You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Michael Mina, assistant professor of epidemiology. This call was recorded at 12:00 p.m. Eastern Time on Friday, October 9th.
MODERATOR: Dr. Mina, do you have any opening remarks?
MICHAEL MINA: No.
MODERATOR: OK, we’ve got a bunch of questions, so let’s get going. First question.
Q: Hi. Thanks for doing this. I was wondering if you could just give us the lay of the land on the pandemic right now as we head into the colder months and then kind of talk through what might be driving the increases we’re seeing in the Midwest. We’re also seeing some increases in the Northeast, which, you know, we’ve already had the large outbreaks there this spring. Is that an indicator of what’s to come with the fall and winter?
MICHAEL MINA: Yeah, I would say in general, the lay of the land at the moment is that we are still running headfirst into the fall and winter. We still have tens of thousands of known cases, probably hundreds of thousands of actual cases happening every day that could be detected. And what that means is that we have a tremendous number of small little outbreaks ready to sort of burst. I recall months ago, this is still in May or something, I was talking about this period of time back then and saying that if we end up in the fall again, this is when there was a lot of media attention in the late spring asking if things are going to die out in the summer. And essentially what I said then is very similar to what I’m saying now, which is, yes, things got lower in the summer partly because of reduced transmissibility, but still the force of infection allowed transmission to persist.
And now what we’re seeing happening is that we’re moving into the fall and the winter, which is generally the season that’s most ripe for coronavirus. And instead of having a handful of cases like what we saw initially with the epidemic in February and March through imports, we have tens of thousands of cases, if not more already to blow up. And I like to think of this as a forest, there’s a lot of leaves on the forest floor and now instead of just a couple of sparks on the perimeter to sort of ignite the whole thing, we have a huge number of little sparks that are happening throughout the entirety of the forest. And so, the moment that things get dry enough in that analogy or in this case into the winter, we’re likely to start to see massive explosions of cases and outbreaks that could potentially make what we’ve seen so far look like it hasn’t been that much. We don’t really know when exactly this particular virus’ most transmissible period of time will be. If it’s November and December, then what we saw last year was really just a taste of things to come because we didn’t get the cases really imported until after that window of time. And so, I think where we’re going right now is, we’re charging headfirst into the fall in winter. And we can’t stop that because that’s time and it can’t be stopped. But what we haven’t done is we haven’t figured out how to actually get the surveillance and testing apparatuses up and running. We haven’t actually come up with a plan yet. We have spectacularly continued to squander any effort and time that we’ve had. And we’re pretty much moving into this fall and winter despite everything, we’re moving into it without many more tools than we started with back in the spring. So probably we’re going to end up in a place that we’re really not happy with. I anticipate that things will start to open up at the same time as transmissibility is increasing. And that’s kind of what we’re seeing. And we’re starting to see cases increase at this point in time. Slight increases in cases that we’re starting to detect all over the place are likely a result of things opening up and people spending a little bit more time indoors because things are opening up. And as the weather continues to get colder, that will continue to increase even more. Then you get this perfect storm of people moving indoors and opening up the economy and opening up schools, which this was always expected to happen at the same time as the transmission is really becoming optimized. And I expect that we’ll have to make some really hard decisions again. Will it be that we closed down again fully? Or will it be that we choose a lot of infections? And if that’s the case, we still haven’t really done a good job that figuring out how to actually keep vulnerable people safe. We can do it to a certain extent when transmission isn’t very high and when case counts are pretty low, we can do a decent job at stopping spread. But in general, that’s kind of where we are. And I think that the moment we have very wide scale community spread, it’s going to be incredibly difficult to stop spread from hitting our elderly population or even just all the people out in this country who are 60 years old and above, all of them are pretty high risk levels.
MODERATOR: Do you have a follow up?
Q: I’m OK. Thank you.
MODERATOR: Great. Next question.
Q: Hey, Michael. So, there was a study published earlier this week in clinical epidemiology which looked at thirty-six thousand people. A couple of really remarkable things in this. First of all, only 115 were positive, but that seemed suspiciously low. This is from April through June timeframe. And then of that group, eighty six percent reported no symptoms. So I think that’s really interesting. I was wondering if you could comment. We see that again and again. I was wondering if that offers any hope in terms of if we’re closer to herd immunity than we think. And certainly anecdotally, I’ve noticed that people in my life who were under 55, a lot of them don’t experience any symptoms at all, ever. So, the question is, on herd immunity, does that mean that maybe we’re closer than we think?
MICHAEL MINA: Yeah. So can you just repeat those numbers that you said at the end?
Q: Sure. So they looked at thirty-six thousand total. And of those, 115 were positive with SARS-CoV-2. And of those, 99 reported no symptoms on the day of the test. Now pushback, OK, so maybe they had symptoms two days later. So is that really meaningful? But in any case, we see this time and again very high, low, non-symptom rate. And I wonder if that speaks at all to whether we’re closer to herd immunity than we think.
MICHAEL MINA: Yeah. And that was viral testing, not serology, is that correct?
MICHAEL MINA: So that’s still point three percent. That’s not a small number. That’s actually for antibodies, that’s a small number. But for current PCR, that’s actually a pretty high number.
MICHAEL MINA: Point three percent. You know, if we had, say, an order of magnitude more than that, let’s say we had three percent on any given day, we’d be a herd immunity in a few weeks, you know. Not a few weeks, but a couple of months. So that’s actually I would say that sets the bell for what we know of this virus and where it’s spreading. And, you know, if there was a major outbreak happening in a major city, for example, then we might expect that to be a very low number. But just for kind of average testing these days, that makes sense. Does it mean that we’re closer? I think that I do believe pretty strongly that there is a lot of cases that go completely unnoticed. I’ve been saying this since January.
Q: Yeah you have.
