Coronavirus (COVID-19): Press Conference with Michael Mina, 11/13/20

You’re listening to a press conference from the Harvard School of Public Health with Michael Mina, assistant professor of epidemiology. This call was recorded at 12:00 p.m. Eastern Time on Friday, November 13th.


MODERATOR: Do you have any comments for today?

MICHAEL MINA: No, I’ll take questions.

MODERATOR: OK, we’ve got quite a few.

MICHAEL MINA: Well, I’ll see where the questions go. I’ll probably have some comments, but I will start by saying, you know, I think everyone recognizes that the virus is completely out of hand right now and we could have had this under control at this point. We’ve really painted ourselves into a corner as a nation. And I feel like I’ve said this a number of times now, but we’ve essentially allowed this virus to get so far out of control that we are now going to start seeing lockdowns and shutdowns that we were really trying to avoid through sort of rapid testing programs that have yet to materialize. My concern with this is that we are going to see sputtering. We still don’t have strategy in any real way. And so we’re going to see sputtering of shut downs in the same way that we kind of saw only haphazard shutdowns in March, April and May. And my concern is that this is going to lead to the worst of all options, where we’re going to have massive economic destruction as well. And the virus is barely going to be dented at a national level. And it all comes down to not having a strategy. And of course, I think everyone on the call probably recognizes that a strategy that I’ve put forth that I really do believe can work and I don’t see a different strategy that could work better, is getting rapid testing into everyone’s home in America so that they can know their status on a frequent basis and stop their onward transmission.

But, you know, there are other strategies that could be envisioned, I’m sure. And if we don’t start demanding, everyone on this call, demanding that strategy be put forth by the current administration that we’re still months away from any real change where that can be made. And the people should be in an uproar for not having a strategy. As a nation, we are now going to largely miss Thanksgiving, largely miss Christmas, largely continue to have our parents and grandparents and ourselves die as a result of this. And I think it’s on everyone on this call and it’s on me and it’s frankly on every citizen in the country to just push to demand that there be some strategy that can allow society to go back to normal. Rapid antigen testing is a strategy that would be extremely cheap and very efficient. And there’s no reason we haven’t tried it yet, but there are other options, too. I thought last night that pretty much a kindergarten soccer coach putting kindergartners onto the field quite literally has more strategy than we have as a nation to tackle this virus so far. And we’re losing because of that and we’re losing our loved ones because of that. And, you know, we’ve talked a lot about nuance and nuance throughout this pandemic, but like we should be absolutely demanding, you know, it should be on the front page of every single outlet in America, a demand for the administration to do something to actually come up with a plan that has a strategy behind it. So I’ll stop there.

MODERATOR: Thank you, Dr. Mina. Looks like first question.

Q: Hi, thanks, as always, for doing this. I’m wondering, earlier this week, CDC updated its guidance on masks to emphasize that they protect the wearer and not just protecting other people from the wearer, and I’m wondering, has the evidence changed substantially recently and why now? And what’s the significance of this change?

MICHAEL MINA: No, the evidence hasn’t changed. We’ve all known this. It’s just I don’t know why the CDC is doing what they’re doing. The evidence is the exact same evidence we had in in January, the same evidence we had February and March and April and May, June and all the way up till today, we know masks work. In the same way that people start to say, well, we don’t know exactly how well that worked for everyone. People are missing the point here in every way. It’s the same thing that’s happening with rapid antigen tests. They cut odds; seat belts cut odds of death when you get in a car accident. Does it mean everyone who gets in a car accident will survive because they’re wearing a seatbelt or have an airbag? Absolutely not. But we know it cuts risk. And so the CDC has just been behind on this. I mean, masks should never have been a cause for all of this questioning. We know it cuts risk. There’s no way around it. We’ve known this for decades.

Q: Great, thank you.

MODERATOR: Next question.

Q: Doctor, thanks as always, appreciate it. All right, I’m going to talk to the governor in a few minutes. He’s talking about opening up field hospitals. He’s going to give some details on that. How important is that strategy? And you’ve already talked about testing, obviously, but what else with testing and field hospitals, what do we need to do? What should governors if the current administration won’t do anything? What can governors do to stem this tide?

MICHAEL MINA: I mean, field hospitals are like having a flood. And an open faucet that’s just leading to that flood and you’re just trying to fix the open faucet by mopping up. You know, that’s really not doing a lot. You have to turn off the faucet. Field hospitals will be necessary, unfortunately, as a result of this virus, but to your point and to your question, what should they be doing? Well, Massachusetts, New York, California, these are very wealthy states. A plan that I’ve proposed that doesn’t require the entire state or country to be shut down is to build rapid testing capacity right here in Massachusetts. We have a number of companies that are on the forefront of building these tests. I wouldn’t be harping on this over and over and over if I thought we had a better option at our disposal. We should be building up testing. It’s the only way to know that somebody is transmitting the virus when many, many, people are asymptomatic. We need to deal with the public health problem first, or at least in parallel to dealing with the medical problem. Thus far, we have treated this public health emergency as a lot of medical problems leading to a public health emergency. But that is the wrong attitude we’ve taken across the globe in many, many countries. This is a public health problem first. And if we fix the public health problem, we fix the medical problems. We have to stop using tests as medical devices and stop having tests be claimed only as medical devices and start thinking through how to use them efficiently as public health tools to stop spread. We have to have strategy behind who exactly we’re closing down and why and when and treat that as a public health tool to stop spread. You know, everything has to be about stopping the spread of the virus unless we’re really going after herd immunity.

So I think building up these hospitals is fine. But you know what? Massachusetts has a lot of money. If we could take two hundred million dollars, which frankly is not that much money, there are people here who could bankroll that independently. We could build up the manufacturing capacity, we don’t need it for the whole globe, for the whole country, but let’s say we just wanted two million tests a day or one million tests a day. There are companies in Massachusetts that could produce a million tests every day. We could get those million into every household in Massachusetts. There’s seven million people in this state. We could have every household test themselves once or twice a week. We get a 50 percent of households test themselves twice a week with just one million tests. That is a capacity we can reach. Imagine if we had 50 percent to one hundred percent of households testing themselves twice a week in Massachusetts. We would see cases plummet. There is no doubt about it. We can do this, this is a simple solution, this virus is costing us much more than 100 or 200 million dollars and we probably wouldn’t need close to that in reality to build up the testing capacity and infrastructure. We have the road. We have PCR testing that is available, but that won’t be good for getting people to test themselves twice every week. People don’t want to go out of their way, and rightly so. I don’t want to go out of my way to go get a flu vaccine or go get a test. None of us do. So we have to bring it to the people, to their homes, give it to them so that they can brush their teeth and then take a COVID test twice a week.

