transcript.
MICHAEL MINA: I’m an assistant professor of epidemiology and immunology. My focus has been a lot on testing, both PCR-based testing and serology and also development of serological surveys. And we have a lot of new research and activities at the state and local level surrounding these types of activities. So, happy to answer questions.
MODERATOR: Great. Thank you, Dr. Mina. So let’s start with our first question.
Q: Hi. Thank you for doing this. So, the percentage of tests coming back positive appears to be falling. Does that mean we’re doing enough testing now or at least we’re doing better than we were? And what are some other indicators we should be looking at to determine whether we’re doing enough testing?
MICHAEL MINA: Yeah, so the percentage of tests that are coming back positive – it’s good that it’s falling, of course. It suggests some things about the epidemic, but it gets obscured. So, we’ve been scaling up testing more or less across the country, of course. Testing continues to increase and what that does is it widens the number of people or the type of person that we are necessarily testing.
So, for example, at the very beginning, it was only hospitalized patients and healthcare workers and we’ve kind of scaled up now that it’s becoming much more readily available to individuals across the population. We expect, even if there was no change in the epidemic from the beginning of it, we would expect that we would see potentially a decrease in positive rates, just because we’re opening up to people who are maybe asymptomatic or have known exposures.
But in general, we do see in most places, at least in major metropolitan areas, for example, places that have really adhered to social distancing, we have seen a fall. And I think the fact that we can capture that does suggest that we’re doing decently with testing. We’re not just triaging to the people who are sick.
But we still – it almost gets to – at this point in the epidemic the fact that we still are under testing, I would say at least the availability of tests are still not adequate in terms of how we want to be using them. I don’t know that we’re doing enough. And I don’t know that just screening for virus in the population is necessarily the right way to do it and virus screening really needs to be done in conjunction with antibody screen so that you can interpret what the prevalence means.
So, I think we still have a long way to go to actually scale up testing to the point where, for example, we can use it to do very robust surveillance. We’re not close to that at this point and we’re barely scratching the surface in terms of getting people who just want to be tested able to be tested. So, I would say that no, we’re not. We’re not where we need to be. We’re much better than where we were and we’re doing better now than I thought we would be just five or six weeks ago, but it’s still not optimal.
Q: Just a quick follow up question. Some states are starting to lift restrictions on letting businesses reopen, so would you expect that positive or the rate of positive tests to start creeping up again?
MICHAEL MINA: Well, I think asking about the rate of positive test to creep up again, that really depends on how widely we’re starting to screen. The real question is, do we expect the rate of people getting infected to start increasing again.
I think, yes. I think when we start opening things up we should anticipate that people will start spreading the infection. Of what we know about this virus if nothing else, and there’s a lot we know about it now, but if nothing else, we know that the virus can and does have the ability to spread very rapidly and be very contagious. And we see that in nursing homes, we see that in urban settings. So, when people start funneling back to work I think that we can expect and we should expect to see more cases.
The question is, can we stop those cases from becoming large outbreaks. And that’s where we need more testing to be able to do what I call enhanced surveillance where it’s a sufficiently enhanced to actually be almost real time to control outbreaks, but I do think we’ll see cases.
Q: Thank you.
MODERATOR: Next question.
Q: Hello. Hi. So, we all know that confinement has saved lives. I would like to know if you could, I mean, if there is a way to provide an indication of the additional lives that could they be saved if a confinement was done in the ideal way, meaning Truck doing enough tests to separate those infected or asymptomatic from those that were healthy or most at risk? So that we shouldn’t accept that there would be some infection or contagion with the confinement. Is that possible to make such a research.
MICHAEL MINA: So, you’re essentially asking what I think is can we estimate what we call an epidemiology, the counterfactual what would have happened had we done something different than we did do.
Yes, there are ways to estimate those types of things. And for example, once we have epidemiological models that actually fit the epidemic from what we know of it and what we learned from it, we can go back and retrospectively look and say these were the interventions we put in place at this point and this was the effect. Had we put that intervention in place three weeks earlier, what would have been the effect. So, we can do what we call simulation modeling where we recreate artificial epidemics that look like the epidemics that did happen, or that is happening and we can modulate those epidemics in the simulations to understand what would have happened had we acted differently at any point along the curve.
And so, and those are certainly ongoing all the time, usually at this point because we’re in crisis mode trying to deal with this epidemic we are very much looking. Most of the interventions, we’re looking at or what can we do now and in the future. And, you know, eventually, there’s going to be time to do the autopsies of this epidemic and understand what really what we could have done differently so we can learn from it and those are also starting to happen as well.
But I think most of us are looking forward at the moment to try to figure out what we can do now, you know, and we’ll go back and explore what would have been different later on.
Q: So, at this point, there is no way to watch it to measure the effect of age that happened in more people confined in the same place between effect?
MICHAEL MINA: No, we can wait. That’s part of what we’re studying now. I might have misunderstood your other question. We can measure the types of infection rates that occur within the household for example, and we can we can test people who are positive and then monitor their family members, for example, and try to understand what are the infection rates that are happening within households. And there’s been the estimates, however, they have been pretty wide. So, I’ve refrained from even giving a hard estimate right now because that has to do both with the R0 of the virus and also what we’ve measured has been, you know, anywhere from one person on average infects less than one extra person within their household to a few people in their household. And those studies are sort of still pinning down what the real infectivity looks like.