MICHAEL MINA: And I think that probably we have had many more inspections that are than are showing up even with serology, because we know that. And also, as expected, antibodies to this virus may not their primary election doesn’t mean the immune memory is not there. It just means that the antibodies signal disappeared. These cells could still be there. So absolutely, I think it could mean a means to a couple of things. I think that our actual case fatality rates are probably still a little bit high. I’ve been saying we should never be talking about a case fatality rates for this virus or I should say infections fatality rate. It is such an extremely skewed fatality rate that talking about the average doesn’t make any sense because I mean, doesn’t make any sense at all. So I think on the one hand, if we were going to talk about an average, it’s probably lower overall than we have estimated. So far, it’s pretty similar at the higher range of ages, but it may be lower overall. And then from a perspective of how many people have actually been infected or not, are we closer to heard immunity, I think in cities maybe. Well, I actually don’t think that we really have anything remotely close to what is really needed to get to herd immunity. But I think often times we forget that herd immunity isn’t a binary thing. Like immunity, like sensitivity, like anything in biology, it’s a harder thing to think about, but it’s all on a gradient. You can think of it as just deceleration. So we’re taking some acceleration away. And so the closer we get to herd immunity, even if we’re not there, we’re slowing cases down. We’re achieving some levels, which is why we continue to vaccinate for flu, for example, despite knowing that not everyone’s been vaccinated, and the efficacy is poor. We know that every little bit counts. And so I think we’re a little bit closer than probably what the official estimates are. But I don’t think we’re that much closer.
Q: OK. If I could just ask one more and sorry for all the numbers, but so we see the case rate rising and then the question is, does it matter from a potential lockdown perspective? So one way to think about it is, OK, so decomposed by GDP. So what you find is that cases are rising in areas that produce 60 six zero percent of the nation’s GDP. That’s interesting because that’s high, but it’s not 90 percent. So do you have any thoughts on that way of thinking about things? And secondly, just really quick. Wisconsin is reporting 80 percent hospital capacity use. That’s scary high. That seems to be what tips politicians over into lockdown. And I know that you work in a hospital as well on the side. And so just that question like, are we going to hit that point where hospitals are full, and politicians freak out and close down the economy. So those are the two points I wanted to ask about. Sorry for taking so much time, but that’s it. Thank you.
MICHAEL MINA: Yeah, I think it should be concerning to everyone that cases are increasing. It just should be because I don’t think they’re going to slow down, you know, we’re no longer in a position where we’re trying to slow cases. We’re in a position now where, predictably, people have gotten some bit of apathy around this virus. They’re tired, rightly so. People are asking. Yeah, COVID fatigue. It’s a real thing. It’s a psychological thing. And so I think what that means is we are going to see cases continue to rise without slowing. This is the opposite situation than we were at in February and March when all options were on the table in terms of shutting down. And now we’re going to see massive resistance around it. And so as long as cases are continuing to accelerate upwards, I don’t see that trend going down either till we lock down, close down or until everyone starts really being diligent about wearing masks and trying to social distance as much as possible. Otherwise, I think we will continue to see a hospital slowly fill up and that will become the point, you’re right, when politicians say, OK, you know, this isn’t good anymore. But we shouldn’t ever get to that point. We should have had this virus controlled already. In terms of the economic issues, sure. Jim Stock, an economist at Harvard, and I did some research on this. And we put out a paper called re-opening scenarios. I don’t remember where it’s published. But in any case, what we were looking at there is really, are there efficient ways to reopen while keeping cases down while balancing economic features and sort of what sectors are maybe most or least appropriate to open up immediately? And I do think that all epidemiologists should be thinking along those lines, too. And that’s how the government has to think. You know, we can’t just take a biased view of only the pathogen we have to be. We have to be considering the economic ramifications of our decisions from a public health perspective, regarding the virus. Because if we take those too much to an extreme, I’ve been very worried, as well as Jim Stock. And the reason we did all that work is because we’re both very concerned at this idea that maybe the economic toll could ultimately be worse than the viral toll would have been. So they have to be balanced appropriately.
Q: Great. Thanks, everyone, for your patience.
MODERATOR: And I will say really quickly that the link to the reopening scenarios paper is in the Zoom chat, if you’d like to take a look at that. And also, we’ve got a lot of folks on the call. So I’m sorry, Dr. Mina, if you could just maybe keep your answers a little bit shorter, that’d be great.
MICHAEL MINA: Sure.
MODERATOR: Next question.
Q: Hi. Thank you, Doctor. Can you hear me?
MICHAEL MINA: Yeah.
Q: So I am a reporter from the paper. I have been following the news about COVID for a long time. And I don’t know if you noticed that today, China has officially joined COVAX. And as there are a lot of countries joining COVAX and Americans haven’t joined it, I just want to ask, how influential is this authority and do you think problems lies in the future, and what does it mean that China joined this, and America didn’t? I guess that’s my question. Thank you.
MICHAEL MINA: I think it’s reflective of the increasingly prominent position that China is starting to take in the global economy and in the leadership that China, to a large extent, is taking over, in this case over the United States. We have decided that isolationism is a policy that we’d rather go with. At least this administration has, at least as far as being greedy about things like vaccines. And I think that it’s disappointing as an American to see that we are unwilling to participate in the global community in a way that makes the most sense. And it’s heartening to see that China is willing to sign into that and agree to be an equal player and a participant in a more global economy. I think it’s reflective of the future years to come. China will overtake America. I mean, I’m not an economist, so I’m just saying words now. But I do believe that China will overtake America in terms of its economic productivity, its leadership and advancing technology. The US has decided that science is not the direction we want to go anymore, and we want to regress. I think our decision to not sign into the pact and the Paris climate agreement. I think that all of this is reflective of a regression on the part of the US. And I’m very glad to hear that China has decided to sign into COVAX because it’s the right thing to do. And I think that it should be a warning to the American government that we’re falling behind not just in many ways, but also in the relationships that we’ve spent decades building with the globe where we’re really isolating ourselves here.
Q: So what’s your comment about the authority of COVAX. Do you think it’s really influential or there will be a lot of problems in the future?