We could have done this in our state many months ago. We could have done this at the country level many months ago. At some point, somebody’s just got to do it because the way that we’re using test and trace right now, we are mixing up our definitions of what our goals are. Surveillance testing for a virus like this isn’t going to get us to make a huge dent in an exponentially replicating virus. And so we have to stop thinking about surveillance testing with testing and tracing and isolating, and we have to move into a new paradigm. And that’s population screening. Put the public back in public health, let people screen themselves. Massachusetts in particular, is a state that I think we would have many people who are sufficiently responsible to say if they’re positive, they’re going to not go to work. It doesn’t need to be everyone. We could have a whole half of the state choose to completely ignore their results, and this plan would still work. So we could do this. We could keep our state open in the long term. We just have to build up the manufacturing capacity and build up the logistics to get these tests into every household. It’s not a particularly difficult thing to do.

MODERATOR: Do you have a follow up?

Q: I do not Doctor, thank you so much.


MICHAEL MINA: Anyone else?

Q: I just got unmuted. Do you hear me?


Q: A new survey from Ohio State finds that about two in five Americans plan to attend a holiday gathering with more than 10 people and a third won’t ask others to mask up. I’m sure you’re aware of these kinds of sentiments, given your opening remarks. My question is, where do you think we’re going to be come January 20th in terms of daily new cases and deaths?

MICHAEL MINA: I think we can anticipate that things aren’t slowing down. We have a president who doesn’t seem or appear to care at all. He’s completely, completely thrown in the towel. And in some ways, I would say that the response from the White House isn’t just throwing in the towel, it’s actually causing perhaps even more damage than would have happened if there was absolutely no involvement from the federal government whatsoever at this point. I think where we’re going to be is, I think it’s going to be pretty darn hard to stop exponential growth. It’s extremely difficult. So we’re going to shut things down and mandate it and stop transport, stop people traveling and things like that. But probably, we can expect that next week will probably hit two hundred thousand cases. It seems like forever ago, but just last week that we hit one hundred thousand or maybe two weeks ago. I can’t quite remember. But next week we will probably hit two hundred thousand and give it another two weeks after that and we might hit four hundred thousand, this is how exponential growth works. It took thirty-five weeks to get to one hundred thousand and two more to get to two hundred and two or three more after that to get to four hundred. So we’re going to have to shut everything down. And if we don’t shut everything down or figure out something else to do, Thanksgiving will undoubtedly lead to a massive new explosion of cases. If people don’t take it seriously, we don’t have enough testing to get everyone tested in an appropriate fashion to go visit their families. Yet most people will. People are tired. We have to figure out new ways to deal with this virus because the population is exhausted. They’re exhausted seeing it on the TV every day, seeing it everywhere. And I think that this is just going to be a disaster. And, you know, when I put on my cynical hat, my guess is if Trump’s not going to be president, he probably wants to give Biden the biggest shitstorm he possibly can. Frankly, that’s the kind of person he is, sorry for the language. And my guess is that’s exactly where we’re going. Back to Brian’s question, you know, it’s really up to the governors to deal with this at this point. We don’t have the federal government that’s working in our best interest as a nation, and governors have to start taking control, I think.

MODERATOR: Are you all set?

Q: Yeah, thank you.

MODERATOR: OK, great. Next question.

Q: Hi, Doctor. You just answered my question on exponential growth, but I mean, just to follow up on that, you say lock everything down. I mean, obviously, we’re seeing lots of states kind of nibble at the edges with some restrictions, small things, indoor dining. Can you just kind of fill in a bit more when you say lock things down? And how long will that take to actually stop this exponential growth, in theory?

MICHAEL MINA: Well, I want to be clear that I don’t want to see things locked down. I think there are other options, but there aren’t tomorrow, and they’re not going to be in two weeks from now. So when I say locking things down, I mean, we either can do this in some haphazard way, which is kind of gradual, we kind of have some places not go to work, some places stay and work, schools sort of open, that’s going to just lead to economic devastation and not really stop the virus. So if we really want to stop the virus, and we don’t have things like rapid testing and wide scale testing available, and then we have to do it in a coordinated fashion. Again, everything we do with this virus has to be strategic. I’ve never seen a single thing ever really work out that was tough, that didn’t have strategy behind it actually succeed. Never seen a business succeed without strategy nor war. And in this case, it has to be strategic. We have to use science to decide what are the most important things to shut down, what are the things that are the most important to not shut down because they would make a society not run. Things like basic utilities have to keep going. And if people have to keep those going, we have to make sure that they still work. But if we really want to tackle this in the position that we’re in right now, I think we have to go back to sort of a March, April, May type of lockdown where people stop going to work, start working at home, stop traveling. We already have curfews, but the curfew is there, but they’ll do not too much. It will stop some bars from having a lot of people in them. And if places want to stay at work, they have to mandate extremely good measures to ensure that spread is not happening. Maybe it’s everyone’s wearing N-95s at work. I don’t think a lot of the country is willing to do that. But Massachusetts is in a different position where I think we have maybe a more proactive population in many ways. So I think it needs to be coordinated. Everything kind of happens at once because that’s how you stop transmission. What the country did as a whole was did not have a coordinated shutdown. And so New England did really well, but a lot of the rest of the country didn’t shut down and allowed growth of the virus to continue building and building and building until it exploded completely predictably. And then even though New England did very, very well, those cases naturally started transmitting into New England and spurred on new infections here, and we can only have lockdowns for so long. And so if we want to lock down, we have to see a light at the end of the tunnel so we can lock down and then we have to open back up. But then if we have a constant flood of new cases coming in from outside as we start to open up, it means we have to go into lockdown again, which is exactly what we’re seeing. So it needs to be coordinated and it needs to be sort of at the same time, because that’s what you do to actually get virus to be suppressed. And it needs to probably be as many things as possible. But along with it, we have to ensure that the financial resources are there for people to be able to stay home, to not work so that they can at the end of it, so that their restaurant doesn’t close its doors for good. But they are essentially able to go back and open up the restaurant afterwards. All of that needs to be taken into account and so far, I haven’t really seen any of that being done well.