Q: Thank you.
MODERATOR: Next question.
Q: Hi, Professor. Thank you for taking your time. My question is about the reopening. So, since the end of April nearly half of the states released their restrictions. But after 10 days or so this reopening the data seems not so optimistic like some new outbreaks in the middle and for the whole country. How did you evaluate the reopening which is in practice? Do you think for some days they should stop and turn back? Maybe in some days later?
MICHAEL MINA: Yeah, I mean, at this point, I’m not, I do not support reopening at the moment. I think I should say I don’t support reopening from the perspective of infectious diseases and public health. There is a serious need to evaluate what are the tradeoffs we’re making maybe without recognizing them at the moment for both the short- and long-term economic outcomes of the country.
The New York Times I think today just reported or – I’m sure that I don’t know where the numbers came from, but over 14% unemployment rate or something along those lines. And, you know, so these are extraordinary numbers that are occurring because of social distancing and localized lockdowns and closures of works. And so, at some point we have to really contend with trying to understand what are the tradeoffs we’re making. And frankly, what are the tradeoffs we as a society are comfortable making if we choose to go back to work as individual states.
That’s one direction that states can go but that will most likely come with added cases and reversal of the gains that have been made to reduce transmission. But the benefit of course would be that people will start going back to work and there is a scenario where that might actually be more beneficial than continuing to walk down and, you know, despite the extra cases that would occur. So, from my perspective as an infectious disease epidemiologist if somebody asks me, do I think it’s the smart thing to do from an infectious disease perspective, I would say no. I think that we should remain in social distancing mode until we really get cases to very, very low levels. They’re still not very low. We still on in the drive thru testing sites for example, we still routinely get 10 or 15% positive results. Luckily, those are starting to go down. But that means that there’s a lot of community transmission on going.
And if we open things back up, we really do run the risk of major outbreaks happening again. In particular because we did not take the last couple of months while social distancing to put heightened surveillance programs in place. So, we are essentially back exactly where we were two months ago before we went into social distancing, only now we have much more localized transmission to ignite new outbreaks than we did back then. So, I think that there’s a real danger.
But I also recognize the reports of 14% unemployment and I have a real concern and fear that by focusing too heavily on infectious disease public health, we might start to neglect other areas of public health related more to the economy. And we need to be all communicating and anytime we make a public health decision that’s through the lens of infectious disease, we have to balance that decision with an economic lens and into societal ends as well. And I think those discussions are starting to happen much more frequently than they were at the beginning.
Q: Just a quick follow up. So, in your opinion, what do you mean by very low level if it is a perfect situation?
MICHAEL MINA: Almost no new transmission events. I think if you can recognize new transmission events on a daily basis, then that’s too many. That means that we are in a state where the moment we open up, we will start to see much wider spread transmission occur pretty rapidly. It might not be in a week, it might not be in two weeks, but multiple generation times down the road, all of a sudden, we find that we’re back on an exponential curve upwards.
And so, I think that what I really mean when I say that very low numbers, I mean low, sufficiently low so that we actually have a fighting chance to detect and use contact tracing to control the new outbreaks. I think at the moment the contact tracing efforts that are being performed in settings with extremely wide local transmission, which makes it almost impossible to keep up with the curve. And contact tracing efforts are, while very important during widespread transmission, they start to lose importance and there’s diminishing returns, and I would like to get to a place where the returns of contact tracing are really readily apparent and that it’s the tool that we can utilize.
Q: Okay, thank you.
MODERATOR: Next question.
Q: Your colleague Yonatan Grad yesterday on this conference call talked a little bit about not reopening necessarily, but what happens after reopening when if cases do again spike, and he said, few people are really thinking about how we would go about repurposing controls whatever they would be, and whether they could be much more targeted based on what we’ve learned. And I wonder, I wanted to get your thoughts on that. Do you agree that folks really aren’t thinking about that, and if so, what kinds of things – how might we reimpose these controls in a way that will be different from the first time?
MICHAEL MINA: I think some people are thinking about it, and some people are not. I know that I’ve been in both sides of those conversations with thought leaders and policy leaders from across the country and I think that, in general, though there is a level of possibly willful ignorance or just blissful ignorance, not quite sure which is the right word to use there, but in states that are choosing to open, I think that there is not a sufficiently serious conversation about what will happen if major outbreaks do start to occur. Can you turn back the tides again?
My personal feeling is this shutdown mode we had that the country was on board with it. People recognize the importance and what has happened because it has been largely successful route, relatively speaking, people have lost track in a way of why they’re doing it, which is fine. We don’t anticipate that the non-epidemiologists and nonprofit you know people that don’t normally think about infectious diseases all day long, there, there isn’t a reason to anticipate that people should have a good understanding of how infectious disease dynamics work.
So, for example, when I look out of my house right now, I don’t see people falling over from coronavirus. And even when I go to the hospital, I don’t see a huge number of people with coronavirus and that I think makes people think that the that the curve is on the downswing and that were that were in the clear and that this is dynamic, kind of like influenza where when you see the reduction that you see, that it continues to decline, despite going about your day as per normal. But what we’re actually seeing is just the decreases that we’re seeing and the lack of coronavirus cases all around us is really in direct response to our social distancing.