MICHAEL MINA: Oh, well, I think it’s necessary. And in a way to ensure that vaccines can be distributed. I think it’s an influential pact that countries are signing into. We’ll see how it actually works out if countries agree to it, especially in the midst of what will likely become increasingly large outbreaks in places in Europe and the US and globally. If people will continue to participate in it and really follow its guidance and not try to forward vaccines, it’s going to be really an interesting question to see how it plays out. But I do think it’s a very important agreement to put in place.
Q: Okay. Thank you so much.
MODERATOR: Next question.
Q: Hi, Dr. Mina. Thanks for taking this time. I just had a question about the NFL we’ve seen now here in New England with the Patriots at least like three players who have been infected with COVID-19 now. And we’re seeing across the league more teams being impacted. I was wondering, what do you think the NFL’s policy has been? You know, we’ve seen how leagues play in a bubble. The NFL has chosen not to. Do you think it will be successful at trying to keep cases down as we continue through this season?
MICHAEL MINA: I think it’s still doing a lot of testing. It’s not bubbled in like the NBA, but it is doing a lot of testing. And ideally, I don’t know what kind of behaviors the players are having with regard to masks and distancing. But they have a lot riding on remaining not infected. And so my guess is that they are probably adhering, at least in part, to those policies. I think it probably won’t be as good as the NBA’s bubble, but probably they will do an OK job presenting wide scale spread. But you never know. I mean, it just takes one person like we saw recently in the Rose Garden. It takes one person to just have an unlucky situation where they’re super spreader and they walk into practice, into the locker room or whatever, and inject a whole lot of other people, especially if they don’t have their masks on. And so I think it’ll be hit or miss. But I think in general, the type of testing they’re doing and as long as they’re also wearing masks, it will probably do a pretty good job. We might see a slow trickle of people getting infected and then recovering. But ideally, without massive outbreaks throughout the league.
MODERATOR: Do you have a follow up?
Q: I don’t, no. Thank you very much.
MODERATOR: Great. Next question.
Q: Hi. Thank you so much for taking the time here. We’ve seen a lot of colleges and universities say to their students that if you’re going to travel home for Thanksgiving, then you should not come back to campus. You should stay there. And in a departure from that a couple of days ago. Northeastern University said they would welcome students back after Thanksgiving travel with the caveat of the testing that the university has been doing. You think that’s a mistake by the university? From a public health standpoint?
MICHAEL MINA: I don’t think it’s necessarily a mistake. I think, again, it’s balancing competing interests and society versus the virus in some ways. And, you know, the reason these schools and so many institutions have employed very high throughput, high capacity frequent testing is to account for situations like this. Now do I think it will necessarily work? I’m not sure. But do I think that the testing so far has suggested that it is possible to keep outbreaks at bay through frequent testing. I think we’ve seen that. Now, we have seen where it takes a little while. We’ve seen outbreaks happen at Cornell, at Illinois, but both of those are actually good examples, despite some recent articles that kind of said the contrary. But Illinois, they’re really getting their cases under control through frequent testing. And I think in general, we’ve probably learned a little bit more even since we did, you know, just over the last couple of months about school testing and frequent testing. And I think Northeastern, as long as they’re really engaging with very frequent testing and ensuring that people, when they do arrive back, should be increasingly diligent about wearing masks, you know, those policies, I think, should be put in place. If you go home maybe your even more restrictive when you come back about wearing masks and social distancing and ensuring that you get tests. Maybe they could test every two days for the first week and a half that somebody is back, for example. So I don’t think it’s a mistake. But we have to wait and see how it actually shakes out.
Q: And then just a quick follow up. If you were to offer advice to students or their families who are unsure if they should travel and get together for Thanksgiving, would you say that if they wear masks, if they travel in a relatively safe manner, that that’s a reasonable thing to do?
MICHAEL MINA: I think if people are traveling, I would try hard to really travel safely, wear a mask where an N95 if you can, even though N95, you know, they’re not officially supported and the CDC is not recommending it. But you know, at the end of the day biologically, if you get a good set of an N95, it’s going to go a long way. Especially if you’re going to go and see vulnerable people, I think that there’s a lot of risk and we might see it. I think we’ll probably see an adverse effect of the holidays on cases. And we actually see that a lot with, you know, this famous time series for measles and other infections where we know that when people go home or then go and start school again. This is the time when outbreaks happen. So I think that people have to be understanding of the risks that are taking. I just saw my family recently. I wore an N95 on the plane. I was in a special position where I was able to have rapid tests that are being trialed. And so I brought them with me just to use rapid tests on a daily basis while I was with my family to ensure that I didn’t get infected on the plane or something and then bring it into my family’s house. But I think that this is something we have to figure out how to do properly. And this is one of the few areas where I agree with the president in a very small way, which is we can’t completely disrupt all elements of society as a result of this. But where I completely disagree with this, I just wish we had this virus under control for good leadership first and then we wouldn’t have to be having this conversation. But, you know, I think people are going to go home. They’re going to have to see their family. This is just a part of being human. We can only go so far with distancing. And I just hope that everyone is very safe. And I think it can be done generally safely. But I think it will probably lead to outbreaks, and that’s unfortunate.
Q: Thank you.
MODERATOR: Next question.
Q: Can I just ask you; you know, people obviously have been looking at the death rate. We’re seeing fewer deaths recently. What is going to happen once we get to the fall and winter? I mean, you talked about how tough it’s going to be in terms of an increase in infections. Do you think we’re going to see the number of deaths go up? Kind of like we saw earlier in the year.