MODERATOR: Do you have a follow up?

Q:  Really quickly, I mean, the idea of a four to six week nationwide lockdown, is that enough to kind of pump the brakes on this and then hopefully fill in some national strategy? Is that basically what you’re saying? Just to be clear?

MICHAEL MINA: Yes, I think a four-to-six-week lockdown would definitely put the brakes on nationwide spread. I also think it could be political suicide. Well, it wouldn’t be Biden’s administration doing it right now. If every governor got on board and decided together, you know, work with the Rockefeller Foundation, they’ve been really good at bringing governors together and things like that. Get everyone on board without Trump’s saying so. Have all the states decide, OK, from this point on to the middle of December, whatever, we are going to prioritize getting cases as low as possible over the next four weeks. We could do that. That would greatly put the brakes on things. But it can also run the risk of devastating economies and if we don’t have Congress appropriating funds to ensure that people can reasonably do it, we’re going to have millions and millions of Americans without food. So we can’t really do it without the federal government is the problem. And we can’t just put people out on the street and say, sorry, you weren’t able to pay your rent. It’s a very, very complex thing. And it’s why I don’t want to see us go into lockdown mode. But we’re running out of choices, you know, it’s either that or we let the hospitals fill up and society can’t run when there are no hospitals, when there’s no room in hospitals either.

MODERATOR: Are you all set?

Q: Yes, thank you.

MODERATOR: Next question.

Q: Hey, Michael, how are you? So I was on a call earlier with the people who run the research at Regeneron and Pfizer and Moderna, and the mutation question came up and it was interesting, their answer. There’s a mutation in Scotland and basically, they all geared towards mutation to the worse. But when I asked you that question a few months ago, you said the Spanish flu went away because it mutated down to a less lethal version. But isn’t the old version still circulating? Like, how does that work? Why is Spanish flu not still an issue?

MICHAEL MINA: So what I was saying there is that the version of H1N1 that circulates today is not the same. There are molecules in the Spanish flu that were quite distinct now.

Q: Right. But if it mutates, the old one is still there. So what happened to that?

MICHAEL MINA: Well, when that happens, you can have viruses. So flu is a really special virus in that unlike coronaviruses, and we’ll have to see what happens at this one, but flu viruses, if you look at a timeline of different viruses, we’re not entirely sure why it happens. But you’ll have like 1918 strain will come and then almost in a single year, you’ll have a complete replacement by a new strain. And this has happened on decades after decades. We can watch these different flu strains just replace each other because a different one with greater fitness comes into the population. These are called genetic shifts of the virus. So those are a little bit of a different situation.

Q: OK, so that could happen here. And then I want to circle back to another question. So are you still putting a 10x on the kind of the hidden cases, because if that’s the case, we’re seeing three million a month? That means really 30 million a month. That means in three months we probably immunize a third of the population. But isn’t that kind of interesting? Where do you get the three?

MICHAEL MINA: Oh, you’re getting the three million a month because you’re adding up. Yeah, I mean, it’s a really important point. And I haven’t made it loudly enough. And nobody is talking about it, but I think it’s confusing. And the first answer is I still think we’re probably only identifying maybe 10 percent of cases, which is why we need much broader testing in the home and not just surveillance based on symptoms. I mean, everything we’re seeing now is just showing how many cases we’re not finding. The answer, I think it’s really, really important to understand this one epidemiological principle, when we identify 100,000 new cases in a day, that doesn’t mean 100,000 new cases happened that day. And that’s because PCR is staying positive for 30 days, or let’s say 20 days. So you have to essentially, in terms of the numbers of cases that are detectable at the population level, you have to separate incidents from prevalence. Prevalence builds. So if on one day, you have let’s say ten thousand. And then the next day, another ten thousand. Ten thousand, ten thousand. At one day, you’re actually getting people who were infected yesterday, the day before and all the way back for 20 days. So a back of the envelope calculation might be to take the number of positives and divide by 10 to 20. And that’s maybe what you’re getting for your incidence. But then you have to multiply to account for the underreporting. So probably actually we’re somewhere in the ballpark of true incidents just for almost disconnected reasons. We actually probably are seeing somewhere around one hundred fifty thousand actual cases happening each day. Does that make sense?

Q: Yeah, I get the math, but how many per month, then? Like actual, not noticed, but actual. I’m just getting at, like is this moving us more quickly towards herd immunity than we think. That’s the whole point of this.

MICHAEL MINA: Well, maybe let’s say we have 100,000 actual cases per day, so we detect 100,000. Maybe that means there were only 10,000 that were sort of happening that day that we would have detected. Then we multiplied by another ten to account for underreporting. Brings us back up to, say, one hundred thousand per day there. So over a month that would be three million. But we haven’t been at that level. So, I mean, if we keep going, sure. That 3 million will become maybe 10 million in December, January or something. But we’re still pretty darn far away from herd immunity.

Q: OK, and yeah, I like the rapid test idea, I don’t mean to detract from that with these questions and I did put that at the top of my last column, and I encourage everybody else as well, I think it’s a real interesting idea. Thank you.

