Coronavirus (COVID-19): Press conference with Michael Mina, 09/04/20

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 12 p.m. Eastern Time on Friday, September 4th.

MODERATOR: Dr. Mina, do you have any opening remarks?

MICHAEL MINA: Nope. Happy to take questions.

MODERATOR: Great. First question.

Q: Hi. Thanks very much. I guess I have an epidemiological question for you. And that is, I guess, in your mind, like what should the goal be right now for the U.S. in terms of controlling infections? Because I think and I asked because, like at the beginning, I think everyone got on board with the idea of flattening the curve to sort of preserve hospital capacity because everyone realized that would be really bad if health systems got overwhelmed. But now that that’s not the most imminent problem, I think people still look to hospital capacity to be like, well, as long as we can take care of enough people, of everyone who might get sick, that’s why we can have things like college football or gyms open or things like that. And so I guess like what should be the goal, really? What should be the metric we’re looking at and how would we get there?

MICHAEL MINA: Getting everyone back to work, I think should be the goal. And back to school. So how we get there appears to be somewhat philosophical but I don’t think it actually is. We need to get ensure that outbreaks are not occurring and we can tolerate small numbers of infections; we can’t tolerate outbreaks, and we can’t tolerate putting vulnerable people like nursing homes at risk. And so I think our goals should be, and really should have been a long time ago, protecting the most vulnerable individuals first and foremost, and having the right systems set up to actually detect and tackle viruses, the outbreaks of this virus, as they start to emerge. Is there an actual numerical value that is going to necessarily be that if contact tracing is going to be our approach to tackling outbreaks when they come about, then we have to keep outbreaks in it in a sufficiently small number that contact tracers can keep up. That number is very small, though, because these outbreaks can quickly get away and get out of hand. So I think a different outcome is to just suppress the virus at the community level through new means. And this is essentially the idea of developing some sort of herd effects.

The vaccine, should it come about, one of the major goals is not just to keep individuals who get vaccinated healthy, but to stop the overall transmission of the virus throughout the population as a whole through a herd effects and, in that case, that herd effect being herd immunity.

I think we can do very similar things through a major push for at home testing. And I think that that’s another way that we could – daily frequent at home testing, especially in hotspots, is a way to keep the virus under control, keep it at bay and essentially suppress it at the community level so that we can continue to go about our day and make new exposures or new outbreaks so rare that we are not consistently concerned about who is sitting next to us at work or at dinner or are there children going to school who are infected. We want to make that absolute risk extremely, extremely low so that we can actually get things back to normal. So I don’t think it’s just about the hospitals. It’s really about ensuring that community spread does not persist when it starts to occur.

Q: Thanks very much.

MODERATOR: OK, great. Next question.

Q: Hi. Thanks so much, Dr. Mina. I just wanted to ask so it looks like the seven day average has been hovering in like this forty thousand something, you know, arena for a bit now, which obviously is still really elevated from what we saw back in, say, May when I think it was more like the 20s. Can you talk about that we’re still seeing, you know, this elevated number of cases. I’m looking at the average, you know, because it smooths out the anomalies. But can you talk about that? Like, are we still at a really bad place because of that metric or what are your thoughts?

MICHAEL MINA: We’re definitely still in a very bad place. Yes, we still have almost a thousand people dying every day with COVID. It’s, you know, it’s crazy. I often like to think back about, you know, where things were as people were watching the outbreak emerge. You know, when you’re seeing exponential growth on a daily basis, it was very clear to everyone just how many cases were happening because from one day you have eight hundred cases and then a thousand and then fourteen hundred, then you passed the two thousand mark. And we have unfortunately, because we already went through the exponential growth, this plateauing seems to be sort of – it should be viewed the same way as if we were still seeing a major increase at that number in the same way that we felt back in April or May as cases were really, or April, really, as cases were still climbing. We should be feeling that sense of urgency to tackle this virus every single day right now. If people weren’t dying, if we didn’t have a thousand people dying of this virus, I would maybe say something different. But the point is, it is a virus that’s killing people. It’s a virus that’s causing what’s much less discussed but I think everyone knows is that there are many longer term consequences, that some people who get severely affected but don’t die. You know, that number might be an order of magnitude higher. So we should be dealing with this with a much greater sense of urgency than we are and plateauing at forty thousand identified cases a day, unless we’re really trying to go for natural herd immunity, should not be our goal.

Q: And then, yeah, do you expect going forward as to kind of hold that this, you know, forty something thousand cases, right? You know, about a thousand deaths a day. Or do you expect to improve or get worse? What’s your outlook?

