You’re listening to a press conference from the Harvard T.H. Chan 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 11:00 a.m. Eastern Time on Monday, June 15.
Transcript
MODERATOR: Dr. Mina, did you have any opening remarks?
MICHAEL MINA: I don’t, I’m happy to take questions.
MODERATOR: All right. First question.
Q: Hey, Doctor, thank you for taking time. I appreciate it.
MICHAEL MINA: Sure.
Q: So Massachusetts recently in the last couple of weeks started disclosing how many antibody tests are being performed each day in the state. But there have not regularly reported results, if you will, of how many are showing antibodies. I know there’s been some questions raised about the reliability of these tests, but I mean, how important, I guess, two-prong, is it? How quickly do you like a meaningful amount of tests? So we have a good sense of what antibody tests can show, but how important is at this stage for the state to also disclose sort of the results of it and how much they’re actually, you know, how many people are finding antibodies?
MICHAEL MINA: Yeah, so as we’ve seen with a number of different attempts at this so far, releasing the data can go awry. When you’re using antibody data, what you’re really trying to do is two things. One, you’re trying to understand how many people have been infected with this, the seroprevalence and how many people are been hit by the virus. And then also potentially trying to figure out what people’s immunological status is. The latter part generally is not reflected at the moment in the tests because they’re generally qualitative meaning yes/no, instead of a quantitative number. But the former question is what you’re getting at. Which is what is the seroprevalence and what we’ve seen in other locations and what is often the Achilles heel of seroprevalence studies is you really need to be doing very representative sampling. Otherwise the results that are released can be very, very misleading.
And it’s sort of similar an idea to the beginning of an epidemic when it looks like mortality is very, very high. But it’s because you’re you’re selecting for for just the sickest people in, for example, back in January in Wuhan. And so in this case, we want to make sure that we’re not selecting antibody tests that come from populations that are at particularly higher risk or lower risk, and then having people extrapolate that onto the whole population. So what we need to do is develop very representative samples. And how you do that is actually an art form and a science unto itself. And it’s similar, for example, to doing political polling. We don’t want to go and just ask one small group of people and then extrapolate that to the country, want to make sure we’re getting representative sampling.
The same exact idea follows for a serological sampling. And at this moment, I would say that most of the serological studies that have been performed. Well, I would say probably all of them have had problems in their representativeness. And so before those results end up getting released, we need to understand how to interpret them in the wider context of the state. And because we don’t want people to misinterpret them and then make decisions based on what the their believed seroprevalence is, when the reality is the whole actual number could be quite different.
So what we’re doing anyway, I can speak for ourselves, is that we’re developing a platform to perform very highly representative studies of people across the state of Massachusetts through a platform we’re setting up in association with Harvard. We’re going to be recruiting people into longitudinal sampling. And we estimate that around 5000 or so people, if we recruit them appropriately so that they represent their communities in many different shapes and sizes, that that 5000 to 10000 will be a sufficient number in the state to follow over time for a seroprevalence studies. But until we really get these well represented in studies, as much as I think that the data is interesting to see, it really runs the risk of being misinterpreted.
MODERATOR: Did you have a follow up question?
Q: Yes, I did. I mean, perhaps it’s like you mentioned, it’s who you’re testing. And so far the state has disclosed that they’ve performed, or at least there have been performed more than fifty thousand antibody testing. But is it not so much the number, but sort of the second layer? Well, fifty thousand is a large sample. But who did you test in that? I mean, its 50000 enough, I guess. Or is that still problematic, given it depends on we don’t know who those people were?
MICHAEL MINA: Well, yeah. So fifty thousand is a large number for sure. But if, for example, all of them came from, I don’t know, one town in Boston, obviously that’s not what went with where they all came from. But if they all came from one little sector, then they would not be representative. So I think that what would need to be happen for me to feel comfortable about that data, I would probably want to see where have, well, how is it all collected? Was it only collected, for example, amongst people who were showing up because they thought that they were sick or thought that they had been sick, in which case it’s a hugely skewed proportion of the population. I mean, it’s a hugely skewed population to try to do seroprevalence studies because it would be enriching for just people who thought they were sick.