MICHAEL MINA: Sure. Yeah. And I want to explain again, because there continues to be misunderstanding about rapid test sensitivity, because people continue to use PCR as the gold standard and these rapid tests, they will not by definition, turn positive all the time that PCR is positive in the same way that if you have a crime that was committed, the crime is only taking place for a very short amount of time. But the DNA is left at the crime scene potentially for months. What we are doing with PCR is we’re looking for the DNA. And so the crime is no longer being committed, and that’s the infection. But PCR continues to pick up the RNA evidence of that crime having been committed. Antigen tests are distinct. They only detect when the crime is in the process of being committed or when the virus is in the process of being infectious. And so we only expect for 20 to 30 percent of the time that somebody is PCR positive, to actually have contagious virus the rest of the time is after the fact when they don’t. And this continues to be a source of confusion about sensitivity. These tests are actually extremely good for detecting contagiousness, and that’s why I’m pushing them so hard. People continue to get it wrong at the CDC, at the NIH, everywhere, at the FDA continue to get this wrong. And that’s because they continue to think of this public health issue as a medical issue, as a physician, as a medical issue. You want all the evidence. You want to go back to that crime scene and pick up that DNA. And as a doctor, you want to go back to that crime scene and pick up the RNA in somebody’s nasal pharynx to know that they had coronavirus.

As a public health practitioner, I could care less if somebody had coronavirus two weeks ago. I can only look forward and do what I can to stop onward transmission. And so I only care about the people who are transmissible. And that’s where these tests shine so well. I also want to address something that happened on Twitter today or last night with Elon Musk because it’s going viral. Elon Musk wrote out that he tried a rapid test four times, and two times it was negative, two times it was positive. This is why, you know, if those were false positives, we know that false positives can happen with rapid antigen tests, but we have solutions to this problem. And the solution is simple. We confirm positives with another rapid antigen test or with a molecular test. We’re seeing a lot of new molecular tests that are going to potentially be able to be in the home like this one here. This is almost like a PCR test, but in the palm of your hand. And so we have to confirm antigen tests. That’s a no brainer. The CDC has to create algorithms. The FDA has to create algorithms and demand that confirmation be a part of it. But we can’t confirm them all with PCR. That would be crazy. We don’t have enough PCR. We have to confirm them with another rapid test so that a five-minute test gets confirmed with another five-minute test right there. And if those were false positives that Elon Musk had, if he were testing himself appropriately, which he was not, apparently, then he would have determined that those positives were not positives. 50 percent of our HIV testing that we do in our hospital that turn up positive turn out to be false positives, but nobody says we shouldn’t be testing for HIV. We just take those positives, and we confirm them. And if they don’t turn positive on the confirmation, we let the patient know that they don’t have HIV. And if they do turn positive on the confirmation, we let the patient know that they do. So this is a really simple tool. They’re really simple concepts. But we’re seeing testing like what Elon Musk must have used inappropriately. And part of that is because the federal government has not been clear about how these tests should be used. And Elon is a very, very smart person, but his expertise is not in algorithms for testing. And we need to ensure that the CDC and the FDA are building out the right protocols. I went and talked to them months ago and I said, if we don’t get the right message out to the population about how to appropriately use antigen tests, then the whole program will fall flat before it even gets a chance to start. It will fail before it gets a chance to start. If we don’t develop algorithms like we did with the HIV testing programs, if we don’t make it accessible to have confirmatory tests right away, and we have thus far seen no movement for them to improve the population’s understanding of how to use these tests appropriately, that’s as dangerous as taking somebody who has no idea how to do a surgery, but they have an M.D. after their name, and throwing them into an OR and saying, go at it. That is a bad, bad idea. And what we’re doing at the population level by just throwing tools at people that don’t know how to use them appropriately is a terrible idea.

Q: Great, thank you. Nicole, thank you.

MODERATOR: OK, next question.

Q: Thank you. You said it shouldn’t be difficult to get the real surveillance systems. It seems you’re talking to everyone. So do you know what is going on behind the scenes with the manufacturers, the FDA? And do you have a sense of whether we’re actually moving at all closer to at home antigen tests? Or is it blocked for the past few months? What is going on really?

MICHAEL MINA: What’s really going on is there’s a lot of companies who are building the tools and building the manufacturing capacity to potentially do this, but we continue to see no progress at the level of the FDA. We continue to see things sputter out. I don’t want to bash the FDA too much, but at the end of the day, they need to recognize, and the government needs to recognize that this is a public health problem. To solve a public health problem, we need to use public health tools, not medical tools. We continue to try to solve a public health problem with medical tools. This is insane, it doesn’t make sense, we need to create evaluations and authorization pathways at the FDA for public health tools. We have to stop treating this like it’s a lot of medical problems and recognize that we have to treat the public health problem first. And if we do that, then the medical problems resolve themselves. And so if we’re going to do that, we have to stop authorizing every test as a medical device. It is insane and it’s destructive to our country. We need the FDA to build a public health test authorization pathway. And if we can do that, then we can use a whole additional set of tools and mathematical tools, data set samples to show that these tests can do what they are intended to do at the population level. Even if they don’t perform as well as a physician would like in the hospital. And this is a simple concept to me, I don’t know why the federal government still it has not done, but we need to do that. And if we could do that, then all of a sudden, we would be able to open the gates to a lot of really good companies to produce cheap rapid tests instead of having to go through all of the rigmarole of getting a medical clinical device authorization, after which then they say, well, we don’t have to really scale up our capacity because now we’re approved as a medical device and we can charge a lot of money for it. Why wouldn’t they want to do that? They may as well charge more money per device and then less money for a lot more. So if we could change the authorization and if we could change our whole perception of how to deal with a pandemic from a medical problem to a public health problem, then we would see a lot of these companies start moving forward.

I’ll give one example. Access Bio is the second rapid antigen test to be authorized in the United States. It got authorized requiring a nasal pharyngeal swab still. We can never do nasal pharyngeal swabs in the home or even as a good screening program. People don’t want an eight-inch swab stuck into their nose to the back of their skull. They just don’t want it. And it’s not comfortable. And we need nurses and health professionals to do it. It will never work for public as a public health tool. Yet, that is how they got approval. That is a disaster because that means that test is not useful at all to tackle a public health problem. So now it’s approved. Great. It’s authorized. It’s out on the market. But you can’t use it for public health because it requires and is a pharyngeal swab. We need to have movement here. We need to have the FDA change its authorization pathways to allow the companies that are making these potential public health tools that can sit in people’s homes to allow them to get through the authorization process without having to meet these bars of medicine. And so, to answer your question, things have been sorely delayed, they’ve had speed bump after speed bump and it’s as though we are not treating this as though we’re in the middle of a war. We’re all just sitting back as a country and saying, well, let’s keep things rolling as normal and keep the authorization process here. And there may be a new test to come out. The federal government should be actively handholding these companies to get them across the finish line as fast as possible instead of slowing them down. And so we just haven’t seen a lot of movement. In fact, we’ve seen backwards movement for many these companies. They go to the FDA and we just saw the day prioritize a company from Canada, a rapid testing program without any good reason.

