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 12:00 p.m. Eastern Time on Friday, September 18th.
MODERATOR: Dr. Mina, do you have any opening remarks?
MICHAEL MINA: No, ready for questions.
MODERATOR: OK. First question.
Q: Michael, hi. I noticed that the rates of infection in Australia and Brazil are really quite low. And they are, of course, in their wintertime. Does that portend anything for us? And if not, how would you distinguish it away as not relevant?
MICHAEL MINA: I would say it’s unclear what’s happening in Brazil. In Australia, I would say quite the opposite, that when they hit our December, their June, they had a pretty massive increase in cases which they’ve now been in stage four lockdown for quite a while. So I think they’ve gotten hit in a number of cities anyway. So I think they’ve gotten it under control through locking down, similar to what happened in New York and Boston, this is earlier in the New Year for us.
Q: So the death rates per capita in both those countries are super low compared to the rest of the world and us in our summer. So that’s what I’m referring to. If that’s irrelevant for some reason, that’s fine. But I’m just curious what you think about that stat.
MICHAEL MINA: I see. Just to clarify, you’re asking about the rate of death, not the rate of cases.
Q: Yeah, sorry about that, I did misstate in the beginning. But I’m happy to hear what you think about. I mean, maybe if the rate of death is not relevant, that’s fine. Just tell me why. You know what you know, the infection rate is more relevant?
MICHAEL MINA: You know, I think the rate of death is very relevant. I think it’s a reflection of a few different things. We’ve learned a lot about how to keep people safe. And that is probably reflected in Australia, for example, that when they started to have a pretty big outbreak, they probably did better by the time it was June for them than we did and in March for us, for example, to keep cases out of very vulnerable areas like nursing homes. So I think that that’s one piece. And 47 percent of all of the deaths in the United States, I believe, came from nursing home residents. And then others who were vulnerable. So I think they’ve perhaps done a very good job of trying to keep certain populations protected from the virus. And then the other pieces are certainly that as the months have worn on, we’ve really determined better ways to keep people alive. Once they do end up in the hospital, once they do end up in the intensive care unit, just really simple things that will probably end up translating to other pathogens as well. Things like turning people over and having them not lay on their back, for example, turned out to really be able to increase airflow into an oxygenation of their body in the way that their lungs were working, changing bench settings and learning how to do that more appropriately. And then things like Remdesivir, and it’s not the silver bullet, but it’s something that certainly leads to some improvements. And so I think when we start adding all of those together, we are seeing improvements in overall survival rates. And that’s my assumption in terms of why case fatality rates are going down more so than, for example, mutations. I’m not convinced that this is really being driven by changes in the viral behavior or the or the viral genome as much as it’s really that we are learning to deal with this virus.
Q: So just moving quickly to wild predictions, which I always ask of you, and I know that you’re really negative on our efforts to, you know, to deal with this, but do you think that there’s a possibility that we may learn from this and that our death rates will be lower and that therefore we may be able to open up the economy more or at least lock it down less going into the winter months? I know that’s a wild speculation and not necessarily your area, but as an economic reporter and business reporter, it’s what I care about. So thank you very much. And I’ll stop here.
MICHAEL MINA: I think it’s a great question. And for four months I’ve been saying that if we could get a good therapeutic, for example, or if we could figure out how to decrease risk of death upon entry into the hospital, I think that gives us a lot more leeway overall to it allows us to walk the line of risk in terms of outbreaks. Much more with lower absolute risk of death. And so I do think that that is a reasonable question. And I think it’s a reasonable thing that we should all be thinking about. If we could take it to the extreme, if this virus didn’t kill anyone, then it wouldn’t be bad to let it go to the population. Of course, we know that that’s not true. But if we could figure out how to keep people from getting serious disease and dying at greater rates than we’re currently able to do or that we’ve been able to do in states, then I think we would have a lot more leeway to tolerate outbreaks. And it’s unclear where we’ll end up. It’s unclear what role in the United States, I mean, this isn’t so different, Brazil or Australia. But we have a tremendous amount of comorbidities here that also increase severity of disease. And so I think we’ll just have to see where it goes. But I do think that that’s a reasonable question. And if we can, you know, the other option outside of getting a vaccine or just completely suppressing the virus is just figure how to keep most people from severe disease. And that would allow us to treat this in a much different way.
Q: Okay, thanks. Thanks, Nicole.
MODERATOR: Sure thing. Next question.
Q: Yes, hi. Can you hear me?
MICHAEL MINA: Yes.
Q: OK, great. Thank you. So, yeah, in Maine, there’s been some outbreaks at several social clubs, you know, like your Elks Lodge, American Legion, etc. And right now, in Maine, they’re not being regulated as bars. They’re being regulated as restaurants, so they’re allowed to operate. And I’m wondering from an epidemiological standpoint, do you think they more act like a bar versus a restaurant? Do you have any thoughts about that?