MICHAEL MINA: Yeah, I mean, in part, the falling death rate is a feature of a couple of different things. One is we’ve actually learned how to keep people alive better through things like Remdesivir, through very simple procedural changes, ventilated patients and how we position them, for example. So we’ve actually figured out various ways to treat this virus that is improving our ability to keep people alive. So that’s important. And I don’t think that’s going to change. We’ll hopefully just keep getting better. I know what I really want to see, and I’ve been saying for a long time that monoclonal antibodies, I think we should be putting perhaps even more early money into the monoclonals than vaccines just because I mean, we have to do both. But I think that if we can figure out how to get a therapeutic that can actually keep people alive, then that’s a huge advantage and changes our risk benefit equation quite a bit. But then what we don’t know are a couple of different biological features. So I think that as we move into the winter, we’re going to see more vulnerable people be put in more risky situations because they’re going to be moving indoors. You know, we’re going to see that instead of elderly groups and senior living centers having meetings outside, they’re going to have them inside. People’s families are going to come inside to see their family members. And so I think we will again see an increasing number of vulnerable people be put in a position where they can get infected. And that’s a feature of just the weather and temperature and things like that. Couple that with potentially increased transmission as a result of weather. And that sort of starts to have synergistic effects to increase the risk to people. So what we’ve seen so far in the summer, as things moved into the summer, we’ve seen a younger crowd of people get infected some bit because they didn’t care. And also because they were willing, you know, while older people and adults or people were really doing their due diligence to stay away from others because they were concerned with a lot of younger people just getting infected through partisan and just being a little bit just more social and a little bit more reckless. And so that drove the mortality rates on an average, if we’re just looking at overall rates of death per case down. But we’re going to see probably the age distribution shift up again with the winter as transmission increases. And furthermore, one thing we don’t fully understand, is there actually a biological relationship between severity of disease and the weather? And we don’t know this. And there is some research going on about it. But is it actually that as you start breathing in drier air, for example, cold, dry air, whether it’s to keep our house or just being outside in the winter? Does that actually cause our tissues to in our defenses to lower a bit? And a number of other reasons why people might get sick in the winter given the same viral loads, for example. So we’re not sure about that. But on all of that, it could potentially factor in and I think we should anticipate seeing the mortality rate kind of increase up again in terms of deaths per case.
MODERATOR: Did you have a follow up?
Q: Just very quickly, when you talked about the kind of biological considerations and the weather, I mean, you mentioned severity of disease, are you also talking about just the spread of the disease in general, or are you just saying that we don’t know if people will just get a lot sicker in the winter because of these factors having to do with the weather?
MICHAEL MINA: Yeah, and a lot of people aren’t saying or suggesting that. And I’m just surmising here that that could be something, that’s something we should be researching, which is, are there biological factors that go into people actually getting sicker in the winter, given the same infectious dose in the summer versus the winter? And is it that our epithelium actually gets drier and more apt for viral growth and things like that. You know, we’re just not sure about some of these things and they haven’t been very well studied. Are there features of our immune system that are truly seasonal? We don’t know that either. It could be the case. I don’t know. It’s hard to think of some of the reasons why that would necessarily happen. Those are the pieces that I think we don’t know a lot about. But I wouldn’t ever discount them as possibilities. I wouldn’t ever discount the idea that people could get more severe illness given the same infectious dose in the winter versus the summer.
Q: Thank you very much.
MODERATOR: OK. Next question.
Q: Hello. We have seen a lot of colleges that have been allowing limited attendance at football games. And I’m wondering how important is mask wearing at these games, even if it’s outdoors and its distance with small groups of four?
MICHAEL MINA: I mean, there’s no reason not to wear a mask at a game. I think even if its outdoors, people are still near each other. And I mean, if it’s truly so, if you’re with the same people who you live with, like in a suite or something and your normally around each other with no masks and there’s nobody else around, you know, maybe. But it’s just not worth it. I think mask wearing should just be a thing any time you’re in a congregate setting like a game, even if you are not around other people right in your very, very direct vicinity. you know. Not wearing a mask, that just starts to have sort of an eroding effect on sort of what people are willing to do other times to. So I think if the school, for example, says, hey, you don’t have to wear your mask, this is outdoors, on the stadium where we have people five seats apart that starts to send the wrong message at a school, for example. It’s kind of a slippery slope. And so I think in this case, the message should just be very clear. Just wear a mask. It’s not that hard. There’s a lot of masks that aren’t that disruptive to our speaking and our breathing and things like that. And you know what? I recommend that everywhere. An N95 to a game? Absolutely not. But I do think that we should just be pushing that as much as possible in the midst of one of the easiest, cheapest things we can do to just all do our part to stop this outbreak.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. Thank you so much for taking the time. I’m curious what your thoughts on the White House outbreak and the Rose Garden event are, and whether it suggests there might be a failing or a hole in the strategy of using the daily screening with less sensitive tests.
MICHAEL MINA: I don’t think that’s a hole. I think using daily screening with these tests is incredibly important. I think, though, the gap was the failure to wear masks. Every one of these is one additional layer of protection. And the daily screening, you know, we should be doing. I think we have to be doing daily screening with the tests that are available for daily screening. Now, if you have a 24- or 48-hour delay to get a result back, then that can’t reasonably be used at the site of entry before somebody walks into something like the Rose Garden. So I would say, on the contrary, that daily screening with these tests is actually probably the only thing that’s kept the president safe from COVID from March through October. He has been reckless in just about every other way when it comes to public health measures. And I mean, he hasn’t just been reckless about himself. He’s been reckless about his neighbors. And his speech and actions have been reckless to cause outbreaks, to continue to persist across the country and frankly, kill thousands or tens of thousands of additional people that probably wouldn’t have died if people just wore masks and who aren’t wearing them because of his rhetoric. And so I would say that the testing actually on the contrary is probably exactly what needs to be done along with masks and distancing. I think that a lot of people, you know, with public health, it’s really easy for public health to go unnoticed when it’s working. And this is the problem with public health in general. It’s why it gets underfunded and defunded. It’s because nobody cared. I mean, people did care a little bit about what the president was doing on a daily basis with testing. But nobody really cared that every day there were not infections happening in the White House, and then all of a sudden, when there is an infection and an outbreak, everyone cares and blames it on the one thing that they were doing, actually. But no, it should all be on the fact that they’re not wearing masks and not social distancing appropriately.