At least that was public. And I haven’t heard from the company any good reason. They were perplexed by it. But, you know, the FDA prioritized their authorization. They want to sell in America. Why did the FDA prioritize a rapid test that was really on the verge? They didn’t even evaluate it, they just de-prioritize the evaluation process that doesn’t make sense. If bombs were dropping on us in the United States, we would not be sitting around wondering whether or not we can get approval to build a missile to defend ourselves. The government would be taking that head on and doing everything they possibly could. Spending billions or trillions of dollars to make it happen. Instead, here we literally are doing zero. We’re just allowing these small startup companies to try to fumble their way to the finish line against this bureaucracy. Instead, the federal government had been taking a much more proactive approach.

Q: And by any chance, have you been contacted by the Biden people and do you have any expectation that the policy will change after January 20th?

MICHAEL MINA: I believe that policies will change dramatically after January 20th.

MODERATOR: Are you all set?

Q: I think he meant that he was contacted by the Biden people.

MICHAEL MINA: I would prefer not to comment on anything.

MODERATOR: OK, next question.

Q: Dr. Mina, thank you for your compelling case for the rapid antigen test. And you mentioned other options, too. I wonder if you could just elaborate from 30,000 feet up as we look out to 2021 with the Biden administration. Can you describe the diversification of the testing landscape? Thank you.

MICHAEL MINA: Sure. So there are other options besides just getting the test into people’s homes, for example, we could really be scaling up pooling strategies. Of course, the FDA isn’t really advocating for that right now. They’re limiting, pooling testing to say, four tests at a time or eight tests at a time. But in reality, we could pull a hundred tests in a single sample. We have to build up the capacity and the infrastructure to do it, but we could do it, and that would be really useful in some parts. So I’ll answer your question, but one of the major benefits, I think, of the rapid antigen test in people’s homes is that this pandemic has obviously become politicized. Many people don’t want to wear masks. They don’t want a social distance. And oftentimes the same people don’t want big brother looking over them. They don’t want to get a call from a contact tracer. They don’t want their private data shared with the government. And so for those people and for people who are too busy to go to drive through, this is not getting antigen test into their homes and allowing them to use that information to just know their status and then make good choices. And we should have Fox News anchors and CNN anchors and everyone else, and they should be on the cover of every paper telling people how to use these tests and what is the goal of these tests. So that’s what we could do there. Now, we have other options in a place like Boston or New York, the school systems, sure, we could use antigen tests. I envision that we could have kids walking to school and in their home room, they have an antigen test sitting on their desk that they take. But on the other hand, we could just have them take a swab and then all of the students in a classroom could stick their swab into a single tube, for example. And those could be processed as one sample as a pool. And then if that pool is positive, we would have to get a second swab from all of those. And that could be either done proactively before it’s run, to speed things up. There would be those logistical challenges with pooling, but it can be done. And we could take the massive PCR sort of capacity that we’ve built in the United States, which isn’t hugely massive. But it’s built up a lot. And we could multiply that by 10 or even one hundred if we use pooling efficiently. It would require immense logistical resources, though, to ensure that those samples are properly getting labeled. Getting from point A to the laboratory would require a lot more resources within each of those facilities to process those samples and figure out who is positive and who’s not. So it would be at a national level. It would be in a very labor intensive and pretty expensive process. But within cities, for example, I can envision a world where we have a lot of pooling laboratories that are able to really do this. We also have, assuming we get to a peace time when the virus starts to drop down, or even not, even in schools right now, we could be testing the wastewater in individual schools to see are there any cases? And so if you don’t want to go through a pooling strategy, you kind of pool the whole school at once. Their wastewater problem there is it might not turn positive for a little while until somebody is really pretty positive and shedding or few people are. But nevertheless, that could work and then you can conserve all of your resources. Maybe your rapid tests on hand, you’re testing the wastewater that comes out of the bathrooms, for example. And then, if you start to see a signal within that school, then you pile on the antigen tests or then you activate the cooling strategy. So those are some of the other options that we have besides social options like distancing and lockdowns.

MODERATOR: Next question.

Q: Thanks again for doing this, really appreciate it. I was wondering if you could talk a little bit about nursing homes and the testing apparently is much, much better in nursing homes. Is it enough, do you think, that we will have a better track record this time?

MICHAEL MINA: It depends where you are. When I look out at the mortality rates that are happening in Massachusetts right now, I think we have learned a lot. We’ve we learned a lot, especially those states that were hit really hard in the spring, have learned a lot about how to keep nursing homes pretty safe. We’ve seen that it’s only a fraction of the overall mortalities have come from the nursing homes. The rates have really decreased in terms of outbreaks in the nursing homes. But they can still be enormously devastating, of course, and as cases continue to tick up in Massachusetts and elsewhere, and really just as cases continue to tick up across the country, it is going to be continually more and more difficult to keep cases out of nursing homes. We need rapid testing to do that. You can’t have a staff member come into a nursing home from the community where prevalence is very high and get a PCR test that has to be sent out and get a result back 24 hours later. You can’t have that staff member be sitting there in the doorway for 24 hours waiting for their results. So we have to use rapid testing as an entrance. This is a different type of screening. What I’ve talked about a lot with at home screening. I call that public health screening or outbreak suppression screening. When we talk about nursing home screening with the test that we use and they need different metrics. This is why it’s so important for the FDA to define the role of the test and create metrics for authorization around it for entrance screening into a nursing home, we can deal with false positives. That’s OK if it means that we have one hundred percent sensitivity to catch infectious people. And so \what we can do is we have rapid antigen tests on the doorstep of every nursing home. If you want to get in and you’re a staff member and you’re coming from the community, then you have to take a test. Maybe you have to do it every single time you walk into the nursing home. And if you’re positive, then you just reflex and you take a second confirmatory test. Or, because it’s a limited number of people, you take a PCR test, and you send it off and you go home for the day while you’re waiting for the result. But it needs to be rapid to make it feasible. We are learning better how to do this. We have a lot more nursing homes have antigen tests. But again, they were sent out to these nursing homes without direction. The nursing home staff, they don’t. And leaders, they don’t know about this stuff. They’re all stretched thin anyway from months of this and they’re just trying to figure out what to do. And now we saw in Nevada that the nursing homes used antigen tests and found false positives. They didn’t understand. They weren’t given enough information to know that you have to confirm a positive. And so they started to rebel against it. And we are not in a position to have nursing homes do not utilize one of the best, most powerful tools at their disposal to keep their people safe just because they haven’t been instructed on the appropriate expectations and how to use them most efficiently and appropriately. So my concern is, while the places that got hit very, very hard to learn a lot of lessons during that period of time, we’re seeing other places like South Dakota and other places that are just dealing with this really for their first time and at huge scale, they may be a little bit less prepared. And I think we’re seeing a lot of scrambling going on to try to keep cases out of the nursing homes.