So you might sort of overestimate by large margins. So until you kind of can discern who those fifty thousand are, using it for public health to understand how to allocate resources and where where we should be expecting the most numbers of cases in the fall, and there’s a lot of really, really important components and uses for serological studies and for serology in general. And until, you know, if it’s just all made up of convenient samples, though, and you don’t know anything about sort of why the sample is taken, then it is very difficult to discern.
Q: Thank you very much.
MODERATOR: Right. Next question.
Q: Hi, Dr. Mina, thanks for taking my question. I want to ask about primarily about diagnostic testing, but also I suppose if there’s a role for antibody testing on this. You know, we’re in the middle of June now. We’re still falling short of a lot of projections of where we’re supposed to be in terms of testing rates on the higher end ones where, you know, it’s staggeringly like 10 million a day. But we’re also falling short of ones that are closer to like nine hundred thousand, one million a day. I’m wondering at this point, you know, because it seems to be like the momentum to try and increase testing very aggressively has started to sort of fade and we are already starting to see many state economies start to reopen. I’m wondering if there is any kind of sense of how to sort of revise those testing projections into something that’s more measured and more practical at this point moving forward. And if there’s maybe a new minimum that we should be striking for. And beyond that, if there’s maybe some kind of new strategies for how to focus the sorts of limited testing moving forward.
MICHAEL MINA: Yeah, I think we have to consider it. For testing, too, because we’re in the middle of an outbreak locally and we’re just trying to do the testing and the contact tracing and get everyone discovered and isolated and quarantined, then that can, if the outbreak is very large, then we just need extremely high numbers of tests to get it done. And that’s kind of where we were. A lot of places, not everywhere, but at least in Massachusetts and other places, we are seeing cases continue to decline as a result of our efforts to social distance and wear masks and and open up more slowly. And I think that that is allowing us a little bit of leeway in terms of how we utilize tests.
I think that once, we will probably see a lull a bit in terms of what the numbers of tests that are required overall, as long as we continue to see cases go down. But I would warn that we should not allow the testing infrastructure being built to necessarily go back to normal. The problem is these tests are expensive to keep the infrastructure developed for because it is, usually for most laboratories that perform these tests, it means that they are not performing other tests that would originally be being performed. And so there’s a tradeoff there. So how to keep the laboratories, in particular the for-profit laboratories, willing to to keep building the capacity when demand is apparently going down is a very difficult task.
That said, I think that we’re absolutely going to need the testing come the fall and sooner. As businesses are opening, many of them are making testing a central part or at least wanting to make testing a central part of how they keep their employees and their constituents safe. So I think that there is room to revise what the testing capacity should be. But in reality, right now the testing capacity is largely not being utilized to its maximum. And so I think it does take some projections into the future to say this is, what will testing look like next week, next month, and then, you know, six months from now. And hopefully that message can get through and testing capacity could potentially even continue ramping in preparation for the fall, despite low demand now. But it’s a very hard thing to ask a company to do. And most of the testing that’s done in this country, unfortunately, you know, a lot of it’s done in for-profit settings and some and not a lot of it also in the hospital settings.
But the not-for-profit and hospital settings have to go back to their daily routine of testing with all the other tests as outpatients start to come back in and things like that. So it’s going to be a very difficult task to keep capacity high if demand isn’t there in the immediate threat, isn’t there. But I think, you know, from a public health perspective, it might not be immediate today, nationwide. But I think, you know, it’s pretty much immediate in terms of the threat that is upon us in the fall, I think. And so how to encourage that is a pretty difficult task then.
MODERATOR: Did you have a follow up?
Q: I guess just along those lines, is there anything that we can do to encourage further demand? Is there? You know, it is just more practical efforts, like a call-out to the public to seek out testing. Do we need to have public health authorities do a better outreach with the communities?
MICHAEL MINA: The whole conversation has up until very recently been about viral testing. And viral testing is absolutely crucial. It’s absolutely essential. We need it to be available. But it’s not necessarily the most efficient test if prevalence is low because essentially even if people become asymptomatically infected, you might not catch them by the time you test them. And there’s a lot of problems there. We need to keep that capacity. But in general, we don’t necessarily want to just be testing everyone. There’s decreasing utility in it if prevalence is low and in a place like Massachusetts now, prevalence is getting quite low, which is very good, of course.