So, I think unfortunately the messaging wasn’t made clear enough to people that the benefit that we’re seeing, that we’re all sort of subconsciously seeing potentially by not ending ourselves up in the hospital and not having, you know, huge numbers of our family members all in the hospital or neighbors is a direct result of us social distancing now and over the last couple of months. And because we didn’t make that clear, people have now come to the conclusion that maybe it wasn’t even necessary in the first place because it’s very hard to recognize what is not actually happening.
And it’s, again, the counterfactual – like we can anticipate that people should understand the counterfactual of what happened, of what didn’t happen, I should say. And that means that people have, kind of, I think, there is a large fraction of America that probably lost some of the energy to social distance, not because not just because they want to get back to work, but they actually don’t necessarily believe that it was useful because they never saw the storm that would have hit otherwise. And how do we go back then? Can we, if outbreaks do start to occur again, can we then say to those people say, hey, we need you to go back into social distancing. My concern is they’ll say no it didn’t do anything last time, look, we have an outbreak. And they wouldn’t have recognized how much their efforts last time did actually prevent the outbreak. They might just fool themselves into thinking that it wasn’t happening yet.
So, I don’t know, that was a long-winded way of saying that I am really concerned that if we try to go back and social distance again, a lot of America might lose belief that this is actually useful and will refrain from being willing to do it a second time.
So, this was kind of our major – I don’t think that we’re going to have a lockdown like we saw the last couple of months. And those discussions have to start happening. Is there some way to prepare for that, to prepare for people to act differently than they did the first time. I don’t think we’ll be able to just say, hey, for the next, you know, two months again at home, people will revolt, I think, and I don’t think serious enough considerations are being taken. People are just assuming that we can open up and if we need to close back again we will, and we can keep it really dynamic and I don’t think in many parts of the country that people will be willing to do that and I worry very much about it.
Q: So, does that mean from a death rate standpoint, you know, it might be pretty grim in the months ahead except people have accepted it, or people can get used to almost anything which is unfortunate?
MICHAEL MINA: Yeah well, I think I do anticipate that if outbreaks do start to occur again, you know, whether it’s in the next couple of months, or whether it’s in September and October we’ll see, I think we will start to see death rates climb again as result of coronavirus. And we’ll have, I think, some areas of the country and some, it might be very localized, will really respond quickly and adapt and so can we have to shut down again, you know, last time wasn’t so bad. We’ll figure it out.
Or was bad. And we won’t figure it out, you know, or things will just go on and we will accept a lot of death and in return will end up with potentially getting closer to herd immunity but at an extreme cost. The real question though is, is that cost a higher cost than economic collapse. These are the really existential kind of questions we’re asking that are not easy to answer.
Q: Thank you.
MODERATOR: Next question.
Q: Thanks for the time here. I am reporting on an assisted living facility with a large number of coronavirus cases and a large number of coronavirus-linked deaths and so one question I had – and this facility, I should say, has a track record of major incidents. So that’s what I wanted to ask, is there any link between the track record of an assisted living facility or nursing home and the likeness of a COVID-19 outbreak at that facility? From what I’ve maybe read there might not be much of a correlation that’s been established yet. But would it be safe to say that a troubled track record raises questions about facilities preparedness?
MICHAEL MINA: Well, I would start by saying that I’m certainly not an expert on assisted living facilities and nursing homes. I have become very, very involved with some of the testing that’s going on in state surrounding it, but my expertise is certainly not lying within that realm normally. So, that’s a big caveat to take whatever I say next with a grain of salt.
I do think, you know, if we consider an assisted living facility or skilled nursing facility or nursing home, you know, in the realm of, you know, similar to hospitals and we say what a troubled hospital that has let big infectious incidents slide and things like that and has had problems with infectious disease outbreaks and infection control, would we assume that a facility like that would potentially be at greater risk? I think yes unless some of those past incidents have really led to important change within the facility, but if they didn’t lead to important changes, then I would say sure. I mean, it would only make sense that if you’re pretty relaxed on your policies and relaxed on infection control in general, then you’re probably not going to do as well during an epidemic or pandemic time as a place that has very good clear policy that they adhere to in place.
So, I think we could assume that if the research were done, well, we might see some correlation. But again, I don’t really know how well nursing homes respond when under the spotlight if a big problem does happen in the past.
MODERATOR: Next question.
Q: Hey, Michael. So, obviously, nobody knows how to predict the future, but I’d like – and you’ve answered part of this – but I’d like you to guess more specifically like what happens between now and New Years in terms of like a virus popping back up? Total shutdown and possibility of a vaccine savior coming along in that timeframe?
MICHAEL MINA: [Laughs] So I’m the Oracle now. I can just take a guess, again like we, I do think that if I were to take guess, and it’s one of many guesses I could take, but I think that we will start to see sort of residual – so we’ll see social distancing start to disappear at an accelerating rate. So, in the same way that social distancing became part of our societal structure. Initially, it happened with an accelerating pace and then all of a sudden everyone put in place policies. I think we might start to see it DSL if people leave social distancing at greater and greater rates over the next month.