MICHAEL MINA: Well, to be honest, I’ve never been to one. So I don’t think I have the knowledge base to really answer that question, but I would say that from what I know of them, they tend to have bars. Usually it’s kind of a central feature, I would imagine. And if that’s the case, I would imagine that that they do tend to act like bars. But really, I wouldn’t be able to say much more than that.
Q: OK, on it, if I could maybe just ask a broader question then. Do you from an epidemiological standpoint, do you see any difference in terms of risk, between indoor dining at restaurants and bars, or do you think they’re fairly similar?
MICHAEL MINA: Oh, no, I think. Well, I think that there’s a huge range for sure. But if we just take a restaurant where, a fairly large restaurant these days might only have six tables or something because they’re really spacing them out and people are sitting at those tables and kind of keeping to their own little clusters. That’s a very different environment than a bar opening up where people are sort of walking back and forth along the bar, they’re crowding in to get drinks. And so I think that behavior – this is completely unscientific and just from experience – but the behavior at bars is very, very distinct and different from a restaurant. And I think that the behavioral changes that you see in a lot of bars and I haven’t been in a bar since things have shut down, so maybe the environment is quite different now. But if I just go back to sort of spaced out restaurant versus a bar with given sort of seventy-five or six percent capacity or something, I think that they would probably be more prone to have transmission across individuals who don’t necessarily know each other. And so you don’t necessarily know who the person sitting next you or coming up behind you and ordering the bar is, which is quite different than if you’re at a restaurant where you’re not sitting in a particular table and you’re really just staying there and everything is kind of a little bit more organized and you don’t have as much mixing. And what we think about a lot in terms of epidemiological terms is how populations mix. How homogeneous is the mixing in a restaurant? I would say it’s not homogeneous at all. It’s very clustered. And in this case, in a bar, I would say it’s quite different when you have a lot more mixing of just random people, which can lead to a spread.
Q: OK, one more question. And I appreciate your help with this. What do you think of the of the CDC report, I think it was last week, that said people who were at restaurants and had COVID-19, they’re twice as likely to have had COVID-19, have been in a restaurant that people who had not fallen ill? And I know you’re saying that bars are more dangerous in restaurants, but do restaurants pose a high risk anyway or no?
MICHAEL MINA: Well, my take on that is really that people who are going out to restaurants, especially in the last six months or so, may fall into a higher risk category. Overall, their overall behaviors may be different. Anyone who is willing to go and go to indoor dining between April and today, I would say most people haven’t been doing much indoor time. So those who are going to restaurants, they probably are also willing to engage in certain other, you know, in the context of COVID risky behaviors. And so that’s really my take on that. That’s it. It’s selecting for our population. And in this case, going to restaurants might just be the variable that is available, but it could be tightly correlated with a whole suite of other behavioral differences. Maybe those people are also more willing to go to shop for clothes or any number of other things and just be out in the environment. And so that’s really what I take most away from that study versus it being specific about restaurants.
Q: That’s great. Thanks a lot for your insight.
MODERATOR: Next question.
Q: Thank you. The official toll is about is around 200,000. What do you reckon is the likely real death toll today? And do we know how much we’ve closed the gap between the official COVID death count and the overall excess mortality?
MICHAEL MINA: Well, the excess mortality is certainly quite a lot higher than the two hundred thousand that are recorded deaths. And so that’s disturbing. There are other reasons that COVID, it could have led to increased deaths. And this is news that I’ve at least talked to a number of you about over the months. And that’s when you have something like COVID and you start to shut down hospitals and you start to have people decide not to get their normal routine medical care – I know there is some superfluous medical care that we give in this country for sure, but a lot of it is for a reason. And so we can’t just shut down medical care, routine care to people and expect no adverse consequences. And so I think when you take a country, 330 million people and a large number of them have comorbidities of cardiac disease, diabetes, and they go a month without taking their medication, for example, when they would have taken their medication otherwise or didn’t get that cardiac checkup when they otherwise would have, those numbers add up little by little. And so I think that there is probably quite a bit of undiagnosed COVID death. I know that back early, early on in this epidemic, we saw one of our first deaths was very likely a COVID death. But there was still no testing available. And I mean, that’s going way back. So it’s not really part of this particular question. But I think that if you’re not really looking, there might be many places in the country that we’re not doing a terrific job of figuring out exactly why somebody might have died. And so I think when you add all of those up, we end up seeing a lot of excess stuff that can be attributed to this pandemic overall. Some of it will certainly be due to COVID directly and some of it will be due to changes in the access to health care and other related events.
Q: But do you think the system has improved in counting all of its deaths? Certainly, it seems in New York it’s something really close to the actual real count.
MICHAEL MINA: Yeah, I think now that we have testing that is much more widely available, certainly unless we go back and do a postmortem back to like March and April and things like that, I think it’s going to be very difficult to get those numbers. But today, with testing available, it’s really not too difficult for pretty much anyone, anywhere in this country to be able to get a PCR test on a postmortem, on an autopsy, for example, and understand the cause of death and whether it was associated with COVID. So I think we are definitely doing much better at identifying the deaths that are actually biologically due to COVID. I think we haven’t quite got a handle on just how many people have died at the expense of the social and behavioral changes that are associated with COVID.