There is a role also for serological testing. And the reason why that is important. A bit to Matt’s question earlier, serological testing gives you a lot of information, not just about what’s happening right now, but it can give you a sense of what’s happening now with a few days delay. But it can give you a lot of additional information for what has happened to allow you to allocate resources, to allow you to know the trajectory and where the highest risk and most vulnerable sort of populations are. So I think that we should be building serological capacity along with building the viral capacity.
And I think in peacetime, I would say that, meaning when prevalence is very low, I would say that serological sampling is actually a very powerful tool because it gives you a lot of useful information for public health decision-making. And then in crisis mode, everything has to switch to viral testing where we’re trying to monitor and track people with the infections at that moment. So how to balance those? I think both need to continue being put out there, whether it’s through subsidies and grants from government, I think should really be helping to fund the infrastructure for some of these testing regimes.
MODERATOR: Next question.
Q: Thank you so much. Michael, I wanted to ask you about the serological testing and we’ve seen some recent data come out about the range of antibody titers that we’re seeing in convalescent plasma, for example. So I wanted to just ask you about how we can interpret that data and what that means as we go into the fall. And as people, you know, start looking to antibody testing, serological testing as a proxy for immunity. How can we interpret those results? And, you know, what are the gaps in understanding what those results could mean?
MICHAEL MINA: So the results will be useful. At this very moment in time, understanding exactly what the correlates of protection are is not well-defined. But there are increasingly more and more studies that will come out that will show that, for example, in this particular test or looking at antibodies against this particular protein, then when you’re above a certain amount on an ELISA-based assay, it suggests that you’re protected based on neutralizing acids. So once we start getting more and more information and this information will, it is being curated now and collected and studied. It will be useful.
At the very moment, I think people have been a little bit down about antibodies and their utility, because the whole field is mirrored by problematic tests that came out first. And that was the first time a lot of people in the media and a lot of people in the public had ever even heard about antibody testing and serology. And so the first introduction of it, and in the same way that a lot a lot of people are just getting introduced to the whole field of infectious disease epidemiology and testing throughout this pandemic. The first introduction of it was through these really poor performing tests, and it essentially made a lot of people lose faith in the role of antibodies or just not be interested in them. But we know just how important it is to do serological testing, both for prevalence and surveillance like I was mentioning earlier.
But what you’re bringing up is using it as a true proxy for immunity, for who is protected, who could potentially transmit the virus. And how can we use that information to our advantage to better understand what people maybe can mix with other people during work-life and things along those lines. And so we just have to be a little bit patient and let the studies come in. These are not rapid studies to perform. We have to wait and see what levels of protection, different levels of antibodies provide by monitoring people over time and seeing if they have a hundred units of antibodies, does that mean that they generally don’t get infected in the future if they’re in a high-risk location? Does just having the presence of any antibodies generally mean that somebody does not get reinfected or is there a higher threshold?
And we’ll have to keep doing antibody testing into the future even when a vaccine comes about, because we’ll have to know where to allocate vaccines to, who needs them, who has already been exposed and infected, and maybe it doesn’t necessarily need a vaccine. And then we’ll have to be monitoring the waning rate of antibodies over time, which we anticipate will occur. So the infrastructure for antibody testing needs to be built up, even if right now we’re not seeing the immediate benefit beyond seroprevalence, it will be there quite soon.
MODERATOR: OK. Next question.
Q: Hey, thanks for doing the call. It seems as though in some places where cases are surging, governors and the President himself have suggested that it’s mainly a function of the increase in testing. Just want to know if you can comment on what extent that appears true or not true and if there are other more useful metrics like positivity rate for hospitalizations that we should be looking at. And what parts of the country maybe worry you the most in those regards? Thanks.
