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

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 20th.


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

MICHAEL MINA: Well, I wanted to start by answering a few questions that came on the heels of a piece I wrote in Time magazine the other day that I’ve gotten via email. And so I wanted to talk about that. And for those of you who aren’t familiar, I think Nicole can put the Time magazine article there, the op-ed that I wrote. But one question was about the cost of actually creating a national rapid antigen testing program. And the idea is that to get the capacity built to actually have, say between 10 and 20 million tests per day, which by my estimations, is really enough to get herd immunity across or herd effects, which are like vaccines, across the population, would cost in the hundreds of millions of dollars to actually build up the capacity to do that. And with the government actually getting behind it, it could happen very, very quickly. Now, a lot of the time that would normally be spent would be finding real estate, finding you, things like that. And if the government actually wanted to do this, it could actually move very, very fast for probably well under half a billion dollars to create the factories. And these are very, very simple factories. So it’s something that is really well within our means. And then to actually produce them and get the whole program out to the whole country for a year, and a year, we may very well not even need close to a year, would be around 10 billion dollars, maybe 20 billion dollars, but probably somewhere in that ballpark. That sounds like a lot of money, but it’s less than point one percent. I believe it’s actually less than point zero one percent of what the actual cost of this virus is at the entire level. So for less than point zero one percent of the cost of this virus is having on our economy, we could potentially have a program set up that would actually be able to remove the virus from most communities or greatly suppress it without the need for waiting for a vaccine. And so I think that cost should really not end up getting in the way here.

There is a different question, which is how quickly, if we had the kind of outbreaks that we have right now, which is exponentially increasing cases across the whole population, if we started testing half of Americans tomorrow with a test in their homes that they could use, say, twice a week. You wake up, you brush your teeth, use a rapid antigen test on a Monday and a Friday, and that’s what people do. If we could get that many people to do it, half of Americans to use it twice a week, we will get this virus well under control within a month if we get started tomorrow. So we could start it tomorrow in more limited areas. These tests do exist. I have packages of them right here. They do exist. We don’t have them authorized yet for home use because we continue to require authorization as though they are medical uses. And we treat every American as a medical patient. But Americans are not patients. They’re just healthy people living their life who want to get tested and know that they’re safe to visit their family for Thanksgiving, know that they’re safe to go to work or to go to school. It’s not foolproof, but collectively, at the population level, it can greatly reduce population incidence and make everyone much, much, much safer. So a little bit from everyone using these tests ends up causing these herd effects. But within a month, we would see a massive drop. We’ve seen it in Slovakia now, and that’s thankfully been sort of reported a bit. Slovakia started this program and within a week they took exponential growth and turned it into exponential decay of the epidemic. And they have continued to see dramatic declines in incidents just after a few weeks of using these tests at about half of their country’s population in a very, very similar way to the way that I’ve been describing. And so we have a tool that can really greatly benefit us. We just have to get the regulatory framework in place to stop treating these as medical problems and allow this test, which I’ll just show it again, because I have it here. You know, this is a test that if we were to get these out, right now, this is illegal for me to use in my house. That’s crazy. You know, we could have these that everyone could use just like a pregnancy test, we just have to get the federal government to change a little bit and we all have to feel empowered to do our part in that.