Q: Thank you.
MODERATOR: Next question.
Q: Hey, I just want to tee up kind of a general open-ended question for you on testing the possible oversensitivity of PCR, public health surveillance testing. If you could dictate that, and also quarantining asymptomatic people who may not be infectious, if you could dictate the national narrative, what would that narrative be?
MICHAEL MINA: Well, the narrative in terms of how it’s gone or the narrative in terms of what I’d like to see?
Q: What would you like to see us saying? Let me put it that way. As far as reporters, a lot of us are you know, I’m a government reporter whose kind of all of a sudden trying to remember AP bio from twenty-five years ago. And it’s tricky sometimes. So what do you want to hear us saying?
MICHAEL MINA: Yeah, well, about testing. I think there’s a few really key pieces. We’ve focused on PCR thus far. I think what needs to be recognized is that PCR is a terrific test, but it has been used in a way that has stretched our laboratories to their extremes at the expense of other clinical testing that we would normally do, in particular things like HIV, gonorrhea, chlamydia and other infectious diseases that normally get performed by the same people in the labs. So it’s got its place. I think the co-option of our clinical laboratories to perform surveillance testing has been problematic on many fronts. On the one hand, these labs were never designed to be high throughput in the way that a pandemic demand, I think. And so what that says to me is we really didn’t have a public health laboratory system set up. And I think one of the most crucial things that I still don’t see happening is we should be taking this opportunity with all of the money that exists as a result of this pandemic, we should be planning and building true public health labs right now. If we’re not doing that, we’re failing for our next pandemic. And I really think that we need to be thinking now when everyone is energized to do so and to put billions dollars into it, to produce actual laboratories that will be able to deal with this kind of thing, the next pandemic becomes around with PCR being too sensitive.
I think that there continues to be just an immense amount of confusion that stemmed from a part of the New York Times article, which I think was I mean, I take some responsibility because it was really a story that I brought to The New York Times. And I think it was written for the most part correctly, but it led to a lot of confusion. And that confusion is that the PCR is too sensitive not for diagnostic medicine, but it’s maybe too sensitive for public health use. If the goal is to identify people who are currently spreading virus, and that’s because just mathematically, you don’t even have to do any biology, you just have to know that people transmit for a short window of time and stay positive on PCR for a long window of time. And that means that the average person taken off the street who’s an asymptomatic individual, will have the average person who’s positive and asymptomatic. And you don’t know anything about their exposure history. On average, they will have already passed their infection status, their infectious stage. And so that could be almost seen as, I want to make clear it’s not a false positive for COVID at all. But it is a false positive or maybe a late positive is the better word for transmissibility. It means you’ve probably missed that person’s transmissible window, which means you’ve largely missed your opportunity to act. And the only thing that can ameliorate that, it’s not a problem with the test. It’s a problem of frequency. But PCR can’t be spun up enough or we can’t increase capacity of PCR enough because it’s lab based. It’s difficult.
And all these things, we can’t get it to a point where we can be doing PCR tests on sort of half the population every third day, for example, maybe at Harvard and M.I.T. and university campuses we can, but you know where we are, ivory towers and we can build our own labs. So I think that that’s really where the PCR issue came in. I want to make it clear that PCR is a terrific tool. If I’m a diagnostic physician, I want to use PCR. If I’m a public health person, I want to really focus on what’s the most frequent tests that I can get. What’s the test that will allow me to test the most people the most frequently? If my goal is to use testing as a way to remove people who are infectious from the population, and that’s where these rapid antigen tests really start to shine, we’re starting to see more and more of them come out. I’ve been very grateful to the FDA to continue. I was a little bit down on the FDA maybe a couple months ago, and they have been extraordinarily active in being willing to discuss it myself and some of these other test manufacturers to see if we can somehow rethink or accelerate the pathway, to just improve the pathway to get these tests out and rethink sort of what metrics a public health tool needs to meet versus a diagnostic medical school. And so we’ve had some very productive conversations with the FDA in the last month or so. And so I think that we’ll continue to see that antigen tests come to market similar to the Abbott Bionics now, which has an FDA claim for a symptomatic use. But we’ll start to see. I have one right here and you can see it is a different paper strip test, and this is actually a plastic one. But if anybody cares, I’ll just show you why I call them paper strip tests. I don’t know if you guys can see me anyway, but if you take off that plastic piece, you have just a little piece of paper in there. So plastic piece can maybe be made, everyone could have one just like a contact case. And then you just put your little paper strip in and do the test. So I think we’ll end up seeing paper strip tests become much more available and they can be made in huge numbers. And I really encourage the federal government and I want anyone who has voice that the federal government might hear to encourage federal government to start producing these, to not wait until each little company comes out and builds one. But just to take the onus on themselves and treat this in the same way that we built jets and bonds and things. And let’s build one of our major tools against this virus at the federal level, rather than just buying whatever private enterprise can sell us.