MICHAEL MINA: So I would say that was the case last month or a little bit longer ago. And essentially now what we are seeing real increases. In a lot of places where testing itself is increasing, we’re still seeing cases go down, we’re seeing population rates go down and positivity rates go down. In other places in this country, we are seeing them go up. In many of these spaces and locations or regions, it is not just a result of increased testing. We’re seeing increased hospitalizations. Florida is continuing to increase in terms of cases, for example, as one state, and other states as well. These are, I think, monitoring hospitalizations, is of course a good proxy for what’s happening in the population. It’s a very narrow window. You’re only getting the tip of the iceberg if you’re looking at hospitalizations and cases. But you can infer what the overall qualitative dynamics of the epidemic are doing in each state and in each location. And it’s no surprise that the States that have opened up the quickest, that have opened up with the most force and the States that maybe didn’t ever put in the same amount of restrictions and social distancing, those are the States we’re seeing the greatest numbers of cases increasing.
And so I think that while there is some very limited argument to say that today, places with cases that are increasing come from increased testing. For the most part, we’re seeing the qualitative dynamics in terms of hospitalizations are correlated with increased cases, regardless of the changes in the numbers of tests. And so in those places, I think, unfortunately, it is suggesting that, you know, some of the safeguards in some of the early control measures are are breaking down.
MODERATOR: Next question.
Q: Thank you. Michael, I just wanted to ask, since we don’t know exactly what results of antibody testing means as far as immunity goes, how should providers be sharing that information? It seems like, at this point the number, the antibody results is sort of half the picture. So what’s the most responsible way that providers should be sharing antibody serological test results with folks who get it, since I think most people would be interested in, does that mean I’m immune?
MICHAEL MINA: Yeah. Well, I actually would say that a lot of people are very interested in wanting to know if when they had symptoms back in March, they were actually infected regardless of the immunity picture. So on the one hand, there is a desire to know. And that absolutely just makes perfect sense. If you think you’ve been infected, you want to know. This is a looming question that probably millions and millions of Americans are asking themselves every day today. So on the one hand, I think having the tests be available for consumers and for patients is just the right thing to do. I do think that the messaging needs to be very clear. That what the antibodies mean, that somebody has. A lot of people are even getting quantitative results. Most of the tests that are performed today are just giving binary results. Do you have antibodies or do you not? And so that can be very useful. I would say that most people who have antibodies will have some level of personal protection and that personal protection will also mean that they probably will not be, if they were to get infected a second time, which we still don’t know how frequently, we know it can happen rarely.
We don’t know if it ever happens routinely. We can use that information to be able to say that if somebody were to get exposed a second time, that if you have antibodies, probably the viral load that you would develop would still be much lower than somebody without antibodies on average. So I think that there is a utility, even without knowing the quantitative value, without knowing somebody’s pure, sort of, risk. I do think that it’s okay to to have that information in mind. I would encourage any physicians giving that information to patients, or individuals for going and getting these tests without necessarily speaking directly with a physician, to just recognize that it’s not a foolproof test. If you are infected and if you’re positive, I think we just have to continue being smart. We have to continue wearing masks. We have to continue trying to, you know, social distance and mitigate, spread as much as we can, regardless of our antibody response.
But having the knowledge, I think, doesn’t need to to mean that people go out and party as though they are not immune. It just can be handled with maturity and responsibly and saying, let people know that they have been exposed, they’ve been infected, and probably they’re at lower risk for severe infection. And, you know, some people are trying to make very difficult decisions. Do they start to see their elderly parents again or let their kids see their grandparents? I think that, you know, whether you have antibodies or not, it’s not going to be foolproof, but it might give some sort of information that could help people make more informed decisions. And it can also help us to understand at a public health perspective when we’re looking, for example, in nursing homes.
I’d say even if we’re not giving each individual their results, we could potentially look at the prevalence that’s happened in the nursing home and understand not just individual level risk. But what is the risk of another massive sort of explosion of transmission within a given location or within a given institution. And if it’s already had 60 or 70 percent of people infected, then maybe, at a more population level, it provides you a little bit more relief, that maybe you shouldn’t necessarily expect the massive outbreak again in that location. So individual level antibody results do inform population-level results. So there’s lots of reasons, even though the analysis of these is still imperfect.
Q: Right. Thank you so much, sir.
MODERATOR: Next question.
Q: Thank you so much. I was wondering if you could talk about the balance of contact tracing and social distancing. A lot of European countries are moving ahead with opening restaurants and even fully opening schools. Could you talk about how risky this is if you’re unable to keep kind of very strict social distancing measures and if you have a robust contact tracing program and testing program in place, can you begin to kind of ease up on those social distancing measures?