And then the last question that I had is, are tests really 99 percent sensitive during the period of infectiousness? Some groups say that they have 30 percent or 50 percent or 70 percent false negative rates. They are about ninety-nine, if not sometimes some studies have shown them to be one hundred percent sensitive when people are infectious, some of the better ones like this one, like the Abbott tests, these can be very, very powerful tools that approach one hundred percent sensitivity when people are contagious, when they are at risk to their family members, their loved ones. And because of that, there’s been a lot of confusion because people continue to compare them to medical diagnostic tests, which are PCR, that look for the RNA during or after somebody has been infected and contagious. And so these antigen tests, one of the real benefits of them is that they turn positive when you’re contagious and then they turn negative when you’re not contagious. PCR tests will then stay positive potentially for weeks more, if not months in some people. And so during that period of time, the much longer duration when people are remaining positive on PCR, they would be negative on an antigen test. And so if somebody goes and does a study and doesn’t know exactly what they’re looking for, they would find that it would look like these are showing up as false negatives, but they’re not. They’re doing exactly what they’re intended to do. In some ways, if your goal is actually identifying infectious people, you could go so far as to say that the PCR is leading to false positives, not for the viral RNA, but false positives for identifying contagious people and that these are actually the more accurate test. So we really have to look very, very closely and always define what is the goal of the testing program. And I think that has led to the lack at the national level and really the global level to a priori define why it is testing has led to the massive confusion around testing that has ensued. And we just have to define it as this a medical test, a surveillance test and entrance screening test or a public health screening test. And if we make those decisions and we define them very clearly, then we know how to evaluate the test metrics. But to this day, we still don’t really do that. And the FDA certainly doesn’t do it. They assume every test is just a medical device. And so the point is the tests work. They work really well. They’re being used broadly across the world, now. The US is just really lagging behind. And part of the effect of that lag is that we have out of control growth. And now we’re seeing, unfortunately, that PCR testing, for example, is really delaying, it’s getting backed up. Again, we’re starting to see four or five, six, seven-day delays, which frankly makes these high quality PCR laboratory tests complete garbage, completely useless. If you’re waiting for five days to get a test result back, it’s not even worth getting the test. These, on the other hand, give you results in 5 to 10 minutes and you can do it in your house without waiting in any line, right after you brush your teeth.

I’ve been heartened to see that Anthony Fauci and Debbie Birx and other people have really begun to advocate for them as well. And Fauci was on CNN yesterday saying that he would really like to see every household have access to these types of tests and that he thinks that that’s one of the best approaches that we can go forward with to tackle this virus. So I think that the message is catching on. The research is certainly there. We have a pre-print that’s out that will be getting published eventually that has laid out this whole idea of test frequency, the speed of the test, the frequency that somebody can use the test which is so much more important when it comes to public health than the individual sensitivity of each test to catch molecules. And that’s why this whole testing program works and that’s why it could get us truly out of the mess that we are in. And I say mess, but really, I should be calling it, like I’ve been doing lately, calling it a war. This is killing thousands and thousands and thousands of Americans every single week. And we should be treating it as though it is something that is causing thousands of deaths every week. And so much for the long-term consequences of not tackling this virus are going to be devastating. We’re going to see partial closures. We don’t have a government that’s functioning appropriately to appropriate the funds to make closures work for the American people. So we’re going to see communities start to lock down, but people are just going to start going broke and hungry because they don’t have money to actually survive without working. And this is truly a national travesty. And it should be considered that we are in a war and we should be acting like it at all levels of government and at all levels of media and all levels of just being in our society. Everyone should be treating this like the war that it is and trying to figure out how to work together as a country, use it as a rallying point instead of a divisive point, which it has become.

MODERATOR: Thank you, Dr. Mina. All right, first question.

Q: Thank you so much, I really appreciate all the work you’re doing on this. Can you also just answer if it works as well on the asymptomatic patients versus symptomatic? Is the viral load as high in those patients?

MICHAEL MINA: These tests work as well for symptomatic and asymptomatic. The really important thing to know is that testing itself, or rather the viral load is not a binary thing. So the point is, these tests only care about the virus. They don’t care about the symptoms. And that’s why it’s so important to distinguish medical from public health. If you’re a doctor, you might be interested, even if somebody is asymptomatic, you might be interested just to know that somebody has the virus inside of them, even if they’re not transmitting for whatever reason, maybe they have some other heart condition. And you’re just really concerned that if they even just get exposed. But if they don’t have enough virus in their system to turn one of these positive. Then they’re very, very unlikely to be transmitting. So that’s why we really have to distinguish, that’s why I make the case that these are transmission detecting tests. They detect you when you’re high enough to transmit. And so if you’re asymptomatic and you have enough virus to transmit, they will detect you. If you’re asymptomatic and you have such a low amount of virus, which is why you’re asymptomatic, that you can’t transmit, then they may or may not turn positive, but that’s OK because you’re not contagious. So we have to stop thinking about transmissibility as a binary and recognize that there are whole gradients of transmissibility. I’ve been wanting to show a slide, for example, and I could actually pull it up here, but I’m not going to because it gets a little too sciencey.