Some places that are going to be a little bit more conservative about keeping social distancing in place, you know, until policies are better policies are put in place. I think even those places will start to see diminished social distancing and that may, you know, if it does lead to new outbreaks, you might see places like Massachusetts or other states where, you know, might end up going back into social distancing. And you might see places like Georgia, say, you know what, we’re not going to do that. Those are just two examples just based on current policy.
I think that what we do next in terms of how we respond to larger outbreaks is going to impart be related to the variant variation that we see across the country. So, if we see that some states that slow down their social distancing or remove it all together, if we say that they do start having outbreaks but we said they can contain those outbreaks and not they’re not taking over there. There are ICU beds in their hospitals and that the testing is in place to actually be able to provide some utility, then we might see that other states also will follow that route.
If instead we see that the first day to really release distancing immediately starts having major, major problems with resource limitations and hospital beds and things, then I think we can assume that other places will look at that and say, oh, well, we don’t want to be there, so we’ll go back into social distancing as much as we can get our constituents to do so. I think it’s going to really depend on how the first few places fair and that’s kind of how we respond as humans we look at, you know, first impressions.
And so, the country is certainly going to be looking at places like Georgia that are choosing to open up a little bit quicker than others
as a testing ground. Now whether what happens in Georgia can be applied elsewhere in particular in places like New York, Philly Boston, Chicago,
you know, I think that that’s a big question just because these very densely populated areas will have different dynamics.
So, moving into the fall, I do, I personally think – I really don’t know what’s going to happen in the summer, we might end up seeing limited spread if this turns out to be exquisitely sensitive to the weather patterns. Now, we don’t have a lot of data to suggest that it will be,
but if it is, then I do think in the fall, probably, it could turn into a bat. Worst case scenario, we might have everyone completely go back to normal because they don’t see spring happening in the summer. And then as fall hits we might see major outbreaks. So that could that could be a real problem for us, and that’s kind of where I think we’ll end up.
I just think that people will probably start trying to get as much back to normal throughout the summer as they can. And we might end up seeing big outbreaks in the fall.
And, you know, in terms of vaccines. I think that there’s the vaccine trials are moving at lightspeed. Adrian Hill at Oxford – I think he’s at Oxford – is really pushing an adenovirus vectored vaccine through trials, very quickly, and they had a big leg up. I think there was a report about it in the mainstream media this week or last, and then we’re seeing these DNA and RNA vaccines get started and Moderna’s trials are going on. So, how those turnout will – it’s really hard to say. I think they’ll probably elicit some antibodies anyway, whether or not it ends up being protective and truly in the efficacy trials. You know, I think that will determine a lot, but I do think by the end of the year, we might have some more decent therapies. I think remdesivir, for example, you know, despite it being approved, I don’t anticipate that being the silver bullet that’s going to save lots of lives. I think it will save lots of lives, probably, but probably not, you know, prevent massive, massive, massive change.
And I think monoclonal antibodies will come out and we’ll see those become used hopefully by the end of the year. We’ll see some going to trials and be more useful. And so, my hopes are a little bit more towards the therapies because if we have a decent therapy in our pocket that we can use, if somebody really starts to turn the corner at a hospital and go downhill, if we can use these antibodies, just different various therapies whatever might come out, as a good and reliable therapy, then it really does change the equation in terms of what level of risk at a population level we’re willing to take. And I think that, in some ways, I’m really rooting for the therapies because they’re a little bit more predictable.
Q: So just another quick question. So, I cover a lot of biotech, and a lot of trials are being delayed. And so, there’s a lot of cancer victims that won’t get treated and will die earlier than expected. A lot of people are foregoing therapies in hospitals or can’t even see their doctors. I mean, pure speculation here, but is there a chance that a lot more people are dying because of these effects and a shut down then the lives that we’re saving?
MICHAEL MINA: It goes both ways. We’re actually seeing – so yes, I mean that the, I don’t know if I would say that we’re seeing more deaths than the lives that we’re saving because they’re shut down, but it is possible that we are seeing and likely. It’s not as possible, it’s very likely that we have people are dying because they are foregoing certain normal things that they would do, so including things like, you know, having a heart attack and not, you know, getting rapid medical attention because you’re fearful of going in the hospital, maybe rightly so. And so, these normal parts of being in the healthcare system are certainly much more limited and I think we can anticipate people are dying as a result at some elevated rate.
I don’t think it’s as elevated as the rate of cases. But on the other hand, from an infectious disease perspective or a car accident perspective and all these things that are more a population level, not an individual health level, we’re seeing those go down, you know, things like we might even as we go into the fall, see much more reduced if social distancing happens in the fall, we may see much lower amounts of influenza. We will potentially see lower, you know, we’ve had measles before COVID. Measles is in the news a lot because there are lots of big outbreaks happening around the world. I wouldn’t be surprised if we see reduced new outbreaks this year from measles. So, we may see reduced cases of other infections, reduced driving accidents and these other things that usually happen as a result of people moving around society.
So it’s all kind of a balance and I think people are going to really be exploring this year for many years to come to try to understand, you know, very fundamental things about social behavior in society that are very, you know, without a natural experiment like this are very hard to interpret otherwise.