And on the contrary, the testing that they’re doing has been actually quite good. You know, assuming that they’re actually doing it daily, I have no idea how much they’re actually doing it. Like if they’re truly just doing it for the Rose Garden, if they didn’t actually test everyone, that was a mistake. And I personally think that they should have actually just built a lab and gotten a better test in the White House than the Abbott tests. But I think from a larger, more general perspective, the Abbott test is actually a very good test. A lot of people have believed that the Abbott I.D. Now tests, which have been used since March is low sensitivity. People have said that a lot. I’ll probably spend three minutes talking about this for anyone is keeping track. But this Abbott I.D. Now test, there was an NYU paper back in, I don’t know, maybe this May or something that suggested that I.D. Now test is not sensitive and that led the FDA to put out a letter of warning saying, hey, you should be careful with this test and allowed the media to largely deride the use of this I.D. Now test in the White House. And a lot of people continue to say it wasn’t a great test, not a good test for this use. Well, on the one hand, it’s one of the best tests or it’s the only, or it and Cephied are the two rapid tests that we have, that are actually molecular tests that the White House has been using. It’s changed a little bit. But what’s really important to understand here is the NYU paper that showed that this I.D. Now test was only 60 percent sensitive, which maybe some of you have heard about. It was a totally biased, skewed paper. And for anyone who understands CT values, if you just take those samples, the same paper, and you cut off the samples that had CT values above 40, which by almost any metric should be negatives. But they kept them as positive on the gold standard in that study, the sensitivity in that exact same paper jumped from 65 percent to ninety three percent sensitivity. And so essentially, that was a that was a failure of paper, in my opinion. It really created so much confusion about the I.D. Now. And sure, is the I.D. now as good as the best PCR test? No, but it’s a test that you can literally have on a table in a park bench and use it anywhere. So there are some concessions, but it is one of the best rapid tests that’s available. And it actually has a sensitivity to detect people with virus and that’s up in the 90s, not 60 percent. That was a terribly poor paper. And I actually wrote a letter to the editor when it first came out and I said, hey, these are the issues with this paper. And the data that was used in the paper were entirely skewed towards exceedingly low viral loads. So to say that it missed them, that’s like saying, you know, it really is not taking nuanced view. Unfortunately, that letter to the editor was just rejected without review by the by the chief editor, Alex McAdams, which I have no idea why, given the importance of this paper. And I’ll share the letter to the editor with you all, actually, if anyone’s interested. And I’ll find it while we’re talking. But, you know, I’m just very distraught that, you know, is it the very best test in the world? No, but it’s a very good, good assay. And I actually think that it’s one of the things that’s kept the president safe all this time. I’m putting it in the chat if anyone wants to read that letter to the editor, that was not accepted.
MODERATOR: Thank you very much for posting that. And if anybody would like that at some point in the future, just let me know. Are you all set?
Q: That was super helpful. Thank you. Just one quick question, just about the FDA ruling for what these tests are qualified for. My understanding is that they’re not supposed to be used for asymptomatic or pre-symptomatic screening, but clearly that’s kind of what they are being used for in the White House and potentially how you’ve suggested as well. Do you think that they are sensitive enough to be used in that manner? And can you comment on why they’re not currently approved for that use?
MICHAEL MINA: So this has been a major source of confusion among everyone. The FDA only approves things with the language that people bring to them. So it’s really easy for Abbott, for example, to get approval for symptomatic use because it’s easy to find symptomatic people with virus. It’s really hard to find asymptomatic people with virus. You have to test thousands of people. So all that means is that what Abbott brought to the FDA was, hey, this test works with these metrics and in symptomatic people. But what I think people are really missing the point of is that these tests don’t care if somebody is symptomatic or asymptomatic. They just care if people have the virus in them. And so when we’re talking about frequent use of a test, whether you’re symptomatic or asymptomatic, if the virus is there and it’s transmissible, then the test should still work. The FDA approval process is completely different from the biological utility of the tests. And I think people have not fully understood this. The FDA is not trying. Their authorization process isn’t trying to make any claims one way, like the FDA isn’t the one doing the studies. They’re only approving based on if Abbott says this is the sensitivity in symptomatic people within seven days of symptom onset, then that’s what ends up in the in the EUA authorization. The FDA’s language, Abbott is the one writing or that the company is whatever company it is. I’m just thinking of the biotech’s now, right now. You know, they’re the ones writing the language and the FDA authorizes it or doesn’t. And in this case, again, the test doesn’t care if somebody is symptomatic. It only cares if the virus is there. So biologically, if your concern is to find people who are transmitting virus, then these tests should all work. If your concern is being able to know if somebody is sick at all with the virus, then sometimes the virus can be in your lungs. It can be in your gut. And then that’s when you really have to be a little bit more concerned about what is the role of the test in determining if somebody is sick from this virus. But if you’re concerned about does somebody have virus in their upper respiratory tract, that’s going to transmit, that’s really regardless of symptoms or not having symptoms. And then the other piece is it could even be that asymptomatic people might even need a higher viral load to be able to transmit because they’re not coughing now. They’re not going to be expelling the virus of high velocity. But they might be around more people. So I think in general, we have to really stop. You know, I’ve just read so much about asymptomatic versus symptomatic use of a test to determine if people are transmissible. And I know there’s a lot of people who want to make whatever statement they can that the president’s doing the wrong thing. And in this case, I would say that there was a reason why Brett Giroir and HHS came out and said, look, these tests are only FDA authorized for symptomatic people. However, we are approving them for use in congregate settings. It’s actually one of the few decisions I agree with. They kind of went around the FDA and it’s because it’s just hard for these companies to get that true asymptomatic claim. But it doesn’t mean that the test doesn’t work on an asymptomatic person. It’s just harder to build up that database. So I think that it’s important to understand why the FDA uses the language it does. And it doesn’t have anything to do with the test biology.