But the point is, when we look at the amount of virus that somebody has in their body, we generally tend to put it on a plot of CT values. And we’ve all heard about the CT values now. Well, for anyone who recognizes sort of how plots like this work, there is something called a logarithmic scale and a linear scale, normal life, the way that our brains think is linear scale. But a logarithmic scale, it expands everything, so 1 to 10 looks the same as 1 million to 10 million in terms of size. And so the reason I’m bringing this up is when people are infectious or when they have virus in them, we’ve been looking at a lot of these like log scales where it looks like a CT value from 35 to 30, looks similar to the same CT values like 20 to 15, but actually 99 percent of somebody’s viral load will happen when they’re really, really high a virus. And then even if they’re still positive with antigen, even for a little bit longer, they have such a low amount later on that they’re just not very, very likely to be transmitting. So it’s a very, very, very short window when people have trillions of viruses and then it comes back down to thousands. And the difference there is enormous. You know, most people have a thousand dollars in the bank account. Nobody has a trillion dollars in their bank account except for Amazon and things like that. And so, you know, that difference is what we’re talking about within each person. So transmissibility and the amount of virus people have is not just a binary thing. It’s like truly the order of difference between me and you all on this call and Jeff Bezos. It’s even a bigger difference than that in terms of wealth. So it’s really important just to keep in mind that if you’re negative, even if you have live virus in you and you’re negative on one of these is the important thing is that you’re very low risk to actually be transmitting because you just have such a low amount of virus compared to somebody who’s really likely to be transmissible. The super roundabout way to describe it, I apologize.

Q: Thank you very much.

MODERATOR: Next question.

Q: Dr. Mina, thanks for doing the call. One quick question I have is about sort of the gap between the amount of point of care antigen test that we have and what’s actually being used. And I’m wondering sort of how much the lack of clear guidance or sort of education is still really hindering their use and sort of what can be done about that?

MICHAEL MINA: Oh, yeah. Well, so we actually have a decent amount of these out in the population right now that are just totally not being used. We have like a whole store of Abbott BinaxNOW cards that are just not being used. And we have some of the BD Veritor and and Quidel tests are not being used. They’re some of the older tests, some of the newer ones like Abbott and others are performing quite a bit better. But we have quite a lot. And they’re not being used, like you say. And that’s because we never created guidance here and we never created strategy. We were using them for the wrong reasons. We’re just kind of sending them around. I like to think in the same context that I often think of this as a war, we’re just kind of like sending guns around and hoping that some soldier maybe picks it up and uses it appropriately, but without any direction. That is, I’m a pacifist, so I don’t advocate for it. But sometimes I suppose they’re necessary to make it. So with tests like this, we have to create strategy. We really have to create strategy about how to use them appropriately, we have to give instructions, we have to get nursing homes to understand, hey, this is the role of an antigen test and this is the role of PCR test, and these are the downfalls of a PCR, these are the downfalls of an antigen test. We haven’t even done that much due diligence to help nursing homes and such figure out how to really use these. And so this has been a real problem. And I think that if we were to create the guidance and create the guidelines and create the strategy around how to use these, we would see them become much, much more useful. We’d also start to see PCR testing not be backed up so much because we could start actually replacing some of that PCR testing with rapid testing, make it more convenient for people, make it quicker.

And overall, you end up getting an increase in the whole system’s efficiency because you start to de-clog, if you will, or unclog the PCR laboratories. So I would say that very few of them are being used because there’s been no strategy. And it goes so far beyond just not having a strategy, because we don’t have a strategy and the right messaging, people start to very, very quickly lose any trust in an antigen test like this because they don’t understand. They haven’t been told that, hey, you know, on the back end of an infection, when you just are PCR positive with RNA, there’s a whole long period of time when you don’t have viral infection anymore, you don’t have contagious virus. But most people don’t understand that. I’ve been trying to explain it to a lot of people. But that’s not common knowledge. And so if we don’t make it abundantly clear when we give a nursing home these tests that, hey, you know, you might see discordance between your PCR and your antigen test. And a lot of times that’s OK. You know, this is how you deal with it. Then people lose trust in these tests extremely fast. And that has been what we’ve seen. And it’s really just a messaging problem. We just haven’t instructed people on what to expect and how to use them appropriately.