MICHAEL MINA: I expect it to get worse. I said it yesterday on CNN or something like that. I was asked a question, you know, why do we really have to get cases completely under control before we go into the fall? And if we’re not going into the fall with a huge running start in terms of having cases of very, very low levels, we still don’t really have a good understanding of just how seasonal this virus is going to be. But we know that it, despite its closest neighbors being extremely seasonal to the point where the virus usually is essentially undetectable levels in the summer months, we’ve seen it be able to break through all of that because the force of infection, the number of susceptible is so high. But what we also see with those viruses is that come October, November, December, they skyrocket. There’s an exponential increase in these cases. And there is a clear seasonality of this virus.

So, you know, I hope that for some reason this virus behaves differently. But I don’t anticipate that it will. And so if we are if we go into this fall with 40,000 cases a day still infecting individuals and that is again identified cases, the actual number might be an order of magnitude higher. We run the risk of having uncontrollable outbreaks once people really start, once we get into this sort of seasonal attack that normally shows up. We’re not completely sure what drives the seasonality. Is it purely behavioral as people will move indoors again? I don’t really think that’s all because people are generally indoors a lot anyway. It’s probably something biological with weather and absolute humidity. There’s lots of different theories about what could be done or what could be driving. The point is, there’s a very good likelihood if history of the other kind of viruses tells us anything that this virus will take off again. And we’ve actually seen it in the southern hemisphere as, you know, they were doing pretty darn well when we were doing poorly, even countries that were pretty close to the origin of the virus. And then, of course, our summer hit and their winter and they have seen places like Australia have been hit pretty hard. So that is at least to some extent, some evidence for seasonality that we might expect.

Q: Thank you so much.

MODERATOR: Next question.

Q: Oh, hi. Yeah, thanks for taking questions. I wondered if you could maybe help me fact check something we’ve been hearing from HHS for a while. And briefly, you know, the rolling averages of cases and deaths. You know, they’re still very high, but they have continued to decline. And HHS has repeatedly said, you know, this drop in numbers, it’s real, it’s not an artifact of decreased testing, even though testing has fallen off from its peak in July. And what they point to is the fact that, you know, the percent positivity rate also has been dropping. It’s getting near to five percent now. Just from a strictly scientific point of view, is that right? Are they right that we wouldn’t be seeing the percent positivity rate dropping if the virus really was still spreading increasingly in different parts of the country?

MICHAEL MINA: It really depends on how we are testing. And so it’s a very, very difficult question to answer without being pretty specific. If you have a program that is purely that’s going out and you’re just testing random, you’re pulling people out of their cars and you’re testing them or test them on the sidewalk randomly, and you’re starting to see this frequency of cases, of positive samples, go down, then that is an indication that those outbreaks are subsiding. If, however, you’re changing your testing and you’re maybe not doing as much contact tracing, for example, not enriching the sample set with individuals that are more likely to be positives because you’re not necessarily putting in the energy to find them. And then that’s a different explanation for why the frequency of positives can decrease.

So there’s a whole slew of them, I think. I do think that frequency is probably a better metric than overall. Like this whole epidemic, everyone’s been staring at total numbers of cases and in fact, we’ve calculated R0 based on these epidemiological parameters have all been based on sort of total sheer number of cases, as though that, you know – that is based on some assumption that you have comprehensive testing, which obviously we don’t. So in that sense, frequency can kind of cut through some of that, frequency positives relative to overall testing. But I would say that it’s pretty difficult for anyone without getting very specific about the individual sampling protocol to really be able to make that claim, because there is such differences across the country about who’s getting tested and why, in particular in light of new controversial guidance surrounding do we contact trace all the asymptomatic and all of this. I would say that now that is – or do we test all these asymptomatics? If we stop doing that, then we are going to certainly decrease the frequency of positives. But that doesn’t necessarily reflect what’s actually happening under the surface in terms of viral spread.

Q: Great. Thank you. And just one follow up. There are some really kind of tantalizing comments there. Has there been a shift? Has there been anything over the summer and a change in strategy and contact tracing that perhaps might explain, you know, these lower numbers and decreasing positivity rate, you think?

MICHAEL MINA: Well, everyone is doing there – I would say that we don’t have a national strategy, so it’s extremely difficult to answer the question at a national level. Everyone’s doing things differently. Individual states are rebelling against the federal government’s guidance. We are seeing this whole time essentially of how the activities that actually occur on the ground have generally been left up to the states and even to counties in some cases to decide how to deal with those. So I would say that there are some areas where that reasoning is very sound and some areas where cases are truly dropping and some areas where cases are truly going up. And we might not actually be doing the right amount of testing actually to recognize it.