Q: Thank you so much.

MICHAEL MINA: All right, sure.

MODERATOR: Next question.

Q: Hi, I keep seeing smart people saying that with a 90 percent effective vaccine, 60 percent of people need to be vaccinated to reach herd immunity. But I heard you say on a podcast earlier this week that that’s not necessarily true for a vaccine that doesn’t prevent transmission. So if you could just talk about that, how that equation works and whether it’s relevant for the way that vaccines are being tested.

MICHAEL MINA: So this is a great question. I want to answer that question. But first, I want to explain something. The 90 percent efficacy that was detected of the Pfizer vaccine, in my opinion, has been blown completely out of proportion in terms of what we actually know. That means it is a very, very good result. It’s an exciting result, but there is a biological reason why we should all be extremely cautious about interpreting it with too much optimism. And I’m going to try to explain it quickly. But these vaccines were devised and developed specifically to elicit neutralizing antibodies, specifically to stop the virus from binding to a person’s cells and allowing it to replicate. And that’s why they all encode the spike protein. Now, when somebody first gets vaccinated or infected, your body as a natural part of its process creates a huge number of what we call plasma blasts. These are, by definition, temporary cells. They’re cells that live in the blood and secrete huge numbers of antibodies. And that’s in an effort to tackle the current virus people have. And these cells, usually, they last for a few months. So that means so far, all of the efficacy data that we have gotten from the vaccine recipients is generally within just a few months. So the scale that we have evaluated, the beneficial effect of these vaccines, unfortunately, matches the lifespan of these temporary cells that have to, by definition, die off. So the question is, is the 90 percent efficacy within the first few months, is it driven entirely by this massive explosion of antibodies that are temporary and so at three to six months or the six to twelve month range? Are we still going to see that same level of protection once by definition, the plasma blasts die and fall away and apoptosis? They have to commit suicide essentially. So then they’re not there to create this massive burst of antibodies. And then at six months, you’re only banking on the memory cells that are left over, the residual ones that are kind of stored as true bonafide memory cells.

We’re hoping that those will create some protection, but this 90 percent is really a reflection, in my opinion, potentially, of this massive explosion of cells that by definition happens during an infection or vaccine and then has to fall away. And it truly is. It’s a few cells become billions of cells and then they collapse, but they collapse over a few months. And so I have a real serious concern that the amazing efficacy results that we have seen might reflect this sort of supercharged period of time when the immune system is absolutely activated and doing everything it can to create a long term response. But it might not represent what happens later on. It’s sort of like somebody being completely charged up on adrenaline or taking drugs or something to make them super strong. They lift a car, but eventually, that’s got to wear off. And then where do they land after that’s over? And this is something we don’t know yet. And so I just want to be really clear that while I feel encouraged by such strong results, it means that the antibodies that are performed are created, are performing and working well. It doesn’t mean it’s going to be a 90 percent response.

To get to your question, there’s a few other things we don’t know. Does it work well in the elderly who are really the ones who need it? We know that the elderly doesn’t have good immune responses almost by definition. That’s why people get shingles and all kinds of other things and die of infectious diseases. A lot of times it’s because they’re immune responses are often not able to create as robust an immune response after, say, sixty-five years old, and then it drops precipitously from that. So we don’t know if it will protect the people who really need to be protected. And then we also don’t know if it will stop transmission. The Phase three trials, unfortunately, didn’t even have a component in their evaluation for, I can’t even imagine why. But they really should have been swabbing every participant in both arms once a week to know if they are actually not getting symptoms but are getting transmissible virus, for example. We don’t know if these vaccines, if they’re just going to stop symptomatic disease sort of by working at the level of lungs, for example. But meanwhile, you can still be growing virus in your nose and therefore transmitting it even if you’ve been vaccinated. We don’t have any of that information. So we can hope that by depleting out the virus through an immune response, people will transmit less. But again, once we get past the plasma blast stage, are we going to actually have enough antibody there to really stop transmission? We just don’t know.

Q: So that 60 percent figure, do you think it’s like bunk, basically?

MICHAEL MINA: Well, the 60 percent, that’s pretty much like if everyone who got a vaccine had no ability to transmit, 60 percent would be sort of where we would be at from that. But if 50 percent of people who get a vaccine can still transmit, for example, then the number needed to vaccinate to really create herd immunity is going to be higher. But also the thing with vaccine, with herd immunity, we talk about a herd immunity threshold. And if you achieve that threshold, that’s when you get out below one and the epidemic starts to die down. But still, just like immunity, herd immunity is on a whole continuum. So a little bit of herd immunity, a little bit of blocking transmission is better than none. A little bit more is better than none. And eventually you hit this sort of threshold where you actually can turn the epidemic over. And that’s kind of the threshold that I’m trying to hit with these rapid antigen tests. But I would say that at 60 percent, yeah, you have to be really careful. And I would say that it’s probably the absolute ideal if we could get it. But we might not achieve that.