Q: Thank you, and one follow up question sort of about the idea of at home testing. So a lot of companies, as we know, the first at home test, it’s prescription based at this point. And a lot of companies have been working on software platforms to sort of be able to report the results to public health and sort of coming with these high tech at home tests, which are sort of a far cry from the little paper strip, cheap five dollar ones. And I’m wondering what your thoughts are of having this test needing a cell phone and an app to meet some of the recommendation requirements from the FDA?

MICHAEL MINA: Yeah, so certainly I would say that there might be a role for those, you know, it’s unfortunate because a lot of the innovators in this country are in cities like San Francisco and San Diego and L.A. and Boston. And I think there’s oftentimes a disconnect between what we need versus what seems cool and useful in certain communities, and I think in a place like San Francisco, some of these apps will go over really well. People can use them. They like to be connected. But then there’s a whole huge section of this country that doesn’t want to be connected. They don’t want to have to use apps. They want their privacy. They just want something like this and not this whole barcode thing they have to read with a camera. And then it removes some of the privacy aspects of it to which we can’t fault people for. We normally are really harping on how important private health information is to keep the doctor patient relationship private. This is a deeply rooted piece of our culture and I think we have to respect that when we’re trying to develop public health programs that we need the population to be a part of. And so I think that these apps will do a little bit, but I don’t think they’ll do a lot. And then I think, you know, things like the test that was just authorized, the first at home COVID test that was authorized the other day. I don’t see that as the winning option. That’s a device that, you know, like these apps it’s got a lot of technology built into it. It’s disposable each time, but it’s got batteries and electronics and it has an app that goes along with it and it’s expensive and requires a doctor’s order. And so it’s kind of like everything we don’t need to fight this pandemic. Couldn’t we put it into a little device that might go to a few people’s homes who are really tech savvy and want something interesting like that? But I would say that we need to not think of this as a technological problem at this point. It’s a political problem. It’s an infectious disease problem. And the simplest solution possible is the winning solution for a problem like this.

MODERATOR: Are you all set?

Q: Yes, thank you.

MODERATOR: Excellent. Next question.

Q: Thanks for doing this. I was hoping you could talk about the state of the pandemic heading into Thanksgiving and what the pandemic could look like two to three weeks after that, given that people are expected to gather and ignore public health recommendations, as a lot of people have been doing already.

MICHAEL MINA: Yeah. Well, we’re in the worst-case scenario, more or less, I guess it could be a little bit worse. We have uncontrolled growth of the virus, of course, and so what that means is that we’re going into a Thanksgiving holiday when many, many people are going to visit their families, and rightly so. This has been an extraordinarily long year. And so we haven’t exactly given the population reason to see a light at the end of the tunnel, except maybe by continuing to harp on a vaccine being a month away. We’ve been saying that for many, many months. So I see this as a failure of policymakers. I see this as a failure of us, as epidemiologists and scientists and doctors and everyone else has been speaking to the American public, that people are going to go home and it’s not because they’re going against public health orders. It’s because people are living their lives and we can’t fault people for doing that at this point, it’s really hard for the average individual who doesn’t understand anything about infectious diseases to know what the heck to believe anymore. Is this virus is going to keep going on for years? Is it going to stop tomorrow? Is it going to stop in February when vaccines start to be seen? When is this going to stop? And we haven’t exactly given hope to people that we have it under control. And so I think we should have expected that people will go home for Thanksgiving. And probably what that means is three or four weeks after Thanksgiving, we will see more people die than otherwise would have. We’ll see more people get infected over Thanksgiving. And unfortunately, it will probably be a lot of older people who are gathering together with their families. So we are really in a pretty bad place, but I’m at a point where I really don’t want to say that people aren’t behaving in the appropriate way for public health because public health hasn’t exactly done the people well at this point, we continue to use failing practices. We’re not meeting the people; we’re not trying to figure out how to work with where the people are. And that is 90 percent of public health or 99 percent of public health should be meeting the population and not taking a paternalistic approach and just telling people what they have to do. If people are rising up against what would otherwise be considered best public health practices, we need to take a reset. We need to say, well, you know, there’s a million reasons why this could be going wrong. It’s politics, it’s other pieces of information that have to do with medicine and all kinds of things. But we have to reset, and we have to say, what should we be doing different? And we still haven’t done that. We just keep beating the same drum over and over and over again. I’ve tried to put policies forward or plans rather forward that could lead to policies that would be different, that take the average American in mind and give them tools to help themselves to be able to feel empowered. We haven’t done that in general as a populace at this point.