MICHAEL MINA: I think the key is to get prevalence very low first. If we start to open up and prevalence has not gotten very low, then we’re feeding a fire that’s already burning brightly. So that’s going to be very difficult to control what happens as a result of opening up. Even if you open up responsibly, in case this is already happening, then you’re setting yourself up for failure. I think driving the cases down very low, for example, to get the prevalence to maybe two per 100,000 in a given state or location before starting to open up could be a responsible way to start being able to open up different stores and restaurants and things like that in a sort of a combed out way where you have fewer tables, you keep people’s social distancing.
I think it can be done. But we have to have the monitoring in place. That monitoring will be monitoring hospitalizations, continuing viral tests and continuing serological tests. Along with that, as you mentioned, if you have contact tracing in place and I think there’s a lot of room for new types of contact tracing to be put in place. The introduction of mobile phones, we still do contact tracing in a pretty sort of traditional way where we go and talk physically or on the phone to somebody who’s been infected.
We try to ask them to recall everyone that they’ve been in contact with, which is very difficult, particularly in urban areas where people are walking on the street, and in Starbucks or whatever a restaurant or store they might be in. We need to understand that people will not know all the people that they have been in contact with. So that’s where I think there can be discussions, if it’s possible to use technology on our side to be able to contact trace very rapidly by leveraging the mobile phones that we all walk around with, as one example. And there’s lots of privacy issues that come into play. And I won’t pretend to understand most of those issues well. I just know they exist and they need to be accounted for.
But the point is, if we can have contact tracing that is setup to deploy extremely quickly and comprehensively, then I think between having the testing on board, the contact tracing efforts on board and ready to deploy when cases come in, I think that puts us in a very good place for being able to start opening things up with an acceptable level of risk relative to the risk of not opening up in terms of the public health economy. And so I think we can do it. But the first step is to really make sure prevalence is very low.
MODERATOR: Did you have a follow up question?
Q: Yeah. Just really quickly. Also on the recent clusters found in China and the effort to bring potentially tougher measures into Beijing. Do you think that’s an overreaction to the under a hundred new cases found there?
MICHAEL MINA: I think if this virus has taught us anything, there is no overreaction to it. I think we have to be smart. We have to not collapse our economies, but I remember months ago, back in February, I I penned this op ed that I never submitted, it was probably going to go to one of your places. But I wanted to call it “You’re not being melodramatic about the coronavirus.” Because at the time, there was a lot of people saying, “Oh, you know, you don’t need to close down. You don’t need to stop shaking hands. That’s too much. And that’s overreacting.” And I don’t think that you would have asked me that question as an example, and this is no offense or anything, a month and a half ago, we would have been assuming that we need to do everything we can. If there’s any cases.
And so as things start to become more peaceful, people start to revert back to their regular way of thinking. And that can get us in really hot water. And I would say that there is no real overreaction to this virus, it has the potential to do extraordinary damage to our society and the key thing is to keep cases from getting out of control as best we can. But we have to have epidemiologists speaking to economists, speaking to policymakers on a routine basis to ensure that we’re doing it smart and we’re doing it in a way that that doesn’t endanger having the economic toll and the cost of that be greater than the virus itself.
Q: Great. Thank you so much.
MODERATOR: Next question.
Q: Thank you for taking the time. Really appreciate it. Can I ask you what your concerns are, if any, about the resumption of large scale indoor events, such as a rally in Tulsa, Oklahoma, on Saturday?
MICHAEL MINA: Well, without speaking too much to the specific rally you’re referring to, I think it’s very dangerous right now. I mean, we’re still talking about spacing restaurant tables apart and thinning them out by, you know, two thirds to not have transmission. We’re still talking about only opening up, you know, different facilities where people can sit outside in small groups of people. And that’s smart at the moment. The idea of having a rally is not smart. It doesn’t need to happen. I think there are some things in society that have been sufficiently important recently, and of course, this is my personal opinion, not one borne of epidemiology. But there have been some events outdoors recently with a lot of people that I think, there are times in history when the moments have to be seized and there have been, with the protests. those have been outdoors, those do run a risk. But at the very least, they’re outdoors.