Q: Thank you.

MODERATOR: Next question.

Q: Thank you very much for doing this. Picking up on the vaccine, you mentioned at the very beginning of the call that there’s no strategy. Do you see any semblance of a strategy for distributing the vaccine that appears on the cusp of approval? And the second part of that is, what do you worry about in terms of bumps in the road with distributing a vaccine once it does get the away from the FDA?

MICHAEL MINA: Yeah, so I would say that the federal government is maybe sort of working on a strategy for that, but certainly there are people in this country working on a strategy for that. There are nice papers, and the WHO is as well. So I’d say if there is any area where there is some strategy being formed, it’s sort of how to allocate the vaccines. And as far as I can tell, Trump is kind of staying out of that, which is good. He should stay out of all of it at this point and let the scientist’s work. My colleague Marc Lipsitch, I know has done some work and I don’t know if it’s appropriate yet, but he has done some nice work modeling these questions. And not just Marc, lots and lots of epidemiologists are working on where the vaccines best should be allocated. But only once we know these questions about transmissibility and how well they work in the elderly and things like that, can we best figure out their allocation schemes. And that work is being performed. And I do believe that federal government is aware of some of that work.

I think that big challenges, as you’ve probably heard in many media outlets at this point and scientists talking, is the cold chain on this particular vaccine requires a pretty serious cold chain. It can’t be just put in the refrigerator and stored that way. And so I think there’s a lot of concern about how exactly we will distribute these in an in a sufficiently efficient manner to utilize the freezers that exist. I think we can figure it out in the same way that I think we can figure out a lot of things if we put our minds to it and treat this as a wartime endeavor and put the appropriate number of resources to these things. So I’m not as concerned. I think that if there’s been one thing that has been planned from the beginning, for right or wrong, I don’t think it was the right thing to put all of our eggs in the basket of vaccines at the expense of everything else. But I do believe that we will figure it out in this country. My real concern is that many countries don’t have the resources that we do, and we’re going to struggle to do it in our country. And I think, you know, unfortunately, many, many countries around the globe don’t have the type of cold chain capacity that is needed. Freezers might sound like they’re simple, but when you get out into the field, sub-Saharan Africa, rural parts of China and India, you know, this becomes a real struggle. And it has been a struggle for many decades for vaccines to be rolled out across the globe.

Q: Thank you.

MODERATOR: Next question.

Q: Thank you so much. So my question, we kind of touched on it a little bit in the beginning that the CDC updated its guidance on masking this week. And the change stirred up arguments for national and state level mask mandates. So my question to you is, when it comes to a national or statewide mandate, what points or standards do we need to hit for that strategy to be employed and effective? And are we already there?

MICHAEL MINA: Well, we’re not there across many of the states because many people just are not willing to wear masks and, I mean, I am very supportive of masks, but I think we should have had a very clear message to the American public at all levels of the government since the beginning of this pandemic and obviously at all levels of the government that the story about masks and the recommendations have been muddied and confused. So I think that if we could have a mask mandate, it should be that any time you’re out, any time you’re at work, you should have to wear a mask if that would help us get things back on track. And I think it would do a lot potentially to really reduce transmission. It won’t be the end all. I think it needs to be supplemented with other pieces or it needs to be a supplement to other potentially more crucial endeavors. But it can be very useful. The real problem, though, is we have to unfortunately be realistic with what’s happening in our nation. We have a peculiar population who collectively, many of us, I think because of our president, have decided that this is a virus that isn’t worth tackling, maybe until they have a loved one die, for example. And what this means is I think what I’ve seen is I haven’t seen enough public health people be willing to truly recognize what the people are saying and try to work with them and figure out good approaches. If we just keep pushing mandates and mandates on people, I don’t know. I mean, I’m not a psychologist, but I don’t think that the people who are not wearing masks and aggressively not wearing masks, I don’t think a mask mandate is going to do a lot. I mean, it’s a political statement at this point. But I do think it will, even in the hardest hit places that aren’t using masks, I do think if you mandate it, then hopefully, if there’s penalties, then they don’t have any excuse, then it’s not about making a political statement. If it’s absolutely essential and it’s breaking the law, if you’re not wearing it, then hopefully that would get people on board to say, I don’t want to do it. This isn’t my political statement to wear this mask, but I have to. And so that’s where I think the mandates could potentially help it. But it will be interesting to see if they if people really adhere to them.

Q: OK, thank you, and you already answered my follow up in that, so I’m going to throw a wild one out. I have been asked to look into this type of rapid test. They’re called Fingerprint sweat tests? Have you heard anything about that? And you have any feelings on those?

MICHAEL MINA: You said, fingerprint sweat test?

Q: Yeah, so it’s supposed to be less invasive so more people would enjoy getting them done, but supposedly the device will read the sweat off of your fingerprints and be able to determine if you have it that way.

MICHAEL MINA: Well, I would be very, very cautious in interpreting it, it might be a nonspecific way to understand if somebody has an infection and in which case, you know, that still would be really useful. But I would be very, very cautious about the specificity of that. It could be falsely positive for any number of reasons, unless they’re somehow assuming that they’re getting minute amounts of viral particles in the sweat. But that’s not exactly how sweat works. So I’d be cautious. But I’m open to anything that can serve as a screening test as long as it is something like that, especially is not is backed up by if that’s a very, very good screening test, mean it will catch everyone who potentially has COVID. But a lot more people, too. That might be a good way. If it’s really, really available and superabundant, then everyone could just do it. And if you flag, it’s kind of a don’t take it too seriously, but do take a COVID test or a rapid antigen test right after it or something. It could be a way to stretch our resources a little bit better, make them more efficient.

Q: OK, thank you very much.

MODERATOR: Do you have time for another question, Dr. Mina?

MICHAEL MINA: Yeah, sure.