So I wouldn’t be able to put a blanket statement on that, but I would say that the one takeaway there is, I suppose, we still, after all this time, we still have not figured out any sort of national strategy for any piece of this puzzle.

Q: Thank you.

MODERATOR: Next question.

Q: Hi, Dr. Mina. I would like to ask you if you could please clarify your statements about PCR tests being too sensitive and the threshold to look at those being too high and explain why that doesn’t make PCR tests a good frontline tool. And how rapid antigen tests would come into play now that outbreaks are raging.

MICHAEL MINA: Thank you. I was actually just before you ask the question, I was just going to take a moment to interject and index and use this as an opportunity to clarify. There was a recent New York Times article that suggested that the PCR testing – I should say. I wanna say this very carefully. And if anyone has questions for clarification, please ask. It said – I think it was interpreted by many people to suggest that 90 percent of PCR positives or something along those lines were negative or are not actually are false positives. That is not what that was intended to say. Reading over the article, I can see that it probably was worded a bit confusingly for anyone who didn’t really understand what it’s about.

What’s actually happening here is that the symmetry of how a viral infection occurs is very asymmetric. You have a really rapid ramp-up of viral load and then you have this really long tail of very, very low RNA copy counts that you can detect on PCR. And so all of these results – so the statement really wasn’t reflective of suggesting that these are false positives or even that the way we’re testing is unnecessary. If anything, it was very much saying the opposite. It was saying because we don’t do enough frequent testing, we’re actually missing people during the peak of their infection and we’re catching them too late. And so if anything, it’s saying we need to be testing more and more asymptomatic people more frequently, as long as, you know, unless we have other ways to control the virus through social distancing or masks, which don’t seem to be working in a lot of parts of this country, different approaches to test very frequently so that we’re getting people at the beginning of their infection and not later on. And so what that was getting at is this recognition and unfortunately, we haven’t published the research yet, but we will probably have a preprint out in the next week or so to describe sort of the intuition behind that article and behind what that was discussing.

And where it really comes from is that with an asymmetric viral infection, you have this period of really high viral load, meaning low CT numbers, because the two are in first on the PCR and those will only be persisting for like, say, a week or so when people are most transmissible. And then some people will stay positive on the PCR potentially for weeks or months even. We’ve had numerous individuals. I’ve had institutions and colleges get in touch with me recently saying we’ve had individuals positive since July, what do we do with them? So some people can and this is just because the virus essentially leaves residual RNA. It’s kind of like a crime scene. We look for DNA at a crime scene because DNA persists on surfaces and in blood spots and things like that for a long time. You could think of the trachea and the oral pharynx and the nasal pharynx as a crime scene. And the virus has left all of this RNA to be detected after the fact.

And the PCR test can detect it in a very sensitive manner. And so that what it suggests is that a bulk of the time that somebody is PCR positive, they are actually post-infection, but it’s not that they’re false positives. It’s true that the test is working as it should. It’s just that we caught them too late and we really should have had frequent testing. The only way to catch them early, because this is an asymptomatic infection a lot of times is to do more frequent testing. Otherwise, just the probability if you’re in a transmissible period where the virus is transmissible for a week, but you’re in a post transmissible period for five weeks, then one-sixth of the time or I should say five-sixths, for example, of the samples that you might collect during just routine asymptomatic surveillance will be people post transmissibility. So it’s really hard to use that to, you know, then we’re quarantining those individuals after they’ve been infected already. And so one approach that I would say is for – and I want to clarify this is for asymptomatic surveillance, this isn’t for contact tracing, for people at really high risk, for people who are symptomatic. This is if you have very little information about a person’s exposure, history, and you don’t know when they got infected and you only know that they have a really, really low viral load. There’s a small chance that the viral load is on the way up. But that window of time is only a few hours really between kind of having a very low viral load and getting to a pretty high one. But meanwhile, you’re at a very low viral load after the fact for a very long time, for weeks or months. And so the chances that you’re actually detecting the people with very low viral loads here are pretty slim just because the time window is so small.