MODERATOR: Next question.
Q: Hi, thanks so much for taking the time to chat with us. My question is about social distancing as it pertains to elderly and immunocompromised folks. Will elderly and immunocompromised people have to stay home for significantly longer than the rest of us, and what can we do to shorten the duration of their isolation? I mean, I’m basically wondering whether elderly people will have to basically self-isolate at home until there is a vaccine, which could take two years or more, or could something else, like an antiviral drug or manufactured antibodies, make it safe for them to socialize sooner? If so, do you think we should be devoting more of our resources to those approaches, drugs, antibodies?
MICHAEL MINA: Well, there’s a lot of resources that are going into them right now and those who can be working on it generally are working on it, so there is a bit of a division of labor that is appropriate at the moment.
But in terms of resources, I completely agree with what you just said.
I do think that we will have to that the vulnerable in our population. I don’t see a clear avenue to get them out of social distancing mode as long as community spread is going on. And that’s why, you know, if we gave ourselves the time to really push cases all the way down so that we didn’t have much local transmission anymore, then maybe we could actually think about, you know, maybe population risk would be so low for different durations of time that we could have more vulnerable people out in society, but right now, I think we still have enough local transmission that it would be very dangerous.
I think that one of the things we could think about doing to accelerate this process, which I do think, in some ways, can be very controversial, but, you know, taking a huge amount of resources and putting it into ensuring that the most vulnerable amongst us are really protected as people do start to re-enter the workforce. So, allow people to re-enter the workforce, in particular younger people, and people whose individual level risk of severe disease is very low. That’s a good place to start.
And actually, you know, if you can divert sufficient resources to actually do a good job of preventing infection of the vulnerable, then maybe you can tolerate these outbreaks happening in less vulnerable people and start building up herd immunity at just sort of a slow pace and that’s this whole sort of flattening the curve, and so if we could do that well, then I would be in favor of it, but I just don’t see any evidence that we’ve really diverted a sufficient type of resources into actually protecting vulnerable.
In fact, even despite all of the social distancing we’re doing now, which I don’t think we’re ever going to get to a place where we do more social distancing than we have done, we’ve still seen infections flourish in the nursing homes and, you know, that to me is very troubling. I don’t know how we, you know it, it’s going to take a lot to really figure out how to actually keep them safe. And until we do that I think it’s going to be, if you are a vulnerable individual and you’re social distancing at home, you might – I don’t recommend if you live in Georgia to start going to the hair salon and out to dinner if those are opening. I think that’s taking a pretty hefty risk.
Q: Can I just ask a quick follow up about that? So, I just want to get clear on what you meant by, you know, what you meant by diverting a huge amount of resources and putting it to ensuring that the most vulnerable amongst us are really protected. I want to know what that would look like in your mind exactly? Because I think that a lot of younger, healthier people really want to be able to see their parents and grandparents, but are actually worried that it will be even less safe to do that once social distancing relaxes for them because then they’ll be coming into contact with more people, which means they’ll potentially pose a greater risk to the elderly than they do right now.
MICHAEL MINA: That’s exactly right. I don’t know exactly what these changes are that I’m envisioning, to be honest. I mean, some of them I just, I feel like there are changes that could be made. So, if we started designing tests – so there’s been a lot of effort to design new diagnostic assays and those have generally been with the general population in mind. And I do think that there would be some role, for example, designing assays that are very specific to sort of use daily use. For example, if somebody wanted to go into a nursing home, I think one of the structural changes that could take place is that everyone just to get into a nursing home, you have to get tested and maybe you have to do it every single day. And that’s going to require new diagnostics.
And, you know, from a diagnostic perspective I actually think that there’s maybe ways to do this. There’s actually quite a few new tests that are becoming available, or that are being developed I should say, that are really rapid but we have become so focused on getting really sensitive tests, this is going to go a little bit off the topic, but it’s more about the use of diagnostics for this purpose. But there’s been this effort to develop the most sensitive tests that we can get which will, you know, detect one molecule of the virus in somebody’s saliva or nasal swab and that’s useful in some ways.
But if you could reduce or relax some of the requirements of the test and say, you know, we just need to make sure that somebody isn’t floridly positive today, and so we actually have to tolerate a test that’s less sensitive but cheap enough to use every single day so that somebody could actually just carry around a carton of these tests and before they walk into their parents’ house or a nursing homes like that, they just test themselves. And maybe even if they’re positive, if they’re positive at such a low level that the test doesn’t detect it then maybe for that day, it won’t be the end of the world, but they’ll find out they’re positive the next day and so they won’t go to see their parents the next day.
So I think that we can start thinking creatively about how to relax some requirements that are currently in place with the trade-off of being able to have like more frequent testing for sort of visiting vulnerable people and for public health measures. So that’s one diagnostic structural change that I could see being made.
Other things might be you know outfitting, it might be very expensive, but making rooms in nursing homes and assisted care facilities more safe through changing the types of pressure that’s in the room and these would require real structural changes to the ventilation and things along those lines. But the cost of keeping these people safe right now is essentially the shutdown of the economy. So that’s trillions and trillions of dollars. So, can we take some fraction of that and start to really revamp the structure of the locations where a senior citizens live I think would be something useful.