And I think there is no other way to have had those happen. To have an indoor rally intentionally at this very moment in time is just not smart. It puts people at risk. Especially if a large fraction of the people who attend are older, above 50 years old, not that above 50 is older. It’s not elderly, but it’s still a higher risk. And above 60 is much higher risk and. And I think that it is liable to cause deaths. And, so what rally is worth people dying. I just don’t know.
Q: I guess also, we’re seeing the emergence, I guess, of the delayed first wave in a lot of states. What do you think is driving that? These are states in many cases that had really low case totals as compared to, for instance, New York and Illinois until a month ago. Is it that these states might have a false sense of confidence in their reopening and then just sort of getting the delayed impact? Why are we seeing the Arizonan’s?
MICHAEL MINA: I think what you said is probably accurate. I do believe, especially the places that didn’t have many cases, despite not doing a tremendous amount of social distancing, probably felt you probably didn’t necessarily see the great benefit of it. Some more rural areas needed more time for the virus to sort of enter into those communities and start really taking off. And I do think that it’s the more relaxed social distancing measures, the more lax precautions and the real drive to open back up that is probably resulting in this sort of delayed wave of cases. And it’s not just a wave.
I think that what we’re seeing in a lot of these places is in many cases, the first wave of this epidemic is still upon us in many of these places. And it’s just been growing slowly. And as social distancing measures have been lifted increasingly and many these areas we are seeing that no place is immune to this virus. And it will travel where people travel and for places that are a little bit less densely populated, for example, than New York City, or Boston or Seattle, then we will see a delay in terms of large numbers of cases.
But that shouldn’t be confused with the idea that cases cannot become out of control. And I think we’re unfortunately starting to see some places beginning to brim in terms of their health care facilities, whereas a month or two ago they might have said we didn’t have many cases. And some of these areas, now they’re starting to see this slow creep up that can quickly, unfortunately, hit a breaking point, at which point new cases outstrip medical resources. And then these places could quickly find themselves blindsided a bit and have to go into crisis mode.
Q: And finally, thank you, can I ask what sort of stage of the pandemic do you think we’re in? A lot of the discourse seems to reflect, we’re sort of over the hump and pivoting to reopening. But in many communities, it seems like we’re just at the early stages. How far through this are we?
MICHAEL MINA: We’re still at the beginning. We’re not through this. The US is a huge country. We like to look at the US as a country with numbers that, you know, but we are essentially the size of Europe. You know, you could think of some large states as as countries. And when you think of it like that, we’re not evaluating Europe as a whole. We’re evaluating Europe per country. And we should be doing the same here. States have their own policies in the United States. And States have their own social structure, physical social structure, as well as personal social structure. And that means that we’re seeing very different and heterogeneous dynamics in different parts of the country at any given time.
And we will see that some places have, we saw clear spikes like in New York and Massachusetts. And we have gotten over that first of what will probably be multiple humps of this of this epidemic in some places. Didn’t yet see that. And they are just slowly increasing and increasing. And so I think that we have to take each state separately and some of them have not yet experienced a critical mass of cases that put them into jeopardy from their public health and their health infrastructure. But it can get there, if the virus is allowed to go unchecked. So I don’t think we’re in a place where in many different places with this virus in this country.
MODERATOR: Next question.
Q: I really appreciate this. I wanted to ask Dr. Mina, about testing in nursing homes. A month ago, you were talking about the role you had in the Massachusetts effort. I wondered if you could give me an update on how that baseline testing has gone. You were emphasizing that it’s not a good idea. It’s not enough to just do baseline testing. Florida has now moved toward testing all residents and staff in homes. That’s where they’re stopping. And it’s just PCR. I know you’ve talked about the importance of also doing antibody testing. So my question is, what is the best protocol, in an ideal world? Where should we be in a testing protocol? And what is it going to take to get to that point so that we can start allowing visitors back in nursing homes?
MICHAEL MINA: So I think that the type of testing we’re doing within a given nursing home should be dynamic and it should be adaptable to what’s happening in the community. If you’re in a nursing home in some part of the United States and that community has not seen a single case of the virus, do you have to be testing everyone every single day, for example? Probably not. But if you’re in a region where where cases out in the community are abundant still, then you probably need to have more frequent testing. I think that having a single baseline test, I won’t harp on that effort. But I would say that for many nursing homes, I think there should be continued monitoring for cases.