Q: And a really quick follow up to that. Is there a timeline that you see on that and what price point would be required to make it legitimately functional?
MICHAEL MINA: Well, to be clear, I want one of the major reasons for the federal government to produce them is because I don’t want the public to pay for this. This should be seen as a public health good. Every person who is not walking around you, every stranger in your environment, if you’re in New York City or if you’re in Chicago or if you’re in Kansas or wherever you might be. We all want to be safe when we walk around. And so by giving our neighbors tests, we become safer. And this should not become a class thing that shouldn’t become anything other than how do we make the public safe. And only the government can do that. This is the epitome of public health. Now, I’ve already said that our public health infrastructure really is terrible in this country. So I’m not convinced that we’ll get there. I’m not convinced that if the federal government does start to produce is, they will figure out appropriately how to distribute them. But I’m hopeful. I think it needs to be free to individuals. I think that they can be made. Now, if the government put 20 or 100 billion dollars into producing this, they could also sell them, for example, to other countries. And, you know, it sounds like a lot, but that’s less than a tenth of what we have, it’s way less than a tenth of what we’ve used for COVID bailouts at this point. And so if we now look at everything in the federal government, and maybe you have a much better handle on this than I do, but I believe that the feds just set the interest rate at something like zero percent for the next few years. Something along those lines, I’m not an economist. But the amount of money that the federal government will lose, or hopefully it’ll stimulate the economy, but just the economic losses are so astounding that it makes one hundred billion dollars in testing now seem like pennies. And I truly think that the funding should come from the Defense Department. I think where there is a lot of money and should be and this should just continue to be treated as such. I don’t want them to be priced to the public. And I do think that these can be built if things started today. I think that in a couple of months, we could be building many, many millions of them. But I think in a couple of weeks, we could probably have partners spin up test manufacturing plants. There are a few cities in China that have a number of plants that can manufacture these. It’s where Abbott, I believe that Abbott uses the Chinese manufacturer at the beginning at the at this point in time. Investigate that more if you if you want. But I believe that a lot of the companies are using Chinese manufacturers because that’s where these things usually come from.
MODERATOR: Next question.
Q: Thanks for taking questions. On antigen tests, I just want to see if you could respond or give us any insights on reports. We’ve been hearing that antigen tests are not being reliably reported to states and to the federal government that this money perhaps be the case counts and sort of undercounting. How many people are actually testing positive for COVID?
MICHAEL MINA: Yeah, I think this is important. And I have two different feelings on it. On the one hand, if it’s truly being under, I mean, there’s no good explanation for why places are not necessarily reporting their antigen tests, except that it all comes back to our public health infrastructure. We haven’t made it easy to report these tests. For example, if a nursing home has an antigen test, the nursing home isn’t used to reporting test results to the Department of Health. It’s usually the laboratory that does the testing that reports results to the Department of Health. So I don’t think that this is intentional or nefarious. It is my guess. I think that this is just a further reflection of just how terribly dysfunctional and underfunded our country’s public health system is. I mean, it’s just astounding how the software that these pretty simple software packages that can be built, that can be deployed. But everything is just so difficult in the public health minutes because we’ve let the technology get away from us or not. We’ve not kept up with the technology, I should say. And so I believe that that’s probably what’s driving the underreporting of the antigen tests. And if they’re being used at this point in time, I think that they should be, we should either be figuring out how to get those results better. County Departments of Health, State Departments of Health need to keep track of where those particular instruments are. And they’re all instrument to test at this point. None of them that are available are these little plastic things or paper things, but they’re all instruments. So it’s easy to keep track of where they’re at. And the companies can do so. And maybe it can be on the company to provide software to for reporting. There are all different ways that it could be done. But I think this is really a symptom of a failing public health infrastructure, which has really been at the whole center of the debacle in the United States epidemic.
Moving forward, I think that there’s other ways to do it. But if these papers tests become household entities, meaning that the government actually produces them in departments of health, passes them out, for example, to people’s homes or maybe schools or whatever might be. I actually think that we should prioritize curbing the epidemic through stopping transmission before we require recording. And the tradeoff would be if we can increase testing, say, 100-fold, so a 100 times more testing in this country than we currently do, as an example, or even just tenfold. And then we could get just a fraction of those people who are using the tests to report voluntarily and maybe even anonymously if needed. There could be a box that you’re allowed to check to say keep it anonymous. That would give public health officials much more data than they currently have to understand what the true incidences and it would essentially so won’t be imperfect test resulting to the Department of Health. It won’t be perfect, but it will be imperfect reporting of a much larger fraction of a much larger bulk of tests. So ultimately, the absolute number of pieces of data that will go to the Department of Health will be greater. And I think it can actually increase our ability to track and monitor this virus. So I think if these things become a point of care at home or a sort of much more sort of de centralized, than we really want to think about creative ways to get reporting in a way that allows people their autonomy to know their status. Because I think a lot of people won’t use these if they had to report the results, particularly people who are choosing not to wear masks, social distance, that rather gives them the option to just know their own status and make their decision to not go out of their house without having to get government involved, because there is a lot of fear of government.