Q: Just to go back to the somewhat similar question earlier, this is quite interesting to me that I haven’t really heard the level of caution that you just spoke about with regard to the Pfizer news. And obviously, 90 percent sounds like a really good number compared to the 60 or 70 I saw. Again, your thinking on that. So this isn’t going to be necessarily the sort of cure all, but it doesn’t mean that we can sort of measure even when it is widely available. And secondly, is there any other sort of people who are sounding similar notes of caution, who I could speak out on this issue that I could reference if I were to write a story on the subject?

MICHAEL MINA: I haven’t seen anyone else really talking about that particular point, which I’ve been very, very surprised about. I think there’s a lot of people don’t want to be too public about throwing caution at this good news and then when we really want some good news. So, I mean, you could talk to Akiko Iwasaki at Yale, people like that, I think she would be good, but I haven’t seen anyone else really taking that viewpoint from me. But you know, there’s a few problems. I think that one of the reasons that I find myself in the middle of a lot of these conversations is because my normal life is by my design of how I run my research programs is mixing epidemiology and vaccine immunology and infectious disease testing. And I normally bring them all together to think about kinetics and build them. And I think sometimes, you know, somebody who normally studies immunology, for example, doesn’t normally study a vaccine trial, immunology. And so it could just be a difference in sort of where people’s interests lie that we haven’t seen a lot of people talking about it. But I think that if you ask any serious immunologist what happens in the first couple of months after somebody gets a vaccine or an infection, do they have a lot of plasma blasts that form a lot more antibodies than persist? They would say yes. And that’s in fact, of course, that’s why for months I’ve been saying that antibody waning after infection is absolutely normal. We expect it that we get really high antibodies and then they wane, they don’t necessarily disappear. But we don’t know where the threshold of protection necessarily is, even if you’re still detecting them. But presumably, if you have a huge number of antibodies in a ten thousand one hundred thousand or a million times more, billion times more, presumably those will be more protective in the short term then than they will once they fall away. And you only have a smaller number. And so I think that you’d find a lot of immunologists would be able to speak towards these types of kinetics as well, maybe who don’t also always study vaccine trials.

Q: And finally, just one thing about the Musk situation, again. I understand false positives are rare in the antigen test, and that makes sense to me because it’s looking for the protein. But what might cause a false positive just as they’ve been contaminated by improper use or something?

MICHAEL MINA: False positives can happen for all sorts of reasons; these are little antibodies on a paper strip. And now a lot of times what we’ll see is somebody will turn false positive and then the next day they’ll be negative, negative, negative. They’ll have one blip of a false positive and then they’ll turn negative again. So it’s all kinds of things like antibodies by definition can be a little sticky. And that’s why we want to find the best ones. And I would say BD and Sofia Quidel, were two of the earliest antigen tests to come out. And since then we’ve had some new companies come out with new antigen tests that maybe are using more updated antibodies. So BD and Quidel probably got some of the earliest sequences of B cells to produce the antibodies from people who are infected, maybe like in January or February and built those tests really quick. The other companies now we’re actually seeing better specificity, frankly. I think the BD and Quidel tests are really, really good. But we’re actually seeing some better tests get to market like the Abbott BinaxNOW and the SD BioSensor, which isn’t in the US, and potentially Access Bio. And that’s because they’ve had more time to update their antibodies that they’re putting onto their test strips. And so they’re getting more specific and more sensitive as time goes on. So unlike PCR, where we’ve seen some differences in PCR, false positives, false negative, things like that, antigen tests are really on a spectrum. And that’s why I’ve called for the FDA, for example, to make like a silver gold platinum coating, for example, of these different antigen tests, because people haven’t talked about these with enough nuance yet. One antigen test is definitely not the same as another antigen test. They could have totally different metrics. I could build an antigen test, you know, in a few days in my lab. But it’s not going to be particularly good. It will probably work OK, but unless you really start digging for the right antibodies, it’s a big endeavor. So I would say that we need to be cognizant of that as well. But in terms of what causes the false positives, it could just be that you inhaled some random particle, frankly, that happens to react. And if you were to test yourself again eight hours later, it might go to a negative status.

Q: Very interesting. Thank you, Doctor.

MODERATOR: Dr. Mina, we have one more question, do you have time for that, or do you need to go?

MICHAEL MINA: I’ll take a 30 second question.

MODERATOR: OK, next question.

Q: I gotcha. Thank you so much for your time, Dr. Mina. And thank you for the brilliant analogy about the crime scene data. That is a wonderful way we can explain it to our viewers, that is so easy for them to understand. So thank you eternally for that analogy. It’s awesome. What’s your message to the governors that are around the country who just continually refuse to take any advanced steps to stop the spread? I mean, we are seeing this across the country, especially here in the Midwest, where our cases are spiking, deaths are spiking at record hospitalizations every single day. Today, we doubled our case rate as of about an hour ago by a thousand. So what’s your message to these governors who believe that they just won’t do anything and somehow this is just going to stop or go away?

MICHAEL MINA: I think the governors are in a really powerful and good position right now to make positive change. I think that they’re up against a pretty tough position where they’re kind of tackling a current administration, the White House, that isn’t necessarily making decisions that appear to be in the best interest of their constituents. But I think that the governors really have a positive and good opportunity right now to look towards the future and say we don’t want this to continue damaging our constituents, damaging our citizens, damaging our economy. And I do believe that the governors can work together, especially if they lean on each other and each other’s science teams to get the right information out into those communities and out into their states to figure out how to tackle this the best way up through January 20th, when we might start having some federal leadership and guidance. But unfortunately, I feel for them in many ways that, you know, it’s very hard. I think I said this about Governor Cuomo back in March, that it was extremely difficult without having the backing of a president for somebody with only limited data at that time to be able to really make hard decisions that go against the mantra of the federal government. And we kind of see a very similar thing now, which is no governor wants to feel the wrath of President Trump, and that’s just a really unfortunate part of where we are at with our politics and our president at the moment. But I think that I hope that that news of change will be encouraging. And I hope that they will. And I believe that they will start really taking this seriously as they start to see the damage that it’s causing. I think that they have an opportunity to make really positive steps for their states.

Q: Thank you, Dr. Mina.

MODERATOR: OK. That’s it for today. Do you have any final comments?

MICHAEL MINA: I got to run. Thanks.

This concludes the November 13th press conference.

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