But one way to deal with this, I would say, is if you’re doing PCR, one of the suggestions that I don’t think came through properly in that in that article is not to change the threshold. That was a complete misunderstanding. Not to change the threshold for what is a positive, but to use the data that is embedded in the PCR results to come up with different types of thresholds for actions. What do you do next after somebody gets a positive result? They’re all positives but how do you act on it? And one way is if you get somebody who’s very high viral load, well, then, you know, it’s a done deal. Isolate them. Get them out of the population. And contact trace their contacts over the last few days. But if you have somebody at a very low viral load and you don’t know anything else about when they might have got exposed or infected, then there is a different way to do it. On the one hand, to make sure that they’re not at this little piece going up, you can bring them back or get them tested a second time, the next day. If they’re actually at the beginning of their infection and then they are going to go from, say, a C.T. value 38 to maybe 28, so you’ll see a huge increase over a 24 hour period if you happen to catch them in this little window of time. But if they go from a C.T. value of 37 to a C.T. value the next day of 37 again, you have pretty good confidence, very good confidence that probably that person is post-infectious and maybe they don’t need to be quarantined or isolated for 10 days because they’ve just shown you that their RNA is stable at an extremely low number. And we know that that indicates that somebody is likely on the post-infectious stage of just being RNA positive and the machine is just picking up remnant RNA molecules.

So again, I want to make it really clear that I was not suggesting these are false positives in any way, shape or form. I am suggesting we need to do more frequent testing, because right now, if we’re doing infrequent testing randomly, then, say, five-sixths of the time that we’re actually detecting somebody through random, asymptomatic testing we’re getting them, if they have a low viral load, they’re going to be on the tail end of their infection. And we can use that information to then decide, OK, instead of telling them they have to isolate for 10 days, we can maybe say, offer them a second test, that they can either choose to isolate for 10 days or they can get a second test the next day and the public health departments would have to figure out how to make that happen safely. So I hope that that helps clarify some of the really large misunderstandings that happened from that piece. But I’m willing to take any more questions that are around it.

Q: Thanks for the clarification. I have another question which is related. Some experts are skeptical of combining antigen tests that look at saliva because they say that saliva has lower levels of virus in it, which, combined with a lower sensitivity of antigen test, makes this approach not a good idea. So do you agree? And how would it be possible to increase the sensitivity of rapid antigen tests?

MICHAEL MINA: Yeah. So the rapid antigen test, so that I didn’t get to that what the other comment I was just making, the really unique thing about rapid antigen tests is that they only they’d largely only detect people during their window when they’re when they’re likely to be transmitting virus.

The antigens, unlike the RNA, the antigens don’t hang about for weeks or months after somebody has been infectious. The antigens are only there – these are the proteins that kind of like the spike protein in the nuclear caps, they’re the arms and legs and eyes of the virus, if you will. So the actual features of the virus, the antigens, will disappear from the body. They’ll get cleared by the immune system. And at the time once they’re cleared, then people are generally no longer infectious with the virus for the most part. And the concern about antigen tests is that they and are less sensitive than PCR to detect molecules. And that’s because PCR is extremely sensitive. It can detect one molecule. And that’s why it stays positive for so long. The antigen test doesn’t have an amplification step during it. It can be just something – I have one right here. This is an antigen test, for example. And it’s just a piece of paper embedded with monoclonal antibodies. And if I were to have coronavirus and spit on this, for example, or put it into a little plastic thing with my spit in it, it would pull up the fluid. And if there are viruses on it, it would cause the line to turn blue, for example. There is no amplification step there. So you actually need quite a few viral particles in order to be able to detect, in order to make that line turn blue.

And so the good thing, there’s tradeoffs. On the one hand, it’s not going to be as sensitive. So somebody is really early in their infection, it might miss them. But again, that’s a really short window of time. If somebody is transmitting, though, if you’re really at risk of transmitting to somebody else, you’re going to have plenty of viral particles, almost by definition, because you need those to transmit. And those would certainly show up here. And the saliva question, I’d say that there’s actually increasing data to suggest that saliva is just as good as a nasopharyngeal swab and could be better than a frontal nose anterior naris swab. I think they’re off for somebody who’s transmitting virus. They’re all very likely to turn positive. And that’s an important thing. Almost all of the conversations we’ve been having about sensitivity of the assay, sensitivity of the different collection techniques, have all been focused really on whether or not we can capture the really low viral loads. I mean, what defines sensitivity is in some ways the limit of detection if we’re thinking about sensitivity to detect molecules. But if we’re really interested in detecting people who are transmitting virus, we have a lot more flexibility there. We don’t have to worry about detecting single molecules or the subtle differences that happen between antigens being in the saliva versus the nasopharynx versus the anterior naris. Because if you have sufficient virus actually transmit to other people, you’re probably going to have virus in each of those compartments in high numbers. But I’d say saliva is probably going to continue becoming a more used platform for collection, along with anterior naris swabbing, and eventually, outside of hospitals and medical clinics, I think the nasopharyngeal swab will probably start taking a backseat.