It just has to do with the with the participants that were enrolled for the authorization sample sets and furthermore, I think a lot of the research that my lab has put out and this whole idea of frequent testing and rapid testing suggests, that we don’t have to be so concerned about the sensitivity of the test. If we’re doing frequent testing, it’s much better to do frequent testing with a lower sensitivity test than infrequent testing with a high sensitivity test. As long as people are continuing to wear masks and social distance and things like that, frequency is what matters much, much more than sensitivity. And this is a whole different way to look at testing than what a clinical microbiologist at a hospital might look at, where they have essentially one test in front of them at a given time, they don’t know who it’s from. If it’s getting tested frequently or infrequently. So they want to make sure that its in their hands. It is the most sensitive test. And that’s what we do in a hospital. But for public health programs and screening programs, if you have to forgo a hundred times or a thousand times lower or worse molecular sensitivity. But you can increase the frequency of testing 10 times, 100 times, then that is absolutely the way to go, because the goal isn’t to detect molecules, it’s to detect infectious people. The only way to do that is with high frequency testing.
MODERATOR: Are you all set?
Q: That was great. Thank you so much.
MODERATOR: Next question.
Q: Mike, there have been a lot of different approaches that people have taken to fans at sporting events. Florida’s governor recently said full stadium, here in New York, we’re still at no fans. What would your recommended course of action be as a public health expert? And I don’t know if this matters, but we do seem to have relatively low test positivity here with a little less than one percent locally.
MICHAEL MINA: Yeah, I mean that the whole issue of test positivity is really hard to discern because it is just a reflection of who’s getting tested and why. Like I said, even a point three percent positivity on a true cross-section of a population is still actually pretty high. So if it’s like one percent of a true random population, that’s actually very high. If it’s one percent of a biased population or symptomatic, that’s low. I think to answer that question, it’s sports. I mean, what we need to do to get sports back, to get spectators back in the stands is we need to stop these outbreaks. We need to have a national plan to get control of this virus. And until we do that, we can’t realistically open up stadiums on a regular basis without serious concern of them, each becoming super spreading events. And is it worth it to open up an NFL stadium if there’s a massive super spread event and three people die as a result of the game? You know, I don’t really think that’s worth it. But I think that it shouldn’t. It’s not out of our reach. And this is why I’m so frustrated at the federal response as, you know, people like the president continue to say we have to open up the economy, we have to open it, don’t be afraid of this virus. But the point is, this is still a virus that kills people. We can open up the economy if we just control the virus. But one thing has to come before the other. And we have the tools and the wherewithal and the ability. If we actually worked as one like I tweeted it out the other day and I just think about it so frequently. Imagine if the president got up in front of the country and said, my fellow Americans, today we’re turning over a new leaf. We are going to take control of this virus. All we have to do is everyone wear a mask and everyone’s social distance as much as possible within reason but wear a mask and be responsible. Those few words coming from this president, combined with all of the people who are doing that already, could really make all the difference in the world to our ability to control this virus. And then we could safely open the economy and open up sports games. But until we do that, we can’t safely open up stadiums, even with frequent testing, because like we saw in the Rose Garden, there’s always a chance that somebody can still get in. So can we can we safely do it if we have everyone tested before they enter and wear a mask and space things? Maybe. But the more important piece is to focus on getting control of the virus at the population level first. And then we can start opening these things. And until we do that, the president can say we should open up the economy all he wants, but he is not exactly making it easier to do that.
Q: And just as a quick follow up, obviously, if you’re going to a sporting event, you are generally yelling, shouting, hopefully while wearing a mask. How does that look? What type of distance would that type of scenario suggest? People should stay away because you’re maybe mitigating it with the mask, but you’re also shouting and yelling.
MICHAEL MINA: Like I said, it’s not going to be until a community spread is so low that it’s very unlikely that anyone’s infected when they go in. It’s just going to be dangerous. And I do think things like shouting, even with a mask, can absolutely cause this to spread. You know, one of the reasons why we say N95 versus the different kind of mask is because of aerosolization. It’s actually held tight. It stops even aerosolized virus for the most part from getting through. But most of the mask that people wear won’t do that. And so we still run the risk of aerosolized virus getting out and infecting people’s neighbors.
Q: Thank you.
MODERATOR: Next question.
Q: Thanks for taking my question. So I just want to follow up on what you just said. So if the president doesn’t get up and ask people to wear a mask and turn over a new leaf. What is Plan B, specifically to get control of the virus? Like, can you do it without that kind of national, you know, Winston Churchill, British kind of, you know, lets everybody work together? What are the specific like plans that would involve more testing, contact tracing?
MICHAEL MINA: I don’t think we have a plan B at the moment. You know, the government’s plan B is a vaccine. And I think the plan B, which we shouldn’t have to be asking the question, what’s plan B compared to a mask? But I think that what I’ve been advocating for a lot, and this is because I think until we have a vaccine, we don’t have any other options. We have three things more or less at our disposal. Before we have social distancing, we have masks. We have economic shutdown, which is just an extreme form of social distancing. And then we have frequent rapid testing. And I do think that, you know, all of our models, everything suggests that if we were to get enough of these little tests, which, you know, underneath them is just a paper strip, if we can get these out into the public at large enough numbers, I think that can be a huge benefit if we can have people use them when they get to school. You have every kid, you know, they get into homeroom every Monday, Wednesday, Friday, and they use a test. That alone can really serve to stop transmission, sever transmission chains, drop the effect of our below one and get outbreaks to dissipate. We essentially take the momentum, take the fuel out of the outbreak, and that can be extremely powerful. So I think that these frequent rapid tests can be the plan B. But first and foremost, we should be wearing a mask. We should be social distancing. And then we should be trying to build these tests. And for anyone who hasn’t seen them, this is what these tests look like. They’re usually this plastic kind of thing. But when you open the plastic, that’s just a holder. The reason I call them paper strip test is you can see this little piece of paper in there that comes out. And these can be made in the millions. Really, you know, these can be made in huge, huge numbers. And I’ve been pushing for the federal government to produce them in those huge numbers to not just wait until the next company comes out to build them, but to really take the challenge on themselves and produce these in very large numbers. Unlike a vaccine, it’s easy to build these things. It’s easy to figure out exactly what their metrics are. It’s not just rolling these out, though, like what we’re seeing in Nevada, where people are losing confidence quickly in them, that this is a huge mistake.