There should be very low bars to ask a staff member to not come into work if they are feeling any sense of illness, and to go get tested instead. Maybe the nursing home that they work in, or if they’re a part of a union, can offer that type of testing to them. A lot of nursing homes, still don’t have ready access to testing. When they do, they’re still getting delays of a day or two before results come back in certain parts of the country. And so if you have a delay of two days, then that really doesn’t do much if you’re allowing somebody to work during that period of time. So to ensure the safety of the residents and the staff in nursing homes and other senior care facilities as well as a community, I think the access to testing has to be there. The leadership within these nursing homes has to feel empowered to be able to do the testing when they need to in a way that can return results quickly, in a way that can allow them to continue functioning.
Whether that means that they’re doing testing of everyone, or a subsample of everyone, every three days or every week or for two weeks or or not at all, and waiting until there’s some reason to test. I think that there’s a role for any of those different options as long as it’s done, recognizing what the risks are, what the what the flags are to change the testing strategy on a moment’s notice to say, you know, we’ve been testing everyone every week or two, but we’ve we just had a case that we believe may have spread to other people. We need to go in and test everyone tomorrow. If you can have that type of ready access to expanding and contracting the testing frequency and amount. I think that is how we need to be able to adapt to this virus, because there will be long periods of time when things are quiet.
And if we’re doing very intensive testing during those periods of time, people will get burned out and finances will get depleted. So we need to figure out how to do it in an intelligent way. The reason I think that antibody testing can support viral testing is because it can allow us to know who is at risk. It can as especially as seroprevalence continues to increase across the population with increased transmission events and of course, if vaccines come around, then serology can really help us almost forecast where this virus is going to go, by looking at where the gaps in immunity are.
Sometimes those will be in specific nursing homes. Sometimes they’ll be in specific staff members in the nursing homes. And so you can potentially use that knowledge to know who is at greatest risk. And maybe you can allocate where they work and who they work with appropriately. But I think the main message I would like to get out is that there is no perfect testing strategy. Everything comes at a cost, both person time and money. And I think the main point is we have to figure out how to be adaptable. And to be adaptable with our testing, We need everyone to feel empowered and know exactly where to go to get testing when it’s needed.
Q: How do you feel about rapid testing?
MICHAEL MINA: I think it’s great if it comes on board. I think rapid testing can be one of the ways to really stop. In general, I would say rapid testing as a long term sero-surveillance program might not end up being the most efficient. It’s appealing and enticing to think that everyone in America will test themselves every day. Maybe that will happen. But that would be a long shot, I would say. If institutions, it should be a part of this dynamic testing process, if you see an outbreak, maybe you have on a routine basis, you’re sending out serological testing and you’re sending out virological testing to a lab that’s a little bit cheaper, for example, to do the test in bulk. But it’s a slight delay.
But if you see an outbreak, maybe then you have point of care or rapid tests right there ready to deploy. Now, of course, if the point of care or rapid test can become cheaper than laboratory based testing, and reliable, then I think, of course, that’s the best of both worlds. And once that happens, and I do think it will happen, then that will become the future. How frequently people will use it is still going to be adaptable, still going to be cost constrained. But once they exist, I think they’ll be game changers.
Q: Thanks.
MODERATOR: Next question.
Q: Hi, Dr. Mina. The NBA has decided to restart its season at a closed campus, Walt Disney World Resort. Some have referred to it as a bubble. They plan to administer daily testing for its hundreds of players and staff with a 10 day mandatory reentry quarantine if you leave campus. That seems sufficient. But one of the biggest question is whether the hundreds of Disney support staff who are currently allowed to leave and enter or leave and return to their families as they please, be it culinary, housekeeping, custodial staff, the question is whether they will need to practice the same strict regulations or whether you think social distancing and temperature checks for the Disney staffers will suffice to protect the NBA’s restart. So how would you recommend the league handle the Disney staff it needs to operate. And do they have to be on the same level of daily testing as the athletes and staff?
MICHAEL MINA: I wasn’t familiar enough with the program, I had heard about it. They’re testing just for ten days and then what are they doing after those ten days?