MODERATOR: Thank you. Next question.

Q: Hi. Thank you for doing this call. Sort of along the lines of some of the questions that have been asked about kind of where we are. I’m wondering, as we head into Labor Day with, you know, how the testing capacity has kind of expanded to a certain degree or at least different kinds of tests that are being ramped up. How should we apply that in terms of a testing strategy kind of post-Labor Day to not have the same spread we saw after Memorial Day and the Fourth of July?

MICHAEL MINA: So, sorry, how would we have a specific – are you asking what would a specific testing strategy look like?

Q: Yeah. Given that now compared to, say, after the Fourth of July, we didn’t quite have antigen tests at the same level, nor did we have the saliva test. And so kind of with the tools we have now, how we should apply those?

MICHAEL MINA: Yeah, well, the saliva test, just to be clear, it isn’t a test. Saliva is just another collection technique. I think there’s been a lot of confusion about this saliva, anterior naris, nasopharyngeal, they all are just collections. So, for example, that saliva direct assay. That’s not sort of a readily available test. It’s another lab-based test that just uses saliva. So I wouldn’t say that.

But the question is really about that we have increased capacity today, how can we best utilize it to stop outbreaks? Well, for one, we can really do it. We could set up ways to monitor for outbreaks that are better than what we’re doing now. I would say at the moment we’ve had largely a sort of haphazard approaches to surveillance. We set up drive-thrus and essentially, if you have the right information to figure out how to get to drive-thru and you have a car to get there, then you can get tested. So that it immediately really disenfranchises the already disenfranchised.

You know, all of our testing strategies have been – there’s been very few places, I think, that have really done a good job at ensuring equitable access to testing. And that’s part of the reason why, you know, the communities that get hardest hit, not only are they potentially more likely to have transmission out of control there, because they usually tend to be more physically clustered together in their living environment and working environment. They also generally have lower access to testing and to information and data or even to masks and things along those lines. So we can start by trying to ensure that we have plans in place, that we have actual plans. How do we do this? If you have a case, you start to see an outbreak there, what exactly do you do? And, you know, this is where we haven’t seen any federal guidance and a lot of it’s been left up to counties to figure out. And a lot of counties in the United States have never dealt with something like this. And I would say most departments of health in the United States have never dealt with an epidemic like this and across the world.

So we need to create guidance for public health individuals. And then also we can leverage – there’s a large amount of testing and additional sort of infrastructure being built in the private sector businesses. Every single day, I get calls or e-mails from CEOs of major companies to talk about how to do contact tracing just within their own company, for example. And they don’t know how to do it. But this is you know, these guidance documents if they existed, and sometimes they do exist in small numbers. You know, they don’t have to be. They don’t have to live just within the public health domains. There’s businesses want to make sure that their constituents or their employees are staying safe and that they’re not that outbreaks aren’t starting within their within their realms. And so they are taking upon themselves to start creating their own testing platform sometimes or contracting.

So I think that all of this needs to be looked at as a comprehensive response. These need to be tracked. Who’s actually doing testing now, what companies are, what companies aren’t. And then, you know, everything else has to flow from that type of coordination. Rapid antigen tests are a new test. They’re not widely available. They will be – I’m hoping that they will be. I want the federal government to create a Manhattan Project type approach to essentially just start making these simple lateral flow, rapid antigen paper strip tests. This is something the federal government could do. They could actually take it upon themselves to make these tests. And it’s something that, unlike PCR labs, they would actually have control over. They could make millions and millions and millions of them daily and distribute them in a coordinated fashion. Whereas when you’re dealing with thousands of small PCR laboratories who are all doing their own sorts of different assays or hundreds of different labs around the country, it’s very hard to corral that and get cohesive testing in a very regimented fashion. But these paper strip tests, if the government wanted to produce them, they could have been producing them months ago in huge numbers. They tend to just wait until a company like Abbott comes out. And then they just buy up all of Abbott’s supply that they’re going to make for the next three months or four months. So that’s good but it’s not enough. That will maybe double that testing capacity in the country, whereas if we really want to stop outbreaks from occurring, we need to scale these up much more if these are to actually be used as transmission-blocking devices, which I think they can be. And so that’s what I think we could be doing to prepare for the fall. We should have started it last month. We should’ve started it four months ago.

But there’s no time better than today. If it hasn’t been started yet, let’s start it today. And that is we can keep trying to ramp up laboratories but you just can’t scale them. We’re not going to have an exponential explosion in the number of laboratories. We could have an exponential explosion in the number of rapid antigen tests.