The government just started pushing out antigen tests without giving people a realistic understanding of how these should best be used. And it’s not just that they should only be using symptomatic people. They can be used as frequent rapid tests to keep communities safe, even among asymptomatic. But we have to know that there are going to be false positives. And so what I think is we should have for every 30 of these, there is another similar form factor, one that comes in the same box. That’s a confirmatory test. So if this turns positive, you confirm it with this one that’s orthogonal, it shouldn’t turn positive for the same false reason. So that can be if we had a plan for all of this, we could make a whole national plan for how to scale up and produce these. And maybe it will cost 20 billion dollars. But that is nothing. That’s peanuts compared to the amount of money that we’re spending on our stimulus packages and that we’ve lost because of this virus. So nobody should be batting an eye about putting 20 or 50 billion dollars into a program that potentially get most Americans a rapid test you use three times a week or twice a week, and that alone could be enough to stop outbreaks in their tracks or at least stop them within a number of weeks.
MODERATOR: Do you have a follow up?
Q: I’m great. Thank you.
MODERATOR: Next question.
Q: Yeah. Hi. Thank you. The governor of Kansas announced that we’re getting about 60,000 BinaxNow tests and eventually around 900,000. And I guess what would you advise a state government to do in terms of figuring out how to use those? Because, you know, we’ve got kids and we’ve got teachers. We’ve got 60,000 people in nursing homes, assisted living. Where do we start?
MICHAEL MINA: Yeah, well. I mean, how many tests did you say?
Q: Sixty thousand is what they said where we’re getting now, and they said eventually we’re supposed to get nearly nine hundred thousand from the federal government.
MICHAEL MINA: Yeah. I mean, I think the power in these isn’t to use them once. They are lower sensitivity. And the only reason why, I mean, they’re better than nothing. But where they really become very, very powerful is when you have the same person using them multiple days, you know, when they’re enrolled in a program and for three months, they’re going to use it twice a week, whatever it might be. That is when the sensitivity hit that these things take is not as important. But if you’re just using these as a one off, you’re just going to dilute them all. We’re not going to use them for how they really could be used. And so for a state, I think not just having a state, not just informing a state how to use them, but we need to have true national guidance. And I’ve talked to a lot of governors about this fact, a lot of senators about it. And so I can have these conversations here and there, but doesn’t really go anywhere. We really need the CDC and the FDA to make it very clear how these tests can be most beneficially used. And I think that the way that they can be most beneficially used is to not have equitable distribution of that, which sounds bad, but we should really be pushing all of these rapid tests to places where cases are the most prevalent. And we should be enrolling people in those areas and saying, good, if we give you 30 of these, will you use two a week for the next couple of months? Or even longer than that.
That would be enough. You’d be distributing them to a smaller number of people. But if you can get enough people in a community to use them on a frequent basis, then all of a sudden you really see the power of them to prevent transmission from continuing. But you have to get them out so that, you know, maybe 30, 40 to 50 percent of a community is actually able to do that. Otherwise, if we just say, oh, you know, we’re going to just distribute this one time to one person. Yeah, it might make a difference. But sixty thousand is not a lot. It’s barely going to make a difference. So I think it’s great that they’re starting to be distributed. But my concern is actually it’s going to do more harm than good because they’re being distributed without guidance. What we saw in Nevada is already the public is losing faith in these. Even epidemiologists are losing faith. And then they’re saying, oh, you know, we’ve got a bunch of false positives. We’re going to stop all of this antigen testing now. But what I haven’t seen is the CDC or the FDA taking a strong stance on this and saying false positives are expected and this is how we deal with them. We deal with that by having a confirmatory test right there, not a confirmatory test that somebody has to send out a PCR and get a result back five days later. But you send to rapid antigen test together. And if we don’t have enough to do that yet, then we don’t send them out because it will show confusion and it will stop the program before it even has a chance to get started. Because the moment people lose confidence in them and start to wonder, the moment people start to say we don’t have to trust a positive because positive isn’t actually meaningful, then we’ve essentially drowned the program before it ever had a chance to swim.
Q: And sorry, just a quick follow, but if we use these in schools or wherever we use them, do we have to worry about supply shortages? Where OK, we have the BinaxNow. But you still need a swab for it. Right? And you know what PPE do you need if you’re a school nurse or something.
MICHAEL MINA: Yeah, well, people can do these themselves and they come with a swab. So all of that would be packaged together. And one of the nice things of self-swabbing is you don’t necessarily need all the PPE to be there. So I think you might want somebody wearing it, definitely want somebody wearing gloves and such. But you don’t necessarily need the whole gown and all that stuff just to go and collect the cards from people.
Q: OK, thank you.
MODERATOR: OK. Next question.
Q: Thanks so much and sorry I’m joining late. I am specifically looking at Florida distributing these tests to schools in order to avoid quarantining people who’ve come into contact with somebody. So DeSantis has said if a student or presumably a staff member either comes to school with symptoms or develops symptoms at school, they would give them this test. And then if they get a negative, they won’t contact trace or quarantine anybody. What do you think about using it in that context?
MICHAEL MINA: I guess, again, I think that the way that they should really be used in schools, it’s not clear like how frequently they’ll actually be available in those schools? Is it just going to be instead of PCR? Is that really what the idea is then?
Q: No, I’m not actually sure about that. I mean, I don’t know that they’re using PCR tests in schools at all. But presumably he didn’t say anything about that. If they get a negative test on this, then we’ll send them to get a PCR test.