Q: Just one quick follow up, if I may. As you know, none of the antigen tests were cleared by FDA. We have a labeling for asymptomatic screening. But HHS has sort of said we’re not going to enforce it, go ahead, use it for a systematic screening. Does that introduce any issues? Are you worried about their performance when used outside of what they were FDA approved for?
MICHAEL MINA: I’m not. But I think using it for asymptomatic screening, we have to understand what the results mean. And so anyone who’s doing systematic screening at this point, I hope if they’re using antigen tests that their goal is to find transmissible people, not to find people who maybe were infected. It shouldn’t be used as a clinical diagnostic. And somebody is asymptomatic because if the virus is in your gut, as one example and it’s already migrated down away from your trachea, it’s simple. And you no longer have it in your nasal pharynx, but you might still have RNA fragments there. So PCR would still pick it up. But an antigen test might not. So I think if it’s going to be used for asymptomatic screening, we just have to be very clear of what the goal is. And in my opinion, my very strong opinion, the goal, if you’re using antigen tests for asymptomatic screening, is to find transmissible people. I think that, you know, there’s been a lot of questions and a lot of scientists have said, well, we don’t know how these will work for asymptomatic people. We’re doing the trials. So I want to make it clear that we’re trying to understand, we’re trying to get the data to show that this works. But for me, if your goal is to find people who are transmitting virus, they’re probably going to be very similar in terms of viral, of a viral load isn’t and transmission is known, if anything, and asymptomatic person to transmit virus and asymptomatic person would have to have a higher viral load, actually, than a symptomatic person because they’re not necessarily coughing all the time. So you’d actually you’d expect that these might even end up working better to find an asymptomatic person who is able to transmit virus.
So I think we’re going to be doing the trials for that. But I don’t expect that the performance will for some reason, the virus is the same in a symptomatic candidate, symptomatic person. So I think that the terms will be the same. Given a certain amount of virus that’s in a person’s needs of parents or in their in their nose or saliva, I do think that the decision to go around the FDA was an interesting one. Not only did HHS suggest that these be used off label. But what was really profound, and I don’t necessarily disagree with the decision, and then it just would have been better if there was coordination, because we don’t want the public to lose faith that our agencies can work together, and we don’t want confusion. But they actually went a step further and HHS not only said we are giving you sort of the green light to use this off label, but they also said and we’ll cover you using a prepacked will actually shield you from location things they’ve got things go wrong. And that’s a pretty extraordinary step, I thought. And it was not hugely reported that that was part of it, but it was really a full-on suggestion by HHS to use these off labels, not just sort of an allowance. And so I think that that reflects some willingness at the federal level to do asymptomatic testing, which completely conflicted with the other guidance that apparently HHS put down through CDC inappropriately. So I think I just wish there was more clarity by everyone. It’s confusing the public. It’s even confusing positions. And I think it’s a serious problem that we have. But I don’t need to tell anyone. That’s obvious. It’s the problem.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. Can you hear me?
MICHAEL MINA: Yeah.
Q: Thanks for doing this. So just to go back to a little bit of the business of predictions, moving forward into colder weather, what do you sort of make of the whole twindemic debate of cold and flu, particularly given that since people are already doing social distancing anyway? And just sort of related to that question, how much do we know about how much the cold weather affects personal immunity and whether sunlight and its impact on vitamin D and how that affects immunity? Or is the jury still out? The reason I ask is, you know, do we know enough to say that, you know, socially distanced gatherings outside in summer, the same level as socially, distanced gatherings outside in winter. You know, can you put a space heater up there and expect it will be OK? Or are there other factors going on in winter that may affect things? Thank you.