Q: One quick follow up. Kind of similar to that, I’m wondering, and obviously this is kind of in hindsight, so maybe it’s not even really applicable given the state of our testing now. But were we, the United States, best served by having testing aggregated kind of among a few top-heavy corporations like LabCorp and Quest? Or did that kind of hinder our ability to adequately test the most people because it was kind of all getting funneled through like major players? I’m just curious on your thoughts on that. I had heard things that maybe if we didn’t have so many, kind of, I wouldn’t say monopolize, but it’s corporations doing most of the testing, maybe more people in more rural areas could have had access. Just curious on your thoughts on that theory.

MICHAEL MINA: [00:35:24] Well, these tests are not easy to set up is the problem. I actually think quite the opposite in some ways. I want to be clear that when I say I think the opposite, I actually think had we had, I think for the next time that a pandemic like this comes around, if we have efficient public health labs could have gone a really long way. If every single state had very efficient public health labs with the expertise and capacity to quickly spin a PCR based testing and at scale, then we could have had 50 labs across the country, or maybe states like New York and California would have four different sort of big labs, that would have been a way to really use the economy of scale. Instead, what we saw, what really slowed everything down, was every single little lab around the country, especially because of the EUA process, had to reinvent the wheel. The EUA meant well but it was one of the greatest hindrances to getting testing going quickly.

At our hospital, we had testing available for patients in February and we were not allowed to use it because there was that EUA process in place. So we had to essentially reinvent the wheel despite our expertise that we had sort of implicit in the lab already and submitted applications and go through all this stuff. And it slowed everything down. And by having all of this spaced out, there is sometimes there is a really good use of distributed testing but that’s when the complexity is so low that the getting the lab setup isn’t the barrier. So something like this paper strip test, this can be distributed. This is how you do distributed testing. But if you have a high complexity assay, which in general all of the PCR tests are very high complexity, then having every single small lab have to go through the trouble of buying robots and figuring out just how to do PCR. Most of these labs have never done manual PCR before. That’s that was actually a problem. So I think the problem isn’t that they were mega labs that are corporate trying to do the testing. The problem is that we didn’t have mega labs that are part of a public health network that run by the federal and state governments to be prepared for this type of thing. And in the future, I would say, on the contrary, we want large labs that can bank on economy of scale, that already have preexisting contracts with manufacturers, that we have plans put in place for in an emergency how the robotic tips are going to be produced, how the swabs are going to be produced. You know, we didn’t have a single plan despite knowing that this was a very likely outcome in the future. And I still don’t think we have a plan for the next time. Not that we have to be doing in the midst of this, but we don’t see, you know, a new pandemic could start tomorrow for a new virus.

And I would say that we don’t have a plan for how to really do all of this. And I don’t think that I’ve seen any real significant discussion at all at the federal level to say, hey, we actually should be creating several laboratories. And that’s a big mistake. And that’s, I think, one of the reasons the U.S. has lagged so far behind in our ability to tackle this virus.

MODERATOR: OK, great. Thank you. Next question.

Q: Hi. Thanks so much for doing this. We were just wondering, we saw that Roche got an EUA for a PCR combined influenza coronavirus test. And I mean, it’s obviously still a PCR test, but we were wondering if you think these have any utility because I know that oftentimes doctors don’t even test for the flu; it is more of a clinical suspicion. But just your overall thoughts on these tests and how you see them being used?

MICHAEL MINA: Yeah, I think they have a lot of clinical utility only because there are a lot of overlaps with the symptoms. And so everyone is going to be concerned, every physician or hospital or clinic or school, is going to be concerned that anyone who comes in with any signs of coronavirus will need to be quarantined and isolated or quarantined. And so what this is doing is it’s going to allow more rapid assessment, not just if you’re negative for COVID, but if you find that somebody is positive for flu, you’ll be able to start parsing these apart. So the symptoms overlap. We’re entering into a phase of the year where it’s very likely that the two viruses will overlap. So I think that this just makes sense. It’s a way to conserve resources. Like Roche, for example, and Hologic, they’re literally running out of medical-grade plastics and so we need to figure out how to either offload a lot of the testing from the clinical laboratories or figure out and make everything more efficient. And this is one way to make things more efficient.

MODERATOR: Do you have a follow-up?

Q: Yeah, just a quick thing. Have you heard of anybody working on a paper strip, influenza coronavirus dual antigen test?