MODERATOR: Alright, next question.
Q: Hi, thank you so much for doing this. I’m working on a story today about recovery data and how important that could be for states to track, even though the definition is still pretty murky. Massachusetts is currently not doing it, but working on a standardized definition as far as tracking how many patients have recovered. How important do you think that data could be when it comes to understanding the virus? What could experts like yourself glean from it?
MICHAEL MINA: I mean, getting recovery data is useful. But essentially, we can we can assume that most people – like, if instead of using recovery data, we just subtract out deaths from known cases or extrapolated cases from serological studies, for example. I think we don’t have to actually measure everyone who is recovered to know what the recovery rate is as long as we do a mostly decent job at tracking people who die or who are in the ICU. We have a general idea of how many people are in ICU, we have a general idea of how many people die, and so we can infer recovery rates even if they’re not formal recovery rates and I do have a bit of, you know, I think we should have some time frame if somebody is lost to follow up, which, given many of the positive tests that we’re getting now are coming from people who go thru drive thrus and things like that, many of those people would be lost to follow up in the medical system.
And so, we won’t know if they recover and it would take a lot of resources to follow back with those people. But as long as we can assume that they haven’t died by utilizing death records and things along those lines, I think that should be sufficient, rather than trying to track every positive case down and figuring out where they’re at three weeks later. So, I think that there’s a definitely utility to know survival rates and recovery rates, but I think we can extrapolate backwards from the death rates.
Q: What kind of things would you be able to glean from that recovery data though, as far as like reinfection rates or that sort of thing?
MICHAEL MINA: Oh, well, if we know it at an individual level, then that’s certainly something we’re looking at. For example, to understand – if we actually have line item data for an individual. If we know that somebody has actually recovered from infection and then gets sick again that’s extraordinarily important information to know. It’s very, very difficult to capture out of the healthcare setting, but we’re trying to set up big studies where we follow thousands of people in the community with surveys and serology and we will be able to know when somebody gets infected and then we’ll keep following them for potentially a year or more, and we’ll be able to actually know when they recover and then if they get sick.
Again, these are some of the major questions that remain about the role of immunity in this virus. And so, those types of things I think we can really get at depending on how good the recovery data is if it’s just population rates, then it doesn’t get us too far in that direction, because until cases get high enough that we actually are getting into the, you know, if we see that 70% of the population has recovered but 40% is infected today, then obviously that would be important information to know. I don’t think we’ll ever get to that kind of thing. That would mean immunity just doesn’t exist for this virus. But I do think there can be benefits, but the more granular the data, the better in that case.
Q: Thank you.
MODERATOR: Next question.
Q: Thanks so much for taking my question. I’m actually doing a bit of a follow on to that previous question. So, looking at a paper that came out from Mount Sinai this week, Alan Weinberg, they were finding that 97% of the people who had positive COVID-19 tests they were PCR tests sero-converted, so, they were positive for antibodies and I’m curious how important a part of the basic piece of the puzzle is that I mean as you alluded to, there’s so many things we don’t know. We don’t know if this if – well now we know that people create antibodies. We don’t necessarily know that if they have antibodies, they’re immune or do we is that known yet?
MICHAEL MINA: So, I think the important part to the – I don’t find it interesting at all that, you know, most people that get infected have antibodies. So, I think that’s a no brainer. We know despite this being a novel virus, we don’t have any reason to believe that this is a virus unlike any other we’ve ever seen. And so, we know that when people get infected with a virus like this that they develop antibodies and we know that the individual kinetics of this virus look just like we would expect and anticipate for the most part, from a respiratory virus and the immune response is similar.
So, I’m not blown away at all by any data that suggests that most people who get the infection develop antibodies. That’s just what we would expect. The real question with this though is you know what do those antibodies mean, and that does differ from one infection to the next. And so, we always have to figure it out with any new infection or even long existing infections. We have to understand that, for example, HIV, let’s say you do develop antibodies against HIV, and most people develop antibodies against HIV when they get it. That’s actually what we use to test people for it. They still have the infection and they still will have it for life and so that’s an extreme example of a virus that knowing the antibody levels really does nothing for you. You really want to know the viral load levels and how somebody is sort of combating it inside the body with this particular virus.
We can assume that antibodies exist post-infection. We can assume that some level of immunity will exist. We just don’t know exactly what level that will be, will it be perfect immunity, so that you can’t get infected again at all, or will it be partial immunity, so that you can still transmit it even if you’re not feeling sick if you get it a second time. You could still be a transmitter of it, or will it be a very poor immunity that wanes after three or five or six months and you can actually get a full-blown infection again.
You know that will probably be – I don’t anticipate that that last scenario will be common but it could be common after two years. So, we might see that somebody gets it now and two years from now, their immunity might wane sufficiently that they can actually get a pretty severe infection the second time.
So, I think those are the questions that we have to be asking, what exactly does this mean and not. To answer those, it’s just going to take time. We have to follow people over time, we have to see that they get infected now, we have to see what their antibodies are and then we have to follow them to see how likely they are to get a second infection. And when they get that second infection, how long after their first did it occur on average. And was it symptomatic or asymptomatic and did they shed virus.