MICHAEL MINA: The second one is an astute and terrific question. And I’ll answer the first, the twindemic, if you will. I haven’t heard it called that, but I guess people are calling it. I think it’s important to recognize that one of the reasons we’re pushing flu vaccines is because flu, we don’t necessarily want. We don’t want these two viruses to become conflated with each other. We don’t want to necessarily have to close down schools if the child has flu and it’s mistaken for COVID. So it’s just important to try to get as much a handle on the one virus that we have a better handle on, to help us. Not so confusion between the two viruses. And I do think, though, that, in general, I imagine my expectation is that our precautions that we’re taking for COVID will very likely extend. I mean, biologically, they will extend to flu. We should anticipate seeing that in places that are social distancing and wearing masks, we should expect to see less fluid than we would have seen otherwise seen. Now, every year we have different types of flu epidemic. Some years there big some or small. So it’s going to be hard to compare. You can’t just say, compared to last year. Maybe you can compare it to the distribution of flu epidemic that have happened over the last 10 years. And if this one turns out to be only 20 percent, the number of cases, then that’s pretty suggestive. But I think in general, we should anticipate that if we’re doing everything we can to prevent transmission of this coronavirus, we will. That will extend to preventing transmission of flu. And I think we should learn from this pandemic. It goes a little bit away from your question. My hope is that we become socialized to things like how to deal with a virus when it’s transmitting year after year after year. We do nothing. We do nothing to try to abrogate flu epidemics. We just get vaccinated. We don’t change our behavior for the most part. We don’t wear masks. No, it’s just not part of our culture. And in many of Western countries and most of the world, really, except for some of the Eastern countries. I hope that that will actually be able to make some changes to our society. Maybe it will become normalized to wear a mask. Swine flu season comes around, and I’ve been really pushing for a public health tool. Part of what I think the infrastructure of public health in this country and across the world should be, we should be building immunological observatories. And that’s what I call it. I want to build a global immunological observatory which essentially just monitors the country and monitors the world. But we could serve the country. Every major city, for example, we’d be constantly monitoring people for like just using ready to access blood samples for antibodies against influenza and COVID and all different viruses, and then we can start to predict where viruses are going to be and when we can ask communities to mitigate outbreaks before they get started through. For example, putting on masks when they go out outdoors, you know, even it’s just going to work. Can you do that for a month? And maybe we see much, much lower flu outbreaks.
I’ll get to your last question in just a minute, but another thing that I haven’t seen written about too much, but which I’m concerned about is with regard to this twindemic idea. If we do really suppress flu this year, we’re not really sure what that means for next year. We could end up having a much larger outbreak at a much larger epidemic coming in a year from now as a result of suppressing flu this year. And that’s because we know that influenza kind of like COVID, we know that antibodies and immune protection for flu, it can last for very long. But there’s also there’s different sort of levels of immunity. And we know that some fraction of immunity does wane potentially within like six or eight months for flu from year to year. Part of that’s because the virus mutates. And part of it’s just because our immune systems don’t do a great job of being immune to flu. And so if we go a whole year without sort of restimulating and re boosting our immune responses because an epidemic doesn’t really grow, we could be more vulnerable population to flu in 2021. And I think it’s something that we’ve been modeling out and mathematically modeling, and I think we should be aware of it moving into next year. The winter question is a really interesting one, I thought about that myself a lot. And the reason I thought about it is because the what we know about coronaviruses today are generally from testing and obviously, when I give talks, for example, I showed a slide that shows the extreme seasonality of coronaviruses. And one thing that’s gone through my mind quite a bit is we only test for coronaviruses when people have symptoms of coronaviruses or of respiratory viruses. But it doesn’t necessarily mean that these viruses don’t often also transmit in summer months at some level. But it could be that people are just not getting sick from the virus in summer months if they get infected. Of course, this virus, we’re seeing a lot of people get sick. So that’s kind of giving us a better window. But I guess what I’m getting at, the real crux of what I’m getting at, is we don’t actually know if just being in the cold, dry winter temperatures, if it may have some impact on severity of disease and our ability to control the virus. Maybe the virus doesn’t get caught up in as much mucus, for example, because our throats are drier. So these kinds of questions, I think, are really important. We could have more fragile epithelial cells in the in the winter months or older cells. And so I don’t know that these are well defined parameters of this virus. And I think it’s at least worth exploring and asking the question you asked, which is, is there a potential that we’ll actually have more severe disease just as some reflection of absolute humidity and weather-related events? And I would say we’re not really quite sure. But I think we should absolutely be monitoring it closely.
MODERATOR: Do you have a follow up?
Q: No, thank you.
MODERATOR: Great. Next question.
Q: Hey, thanks very much, Dr. Mina. My question is not about winter, but what you just said was totally fascinating. So thank you. I wanted to pick up on comments you were making earlier on testing and what we need to do to get ready for the next pandemic. So I just wondered if you could talk a little bit more about that, about what testing system would you have to have in place? I guess a public health level and also at the individual level. What would you have to have in place in so-called peace time, I guess, to identify the next new pandemic potential pathogen at the earliest possible signal?