MICHAEL MINA: Not so much the paper strip, but other rapid tests. Yes, some CRISPR-based tests. This has been discussed a lot. I think that the paper strip tests should be doing that. And I anticipate that eventually, they will. But just getting the first ones out the door for a single pathogen is a good start anyway. But they should. And there are rapid flu tests, for example, that have existed for quite a while.

Q: Great. Thank you.

MODERATOR: Next question.

Q: Hi. Thanks, as always, for doing this while we’re on the topic of flu and COVID, I’m curious if you can just give us a kind of a big picture of what’s on your mind as we enter into flu season. Like, what are your kind of top-level concerns about? About where we are at this point with COVID or flu and what kind of keeps you up at night at this point with those two diseases interacting?

MICHAEL MINA: Well, I think the biggest thing on the one hand, actually I hope that all of these effects that we or all of these non-pharmaceutical interventions that we’re putting in place for COVID like masks and social distancing in a lot of parts of the country will help to really abrogate the size and scope of influenza this year. That could potentially have a detrimental effect next year if we end up having people not sort of boost their antibodies, boost their immunity from flu this year, we could see a greater outbreak next year.

So that’s one sort of somewhat theoretical adverse effect that could occur. But I think that we need to get our economy back on track. And if we have a bad flu season that doesn’t get mitigated pretty strongly by all the interventions we’re putting in place, then it will lead to major concerns. Is this COVID? Is it flu? It will lead to confusion. And I think that might be my biggest concern is really about it continuing to delay our ability to efficiently get people back to work and then back into schools and everything else. And so I am most concerned about that aspect of it, just muddying the waters and making everything even more difficult. It’s already been sufficiently difficult.

Q: I guess the other thing I was wondering about is as we’re going into Labor Day, you know. They’ve spent a fair amount of reporting on the risks that we’re gonna see a spike. And you certainly have seen what appears to be more of these kinds of events. We’re hearing about college parties. We’ve got these TikTok stars in Los Angeles that got their power cut off. We’ve got this wedding in Maine. We’ve got the Sturgis motorcycle rally. We’ve got the President’s speech on the White House lawn. I’m curious, like where you think, you know, we are at this point with, you know, people kind of getting the message that this is a good idea to take up these measures. You know, do you expect to see, you know, that the numbers have been kind of flat to declining recently? And I’m wondering if you’re kind of on the lookout for another rise after Labor Day.

MICHAEL MINA: Yeah, I think that what we’re seeing is complacency and we’re seeing not – and I understand why people are becoming complacent. Everyone’s tired. Everyone is really worn down by this virus. I’ve been sitting in this damn chair since March. And so I think everyone is frustrated. Everyone just wants to get their life back. They want to see their parents. They want to see their kids. They want to get back to school.

And so this is why it was just so important – I mean, it’s not really worth talking about anymore because you can’t change the past, but it’s why it would have been just so important for us to do it right the first time, to not let this drag out in the way that we have, because eventually, we’re going to see what is happening now, which is complacency and parties, getting things back together, getting people back together. And, you know, unfortunately, what’s going to happen is we’re going to see all of this happening at the social level. And then the companies are going to still, for various reasons, they’re going to still remain closed. And so you’re still going to have populations getting together and spreading disease. And then the restaurants are going to continue going out of business. People are going to continue being out of work. We’re going to continue getting evicted from their homes.

And so I think that there is a clear reason why we’re starting to see people engage more and more. And some of it’s complacency, some of it’s outright sort of outrage or rage against any sense of coordinated response. Some of it’s making political statements. You know, there’s a lot of different reasons why people are doing it. But I think overall, the fear factor is gone. And that’s, you know, that’s OK. But it doesn’t need to be fear that drives people. It should be common desire to keep people healthy that really drives people to make these decisions. And I think that there was no real way around this. You know, short of enacting martial law or something, we were always going to see people start to move back and try to create some sense of normalcy in their life again. I just wish we had been able to get the virus under control beforehand before people got to this point where they just don’t care anymore.

And I am not a psychologist. I don’t know how to understand human behavior in this way. It’s not my area of expertise, but I’m saddened to see what’s happening. But I would be lying if I said I didn’t understand why people are making these decisions.

Q: Great. Thank you.

MODERATOR: Next question.

Q: Hey, Michael, On the issue of whether some of us want to know whether we’ve been exposed or not, what are the tests that detect antibodies? And how long do the antibodies persist at levels that are detectable by those tests?

MICHAEL MINA: I don’t understand (laughing). I thought you were gonna ask me what’s gonna happen with this pandemic in 2025.

Q: Yeah, you got hit with that question a couple of times already, so no need to (laughing).