MICHAEL MINA: Yeah. I mean, the benefit of these is that they can be distributed more widely and be available where PCR isn’t. So a lot of people have said if you get a negative on one because they’re less sensitive, you should get a piece. But that’s unrealistic. Otherwise, we’d just be doing PCRs. So I think that again, I think that the best way to use these in schools, if somebody is symptomatic and is what you have, the good thing about these is that if you’re positive and if you’re symptomatic, and somebody is around and you have a high reason to believe that they are infected and it turns out that they’re positive, then it’s an immediate signal to say, OK, go home. And if we need to get a PCR to confirm it. Great. But that’s one person less that’s at risk of infecting others. But if you’re just using it sort of haphazardly, one offs here and there, I don’t really anticipate that they’ll be that powerful. And I think we’ll just kind of run out of all of them. You know, we have the potential to just blow through all of our supply of these unless we have a really clear, targeted plan. We’ll just use them all very, very quickly. So I think in a school system, the best way to use that again is I mean, you can use it if you don’t have any other testing modality and you’re concerned about sick people. Sure. But that’s not going to stop the outbreaks because especially in kids these days, infections are asymptomatic almost, you know, almost all the time for little kids. So I don’t anticipate that just testing the symptomatic people will really have much of an effect. And it’s why we have to be testing a lot of people frequently. So in a school, if we can have most people testing once or twice a week, that would be ideal to stop outbreaks there. We could be doing pool testing. I’ve been trying to suggest to lots of schools and policymakers and government bodies for months and months now that we should be doing massive pool testing. Screw with the FDA said about four. That’s just wrong. You can pool hundreds of samples together for surveillance depending on what your goals are. And we could have whole classrooms or whole grades in schools that are getting a test, that are pooling them all into a single tube for a test. And so we should be really increasing our testing capacity for all different reasons. But I do think just using these is your way to kind of try to stop outbreaks in school probably isn’t smart unless you unless you have frequent use of them by most people.
MODERATOR: Do you have a follow up?
Q: You know, I think that that answers my question and I look forward to listening to the rest of this.
MODERATOR: I think last question.
Q: Hey, thanks. I’ll try to make this quick, since I know we’re way over time. My questions about the latest numbers in Massachusetts. I know that as you and I both know; Governor Baker has been trying to target interventions on a town by town basis in this state. But we saw a number of communities go into the high-risk category this week. It would jump from 23 to 40 from last week. And some of the cities who were already categorized high risk increased quite a bit with their sort of average daily case rate per 100000 people. Milton, for example, went from twelve point five to fifty-eight point one in the last week. Does this mean our targeted interventions are just not working? Is there something wrong with them or are we missing something here?
MICHAEL MINA: I don’t really know what the targeted interventions are, really. Yeah, so, I mean, we’re doing some testing, especially in the schools. But in general, no place is really doing the type of targeted interventions. Nobody ever said contact tracing was going to work for this virus. And I think, you know, my estimate is that we’re probably capturing five percent or less than the actual number of people who are infectious at the time they’re infectious. So I’m not entirely convinced that our targeted interventions, whatever those might be, are really in a position to work. Well, now what we have done really well is we have a whole state and we have leadership who has encouraged mask’s, who have encouraged testing, who have tried to make it available. There’s a lot of communities in our state that still do not have wide scale testing available. And again, infrequent testing is not a way to deal with this virus. We can’t bank on that as being our approach to capturing infectious people most times with low with low frequency testing. Most people who are caught as positive are we’re getting we’re capturing them as positive. After they’ve already been infectious or at least on the tale end, by the time they make an appointment, figure out that they’re sick, make an appointment. They’ve already spent five days being infectious, if not weeks after the fact. And so I think in Massachusetts, we’ve used masks with distance and we’ve gotten cases to pretty low rates.
But as long as cases continue in other parts of the country, we’re kind of just sitting here and trying to keep treading water when we would like to be eventually getting to shore. But until we have cases dealt with everywhere, we’re going to keep treading. And I think one approach is frequent testing, which would potentially get us back on our feet along with masks and things like that. So I think Massachusetts or California or some of these very high net worth states with a lot of innovation could be actually taking it upon ourselves to change the landscape of testing. We’ve done it a bit at the Broad, for example. But that’s just one place we should be building the manufacturing plants and really producing huge numbers of these tests and getting them out to the community. You know, the federal government’s not going to do it. Maybe at the state level we can, but it’s not cheap either. So although I’m assuming that there’s a lot of money that has been doled out or that’s still waiting to be doled out to states from the stimulus packages. And so maybe some of that could be used. Some states could get together and build it, for example.
MODERATOR: Do you have a follow up?
Q: Yeah, just again, briefly. I know you talked about us being in the fall right now in the country and having lots of those sparks everywhere in the northeast. We have done pretty well getting cases to low rates, but it seems like the trend is starting to move again in that direction where cases are on the rise a bit and we’re seeing rates just seem to go in the wrong direction. Is it accurate to say we’re also in a COVID Autumn, so to speak?
MICHAEL MINA: I think so, yeah. This isn’t surprising to me that we’re seeing cases increase. You know, we think that a lot of our actions are what have really improved our ability to control this virus. But a lot of that, I don’t think we’ve paid enough attention to the fact that this virus naturally or these viruses like this naturally go down during summer and come back up. So is it our actions that have really led to the massive reductions in the Northeast or is it the weather or a little bit of both? I think it’s both. But what it also implies is that maybe the actions that we’ve taken thus far to control it are not sufficient to control it through the winter. My guess is that will be the case. And I haven’t really seen in any states the type of urgency that we really should be putting towards this to get ready for the winter. I think most people would rather look at the glass as half full. And so it’s easier to sit back on our laurels and say, hey, look, we figured out how to control this virus. Well, maybe, but likely not. And so I think that it’s definitely fair to say we’re in a COVID Autumn and were probably going to see a massive uptick in cases as the winter sets in.
Q: Thank you so much. Really helpful.
MODERATOR: I heard somebody tweeting something about winter coming at some point, too.
MICHAEL MINA: It’s funny. I think the Boston Globe actually wrote a whole article just based on my tweets. They didn’t interview anything.
MODERATOR: Do you have any other final thoughts or comments before we go?
MICHAEL MINA: No, my laptops at one percent battery.
MODERATOR: OK. I think we’re done. Thank you very much, Dr. Mina. And thank you for everyone who’s been on today’s call. Have a great weekend and we’ll be in touch about next week.
This concludes the October 9th press conference.