Q: They’re testing the players and staff. I believe every day or every other day upon entry into the bubble. And they’re also testing them before they fly into Orlando. But the Disney staff are a separate issue. They are subject to the union’s guidelines, which are temperature checks upon arrival at work. And there’s some worry out there that if players or staff are interacting with these staff members, that it will kind of puncture that bubble.
MICHAEL MINA: I’ll answer the question, but I do want more clarification after about what they’re planning to do after that first reentry period. But the short answer is this virus doesn’t stop at basketball players and coaches and teammates. This virus will transmit to anyone who is susceptible and gets in its way. So, of course, I think that if these staff members are, and they’re essential to the normal functioning, I’m sure. So if they’re going to be in a location, then that is clearly a way that the virus can get into the space.
And I would say that they should be offered very frequent testing as well to make sure that they are safe, that they’re not bringing cases into the bubble and they’re not bringing cases back out of the bubble as they occur. And it’s just the right thing to do. So I do think that if the effort is to get it to a point that after the reentry period in particular, that testing frequency declines overall amongst, in this case, the basketball players and teammates, then that that’s a clear risk that the virus could start spreading unabated as it comes in from a staff member. So one question I had is after that, you said that there was a 10 day period, are they planning to continue testing the teams after that reentry period?
Q: Yes, so I’ll give you an example, if a player needs to attend a personal matter outside of Orlando and fly to Los Angeles and come back, they would be subject to a 10 day quarantine bubble. And then, you know, daily testing for that. And then after that, they are still going to undergo daily testing. So 10 day quarantine will only apply to if you say get a hall pass and you can leave and come back. You would be quarantined for 10 days.
MICHAEL MINA: Yeah. That makes more sense. So, you know, the answer to your question is very clear cut. I would say that the staff members are clearly able to pick up the virus just like anyone else, and they should be tested just like anyone else who might be entering that bubble.
MODERATOR: Next question. There we go.
Q: Thank you. Thanks so much. I was wondering, Dr. Mina, if you could talk a little bit, a little bit more about what you called that art and science of representative sampling at the beginning. You know, for a seroprevalence study, what is the best way to recruit volunteers and make sure that you’re getting a representative sample?
MICHAEL MINA: So you need good databases. So the census type of data is very powerful. It’s a little bit difficult to get access to, but it can be very powerful data to be able to build representative samples. And it’s very similar, for example, to how politicians will poll. You don’t want to just go and call a whole bunch of college students in a small state and then assume that their responses reflect the state as a whole. So you want to know sort of what are the demographics of individuals who want to you want to understand what’s the sort of demographic of the region you’re trying to poll or in this case, test, and ensure that you have some balance that reflects the right frequencies of those individuals in their communities and in the larger community as well. And so a lot of it would come from political type of databases, which generally are where a lot of these things live.
But also the Census Bureau. Those can be a powerful source of information. If you don’t have access to that, you can go out and there are institutions that perform this kind of work and they’ll essentially go through and find random people from from essentially, like opening up the White Pages and picking random people and calling them up and based on who you end up getting as respondents, then devising a pretty representative sample that looks like the makeup of the community at large. So there is a lot of effort that needs to go into building a good representative sample. But once you have it and you can follow them and sort of recruit them into a long term study like we are trying to do, it can be very powerful moving forward and for a State, for example, in an efficient way, be able to monitor the larger sort of dynamics of the virus.
Q: And can you talk a little bit more about the shortcomings of the seroprevalence studies that have been done to date?
MICHAEL MINA: Many of them were based on, for example, going and sitting on a sidewalk and asking people to give a drop of blood. So there were there were problems in two parts. One, many of them were just not representative. They were very localized. They went into areas a lot of times that were underserved and offered tests or areas that were overserved and offered tests. Hospitals are a biased population to do testing in, for example. And then a lot of the test themselves early on, we’re just poor. They’re poor performing tests. They were off in their accuracy. Whereas now we know that the accuracy of some of the laboratory-based tests approach a hundred percent sensitivity and 99.6% or 99.8% specificity. So we know that most of the results that we’re receiving now from laboratory-based tests are accurate. But those early tests, really caused a lot of problems earlier on.
Q: Thank you.
This concludes the June 15 press conference.