So, all of that needs to be done and that just takes time, because we’re not, at this point anyway, we’re not going in and challenging people with the virus or not actually doing experiments and giving people this virus to accelerate that research, it’s more something that has to happen naturally. And we can study them, and these long-term cohort studies.
MODERATOR: Next question.
Q: Hello. Thanks for taking the call, Professor. I just wanted to ask you what you think the impact of summer weather will be on the coronavirus. A new study came out from MIT that suggests there’ll be some impact, but it won’t be enough to stop the coronavirus.
MICHAEL MINA: Yeah and I would agree with that. If we look across the globe, we have seen that this virus can transmit just fine in warmer climates.
So, in other seasonal viruses, we have a lot of pre-existing immunity in the population, whether it’s other seasonal coronavirus or flu and things like this. And so we actually see that if they come up in the winter, that they actually start to decrease, both because of herd immunity and the weather, you know, can, can have an impact on transmission and so those kind of work hand in hand to bring cases down to reasonable levels.
What we see in this case though is we have just a massive number of susceptible still and that is something we call the force of infection in epidemiological modeling terms, that force of infection is just so great right now because there’s such a separate pool. It might slow it down a little bit, relative to what it would be otherwise if it was sort of winter all year long. But I don’t anticipate that it will actually stop it. I think it could slow it down. But I think it’s going to be moderate at best because people will still be able to transmit it.
It might not live as long, for example, out in the environment during summer, it might not be as transmissible but if we go back to normal, I do think that we will see pretty consistent spread. One thing that could,
one thing that I might hope for is that if spread does continue into the summer, maybe a difference in the air quality will actually or the air sort of humidity will reduce the pathogenicity of the virus in us. So maybe it could be a less lethal virus, for example, during summer months, just because of the type of air that we’re breathing in and out.
I have no data to back that statement up but that’s one thing that I, you know, think could also happen, so that if infections continue, maybe possibly the mortality rates associated then would go down, but that’s kind of where we’re at. We haven’t seen the weather make much of a big difference in the past.
Q: Thanks very much.
MODERATOR: Next question.
Q: So, I would love to hear your thoughts about things governments could be doing to devote more resources to, you know, bring spread under control and more quickly. In particular there’s been some discussion of, you know, the importance of testing and tracing and some people argue that like a large increases in those will be our key to bringing the infections under control. How do you think about that versus other things that governments might be doing?
MICHAEL MINA: Well, I think that testing and tracing can be useful if done at the right times. I think testing is definitely needed. I think, though, that when local transmission is really widespread, just social distancing is kind of the thing, the best thing we could be doing what governments could also be doing though, you know, in the US. Anyway, we have no sense of public health laboratories. We barely have a sense of a public health system, to be honest. Our system, our public health system is essentially our private health system, meaning we utilize the hospitals and clinics to serve as our public health surveillance system. And that’s just poor planning. We can’t, you know, that doesn’t work in a big epidemic like this as we’re seeing. So, I think that’s something that governments should be doing right now and where resources should be going in particular because we do have some time. We keep squandering the time, so we just need to act.
And we need to build true public health systems to do surveillance in a fast way to be able to spin up a whole new surveillance systems and tests that, you know, have never been used before to be able to have the facilities and the structure in place to move samples back and forth. These are like having a true national surveillance observatory and laboratory is something that I think is really crucial and it’s something that that we are trying to develop now, which is essentially to create an immunological observatory where we can actually set up a system to be a true public health lab where we can monitor the current state of infectious diseases through antibody repertoires, for example, across the globe, or at least starting with Massachusetts and the country and using different tools that might be available to us. Blood banks and national donor systems, things like that are great ways to just be able to survey the population at large on a continual basis.
And then to go along with it, you just have to build the laboratory infrastructure to take in those massive numbers of samples and test them on a regular routine basis in the same way, we might monitor the weather That’s something we’re developing here at Harvard, and colleagues elsewhere as well. And I think that these are the types of big thinking projects that need to be really sponsored by the government, in my opinion, rather than a bunch of, you know, ragtag academics like us just trying to push these programs forward using anything from NIH grants to philanthropic donations. I think having real political support for actually making real public health systems get put in place and supported in a sustainable way is crucial.
But it does take a whole different philosophy about what testing is in our community in our, in our society. We believe the way our whole healthcare and public health system is setup is that testing is a medical intervention, and if it can’t be reimbursed by the Centers for Medicare, Medicaid services, it’s probably not worth doing, you know, or creating. And that’s a big departure from public health testing which, you know, really doesn’t exist outside of the blood banking system. And you do see it a bit. We test our blood supply to keep the blood supply safe.
But why not leverage that same blood supply to actually monitor for the presence of infectious diseases in the community on a routine daily basis.
I think that those are some big public health infrastructure changes that could be put in place where every state is actually monitoring their populace in a real public health way and then that same sort of facility could be set up for example, different ideas. I look at the Defense Department, and I say, you know, however much their budget is I can’t even keep track but, you know, it’s far too high number. I think, and it’s being placed into protecting against people, against bombs and things like that from coming into our borders. And that’s great. But what we’re finding through this epidemic is the potential for catastrophic effects from viruses are maybe much greater than the potential of some foreign power you know invading us or bombing. I think that, given the balance of these tradeoffs, we should actually be really supporting a true national defense from natural pathogens and, you know, I don’t see any reason why we don’t have warehouses full of Roche cobas 8800s ready to fire up if they’re needed to really do a lot of testing.