MICHAEL MINA: Yeah, so I’ve been calling for a few years for this idea of an immunological observatory. And really what I’m calling for when I say that is surveillance. But the nice thing about the immune system is every time and all of us, every human, most animals as well, we evolve to have little recording devices inside of us. And we can all act as sensors for infectious diseases. And when we come in contact with them, we record them, and we record them in our cells. And what’s really nice about that is we’ve spent a lot of years, my lab, other labs in the world, and scientists from the world in understanding how to decode B cells. Now we know how to read them. So this is like imagine if you had a computer that was just always recording and monitoring and listening, but it had been encrypted for all these years. And then you figure out how to decrypt it. Then all of a sudden, you can use that as a powerful system to monitor whatever it is you might want to monitor. I think a B cells in our immune system in very much the same way. We’re all a little recording device. We can’t get around it. You know, it could be for bio threats. It could also be for natural pathogens like this virus, and it can be used. The nice thing is there’s a lot of people who readily give up their blood every day. That’s for things like blood donations, which we’re not getting away from. Blood donations are extraordinarily important. Plasma donations. It’s also hospitalized people, and also even just saliva. We can do a tremendous job getting antibodies out of saliva. And now we have technology. For example, my lab and I was at Harvard, we’ve been building tools to profile somebody’s antibody repertoire from five dollars or so. If we really want, we can test for a hundred and fifty thousand distinct antibodies in a drop of blood, just a drop of blood that you find on a paper on a on a dried blood spot card. We can essentially look at somebody whose entire immunological history, and so say we know that 80 percent of blood donors are repeat blood donors. They give blood, you know, every few weeks or every few months. And so that makes a really powerful set of data. If we were just monitoring the blood system, which we already have to do anyway, because we have to test blood donations before they get given other people. That becomes a very powerful tool. We could do that globally where we just start using these really high throughput novel antibody testing instruments and tools that we’ve been building to essentially just start monitoring the global blood supply every day and in every major city in the world. And that alone, if we were doing that in February, I was trying to get this set up and get it funded by Gates, and Wellcome Trust and things like that years ago at the time, there was little appetite for it. But if we had this running, for example, in the United States and in last year and into this year, we would have detected this novel coronavirus before any PCR test in the US was ever done for it. It would have been abundantly clear that the virus was transmitting in New York and we would have that would have given somebody like Governor Cuomo the firepower and the data needed to say, hey, this is already spreading, we don’t have any viral testing for it, but we see immunologically that people are getting exposed to this virus and we need to shut the city down in February. That could’ve potentially saved tens of thousands of lives if the data was there to give policymakers the the information they needed at the right time. So I think what I’m getting at is there are ways to have sustained surveillance systems. I essentially want to make a weather system for viruses where we can all go on. We can log onto our phone and say, hey, what’s the rhino virus or coronavirus or influenza virus look like in my town or my county or in Uganda? And that alone would give us just a tremendous amount of information to follow novel viruses, follow the regular ones that are making our kids ill, especially moving into the future. We’re going to want to know if I have a child, and they are sick, for years, potentially, now we’re going to be worried that every time our kid is sick that they have coronavirus. And we would I would be a lot better if somebody could open up their phone and say, oh, no, it’s okay, you know, my county is seeing a real elevation in rhinovirus today. It doesn’t matter that, you know, it’s unlikely to be coronavirus. And so that kind of thing, I think could be extremely powerful for public health surveillance. So that’s the surveillance piece. And I think our immune systems can be absolutely crucial for it.
And the other thing, the reason why immune systems are so good is because you don’t have to find somebody in the act of being sick. If you’re just monitoring lots of people and most of them, you’re just getting a blood sample from every six months or so. You have sort of you have information from them, see if their antibodies look like this, like this, and then I’ll suddenly see a shift. And you can know that sometime in the last six months they got a new exposure. The other piece that I think we should actively be doing right now is treating this. We need to change our thinking about what natural threats are. We have the Defense Department, which they defend from foreign enemy as being foreign human enemies. And then also bio threats. But they make it clear they draw a clear line in the sand that the Defense Department might be interested in bio threats, but not natural bio threats, not natural things like this coronavirus. But that’s really bizarre that we don’t treat this with the Defense Department type of approach. And if we did, you know, I think one thing that we can be doing for the next pandemic now is we do not want to find ourselves blind again as the next virus comes into our country. So some of it that it might be immunological surveillance, but if once the virus is in, we need to find who’s infected when we can’t deal with the very poor infrastructure that we’ve had. We should be building bunkers of testing. I mean, this might sound crazy, but I don’t think it is at all. We should have bunkers of tests and test machines, rather.
And we know how to test for viruses. We were able to get the first PCR test going in China, and within a month of just first discovering the virus. So we know that in general, these are any natural threats that are going to spread like this. You’re going to be viral. We’ll know we can pick them up with PCR because PCR, anything that spreads is kind of a genome. So we just have to we have to bank huge numbers of PCR tests, high throughput ones like the Roche instruments, things like that, and just start building up an armamentarium of them, have them in different regions in the United States, have maybe 10 regional laboratories, each of which can process five million tests a day. Now, we could do this with a fraction of the defense budget and just stock these things in the same way that we stock missiles. There’s no reason not to. You could do it for 10 billion dollars. We could have 10000 high throughput robots scattered across this country and deployable. They don’t move around, but they stay where they are, and we deploy the National Guard or something to run them. This shouldn’t be difficult. These are difficult things to do. These machines, the ABI 7500 that CDC wanted everyone to use, these are decades old machines. So they don’t go out. They don’t go out of style. They don’t go out of technology. And that’s the good thing is RNA and DNA is always going to be RNA DNA.
That means we can always use the same instruments to read it. Insurance will get better. But what we’ve put in place now will still be good 10 years from now and maybe we just keep updating it. So I think if we don’t start doing that now, then we are just setting ourselves up for failure for the next coronavirus or the next flu pandemic that comes around into our country. There’s no reason we’re not doing already.