MICHAEL MINA: I’m just joking.

Q: That is fair enough.

MICHAEL MINA: The antibody tests. They are good tests. What we’re seeing is, again, – I’ve said this in the past and I’ll reiterate again – the waning of antibodies during a primary of response like people are having – primary means first time that somebody is getting an infection with a given virus – waning antibodies is a normal and anticipated effect. And so these antibody tests, we saw a whole slew of antibody tests early on that just didn’t work. They were pieces of plastic and they were, frankly, pieces of garbage. The FDA, in a rash decision, decided to approve a lot of them, even approved them for diagnostics. I think was all a really bad decision making that has been in some ways ameliorated. They pulled a lot of this off the market again. It, of course, did swing the pendulum to make them even more cautious about it, to care rapid antigen tests, things like that.

But the antibody tests that exist now – some of them are made by Roche, and Abbott, DiaSorin and these companies – they actually do a very good job. But there’s never been more scrutiny on antibody tests than there have been during this outbreak. And so what we’re seeing are the known limitations of antibodies. People develop antibodies at different times after infection, so you can’t just say this is you know, everyone’s going to be positive for an antibody 10 days after infection. It might be that 99 percent of people are positive after 20 days after infection. We don’t really have great information on what are the true rates of people who are asymptomatically infected and what are their sort of production of antibodies and how long do those antibodies last? Nor do we have really great information on what exactly they will mean for immunity. But I think we’re going to continue getting there. These are usually studies that take years and there’s been so much intense interest that I think we’ll start to see the utility of these to understand the immune protection associated with antibodies that we measure.

And so the current state is that antibodies can be measured very well, I think because of waning antibody levels, which doesn’t necessarily mean the waning period just that anybody levels are waning, after a big outbreak, they might become less and less useful to understand sort of what happened in a community five months ago. But they’ll be very good to know it has been a community a month or two months or three months ago. So they can be very powerful public health tools. We should absolutely be putting huge resources right now into setting up whole networks of antibody measurement systems to do not just coronavirus, but to be measuring all types of viruses and antibodies against all types of viruses because of just how powerful a surveillance tool is as a public health tool. We’ve been trying to develop, for example, what we call an immune observatory, a global network of laboratories, able to all work together to let us know where different viruses are at any given time based on people’s immune responses. So in assays, the tests can work very well. We just were unfortunately back in the beginning with a bunch of tests that didn’t pass.

Q: OK. Just a quick follow up. So the Quidel test, is that now just toast? Is it because of the Abbott test? Is it no longer ever going to be used or is there still a role for that Quidel test?

MICHAEL MINA: So those are the antigen tests.

Q: Yeah. Yeah. All right.

MICHAEL MINA: And that’s looking for the virus. So that will probably double still be used. I don’t think it’s toasted. There’s the Abbott BinaxNow, there is the Abbott ID Now, there’s the Quidel and there’s the BD Veritor. Those are the rapid ones that are on the market at the moment. The major ones. And I wouldn’t say that any of them – they’re all needed. They’re all decent. They all have their benefits and their limitations. But when used in a coordinated way, I think they will all stick around.

Q: OK. And just going back to the antibodies, just real quick, I know I’m abusing the rules here, but. So if it’s eight months have gone by, is there a test out there that can pick up the antibodies, or is it just too long a time to detect that you’ve been exposed? Not for surveillance but just in case, we thought maybe that might give us immunity. And I know that you dispute that. But just in case that was the motive.

MICHAEL MINA: Yeah. So the antibodies, it will be very individual dependent. We see some people will keep antibodies for a very long time after a primary infection. And some people, their antibodies will wane quickly. In my lab, some of the things we work on are developing very, very high-resolution antibody detection system, really sensitive. They can detect for a given pathogen not just a single value, but maybe 100 different antibodies, for example. So we’re trying to see can we do a better job with these types of more futuristic, if you will, or next-generation type of antibody tests? Can we actually get a better ability to detect antibodies much longer out to know if we can sort of make somebody’s blood a year later and understand if they actually had the infection? For a lot of viruses, we can. And I anticipate that after people get multiple exposures to this virus or to the vaccine, they’ll probably build up a longer-term immunological memory.

Q: OK. Thanks. Thanks for allowing me your questions.

MODERATOR: I am going to say, Dr. Mina, it’s one o’clock.

MICHAEL MINA: Sometimes I can stay on but I apologize for those who have been on with their hands raised. If you want to send e-mails, I can try to get to them today. But I do have to run.

This concludes the September 4th press conference.

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