Some people might say it’s too expensive, but it’s peanuts compared to building an F 22 Raptor or whatever those jets are. So, I think that these are the things that we should really be considering as we think about like what the federal government in particular should be should be doing to protect us.
Q: So to ask a little more about the tracing question. Obviously, I understand why, you know, the social distancing is important right now because the tracing doesn’t work on its own. But wouldn’t having more people tracing still help to reduce the, you know, the R0 value and you know allow that the quarantine effort to work a little more quickly?
MICHAEL MINA: It can, it’s just a, it’s a balance of where the resources are going if somebody is saying, Okay, we’re going to set a contact tracing protocol up to try to capture all the infections that are happening, when point prevalence at any given time is 15% of the population, I don’t think that contact tracers could keep up with that. You know, you might put millions and millions of dollars into getting just a small fraction of the cases under control when you have exponential growth happening of the other 95% of cases. So, I think that yes, it might do some small amount, but relative to where those resources could go, I think, you know, I don’t necessarily advocate for contact tracing when prevalence is very high.
If prevalence is low, or it’s in a rural community and you can really stop small outbreaks, then great. I think it’s actually, it’s one of the top, one of the most important tools we have. We also have to ensure that contact tracing is being done appropriately. So, for example, I have had experiences where I have contact tracers calling me up to ask about some patients that were positive in facilities that may be have 30% positive individuals and they’ll call me up about somebody from 25 days ago who was positive. And that’s a futile effort. There’s no purpose to put resources into tracking down somebody who was positive 25 days ago in a center that had 30% positivity.
So, I think if we are going to be incorporating contact tracing, we need to make sure we’re doing it right and that the protocols are in place to ensure that we’re getting the most out of it. And many places across the country. I think are, you know, so for many people, it’s the first time contact tracing is being deployed in the US and in many areas and in this type of way. And so, there’s a lot of uncertainty about how to do it well, and we’re going to put the resources and we may as well have the right experts advising on it.
MODERATOR: We have one question left.
Q: Thanks for for fitting me in here. The FDA today cleared the first at-home saliva test. I’m wondering if you can sort of talk about maybe the advantages and the disadvantages of having a test like that at home, and if this is sort of the start of the future of diagnostics for this virus.
MICHAEL MINA: Yeah, so can you just explain, was the saliva test that was approved are you referring to just to at home collection and then send it in or was the test actually be done at home?
Q: From what I understand it’s a send it in test.
MICHAEL MINA: Yeah okay that’s. I thought you were saying it was something else. And I was surprised. So, I think this is good. I mean, I actually have one sitting – you can’t see it, but I have saliva collection tubes sitting next to me here.
I think that there’s a real utility of it, to just start being able to have people tested in their own home without having to go to the physician to get swabbed and things like that, I think, is safe and better if it can be done reliably and it can get sent to a test facility to get results. The one thing that I think needs to be put in place is it needs to just be explained very well to the individual what to do if it’s a positive or negative test. What does it mean, and what can they interpret. If people are getting clinical tests in the absence of a physician or a nurse or healthcare professional kind of advising on the interpretation of that, then there needs to be a lot of education, or at least opportunity for the individual to ask questions.
And so, for example, we are setting up a very large study now that will go live soon. And it’s going to be sending kits out to people’s homes in order to do large-scale surveillance of the population of thousands of people over time. And part of that will be saliva collection test kits and blood pricks for antibodies and things like that, the finger prick.
And, you know, if we can get those going, I think that they are useful ways to do surveillance, especially during pandemic times when we don’t want people coming into a center to get tested.
So that they can be as long as they can be done reliably and in good labs that have approved and invalidated the processes of collection. I think that they can be very useful tools.
Q: Is there a concern about the time that it takes you know you were talking about the difference between, you know, get it done at home versus send it in the lab. I mean, is there a concern that the labs might take, you know, with longer than normal, or that might be a backup or something that, you know, might be, you know, easier solved and just having done yourself.
MICHAEL MINA: Well, the labs may well have a backup and we’ve been seeing that anyway. My anticipation or hope is that labs will start to be able to get much more rapid with their turnaround time taking a saliva sample. FedExing it to a lab though could actually be just as quick as going through a drive through right now. For example, the longest delay that we have in our setups that we part of the some of the setups that we run.
In Massachusetts, it’s actually not the laboratory that the delay is happening in, at least in our facility at the Broad where we have very high fast turnaround time. It’s actually getting the sample to the Broad, to the lab, can take a very long amount of time and that’s because it has to you know get carried and wait in this place and then get moved to this place and then eventually it gets to the lab.
So, in some ways maybe taking a saliva test, having a FedEx delivery person planning to pick it up at 3pm that day and deliver it to the lab that night and having result by the morning can actually become a pretty efficient process. So, I’m not so concerned about that as long as the processes are put in place.
This concludes the May 8 press conference.