MODERATOR: Do you have a follow up?
Q: Just a quick one. Thanks for that. You mentioned trying before this pandemic to get funding for the immunological surveillance. And are you still trying to get funding or what’s the status of that?
MICHAEL MINA: I’m trying. There was a lot of interest from private funders as the pandemic came in. But then, unfortunately, the antibody testing got a terrible wrap because there were a bunch of really terrible antibody tests that came onto the market. And pretty much everyone lost their interest in serology, and it’s because we had a lot of people, a lot of scientists starting to do serological surveillance and not understanding how the immune system works. The number of cancer doctors and orthopedic surgeons who decided that they were going to become serological epidemiologists overnight was astounding. And what happened with that was we had a lot of people making bad decisions about what tests to use, and it caused a lack of confidence in antibodies. Antibodies are still the most powerful public health tool we have. I think for monitoring populations. And so I’m still plugging away, trying to do it. But, you know, I’d really, I think that this should be funded. I have nonprofit business plans for how all of this can work, how it can be sustained. It can be extremely cheap per sample. You can run tremendous numbers of samples, even just in a single lab. You can distribute the labs across the globe in many ways, like how we have weather stations and weather buoys. So I’m still trying to figure out how to get it funded. And I’m going to keep working on it. We published a paper in e-Life a few months ago. I think that title was something like “A global immunological observatory for a time of pandemics”, and it kind of lays out what I think needs to be done. I was the first author of that. I looked it up, but I would like to get it, funded it, and I think it should be funded across the globe. It’s not a moneymaking thing for me. It’s a it’s a public health tool. And I don’t know somebody who reads any of what you write wants to fund it, they can call me up or call the governor or the government and tell the government to do it.
Q: Great. Thank you so much.
MODERATOR: Next question.
Q: Thanks, Mike. I appreciate it. I want to go back a little bit to testing, and I wanted to ask you about saliva tests. You’re speaking about how we sort of need to make these more available and accessible. And I would love your perspective on the point of care tests like saliva tests that people can do in their home in ways that we might be able to connect those to an app that could that make reporting easier as well, and perhaps people doing it on their own might be more willing to submit to that and agree to that. Could you just talk a little bit about the science behind this lab tests and also what role you see those types of DIY point of care test play?
MICHAEL MINA: Yeah, I mentioned a little bit about this before, so I want to make it very clear that the saliva is just one way of collecting the virus in a person. It can also be a nose swab that you do on your own or saliva. So both of those can work. So I just I’ve seen a lot of confusion, people equating saliva. It’s not so rapid. But like saliva, direct is not a rapid test. It’s just a saliva tests that goes to a lab and PCR based, for example. But in any case, I think that these tests can be they can be set up to require or not require some sort of outlet, because they want to increase access to the most. But they could come within what Abbott has produced. Abbott produced with the Bionics. Now it comes at the right spot. And do you scan a QR code in it and it’s designed so that it could report the result. Where does report the result currently? And so I think that there’s a lot of utility of that type of approach. And I can’t imagine that we won’t see a huge number of third-party apps search be developed. I want Google, you know, don’t want the federal government essentially to create a Web site or create a suite of software tools that can be extended to anyone, that there will be certain things about each of these tests that will be different. But the reporting cannot be the same and it can be centralized. It could potentially go out to each individual. Once somebody reports it, it can go to the federal government, for example, and then from the federal government, it can be spread back to the state and county levels as one example. And I think that that is something that we can do so we’re not asking every county, every state to recreate their own software. And this is something, you know, that’s the kind of software you put Google. Ask Google to do it by the federal government contracts that Google make it. They could probably do it on a weekend to make software that would really do the job. And so it’s not much software to produce. And I think that there’s a huge role for it in these distributed tests.
MODERATOR: Do you have a follow up?
Q: Yes. Just a quick follow up on the saliva itself and what we know about the science, I think early on, if I recall, there was some question about how good a medium saliva was for picking up SARS-CoV-2. How is that evolved? And where are we now with understanding saliva versus the nasal pharynx, for example?
MICHAEL MINA: Yeah, I think saliva has some benefits. It’s easy to access. It has some drawbacks that it wants to be a collection has to be right. It has to be kind of getting saliva from, for example, in the glands, from under the tongue and a lot of people get confused like saliva and stuff and get sputum instead. And so it’s a very heterogeneous matrix, but it can be used. There is a nice paper in New England Journal not too long ago, but in our last topic, and that was essentially showing that in given samples, you can see that saliva can be as good as it is pharyngeal swab. But there’s been really conflicting papers as well over the months. Some of them show that saliva is less reliable. Some show it’s more some show it’s on par with a front nasal like stuff like the nasal swabs. I’m sure it’s better. So to the jury is still out there about the real role. I think what we do know is that there is a potential for it, that it can be used, and it can be a very powerful tool for this.
This concludes the September 18th press conference.