So we will see people go home for Thanksgiving. That will happen and people will do it. My best recommendation is for all of those people that are going home for Thanksgiving, try to start quarantining yourself last week, but now it’s too late. If you haven’t been doing early, start today and if you can get a test, you know, unfortunately, it’s almost too late now because testing is going to be backed up. So it might be very hard for people to even get a test between now and Thanksgiving. So by these tests, if everyone could have taken this on Thanksgiving morning, they would probably make Thanksgiving across the country much, much, much more safe. So I think the end result of all of this is going to be that we will see Thanksgiving break or holiday accelerate cases even more than they’ve been accelerating. It might claw back some of the gains that have been made in some places, if there are any places that are have made big gains, there’s not a lot of them in the country. And we should expect to see a bump in probably mortality and disease and hospitalizations throughout December as a result of Thanksgiving. And then the same thing will likely happen in Christmas time. I think that if we really wanted to make Christmas much safer, we could start today. We could start today to figure out how to get testing in place, rapid tests at people’s homes, start producing them, work with international partners, since we didn’t build up the capacity enough in the country. We have millions and millions, tens of millions of BinaxNOW cards we could use strategically and make Christmas at least a little bit safer, if not a lot safer, if we actually treated this like a war and actually got the US government fully on board with doing so. But otherwise, I think we’re really kind of in for a hard December and January.

MODERATOR: Do have a follow up?

Q: No, thank you.

MODERATOR: Next question.

Q: Thank you so much for taking questions. I wonder about the economics of this, knowing that the antigen tests are so easy to get done, they’re so cheap to get made and to sell. Is the problem that it is not easy to contract and distribute with some of the makers as broadly as it is with some of these established testing companies? Do you see that as part of the issue? Why are we not able to get it out in a in a large-scale distribution the way that you’re hoping?

MICHAEL MINA: Because they’re illegal. They’re literally illegal right now to use. There’s no other reason we just haven’t prioritized it, we haven’t prioritized a different way to look at this pandemic and the approach to it. It’s not a manufacturing problem. If we really want to get these tests built in a way that we want, we could do it. We can build stealth bombers, and we could build, I don’t know, all kinds of weapons in World War II on the assembly lines very quickly, we could build up these factories if we wanted. If we actually threw the weight and might of the US behind building these factories on our soil, we could do that in a heartbeat. This is not hard. Have the US Army build it all. China is able to build hospitals in two weeks. We could do this. I think the only reason we’re not doing it is because we’re not doing it. And Fauci, yesterday on the Chris Cuomo show, said something that I was so happy to hear. He just said, let’s stop thinking about it and let’s do it in response to a question very similar. And that’s really all it comes down to. I mean, if we want to mobilize this country, like we’re literally just talking about getting two pieces of paper out to every other household in America. That might sound daunting, but it’s not. We have Amazon going to practically every house in America. We have the US Postal Service going to pretty much every house in America. And so we just have to act. We have to want to tackle this virus. And so far, we haven’t wanted to deal with the virus as a country, we’ve wanted to sort of deal with it in ways that are not working and then not think creatively about how we can actually come up with new ways that are working and put those into action. And so much of it is certainly at the highest levels of politics and government. The inaction is literally killing Americans. You know, and I would guess that completely on the feet of Donald Trump. Had we had coordination and had we had a clear message at the highest levels, that’s where the message needs to start. And so I think by inference, he might be responsible for hundreds of thousands of deaths. And this is a solution to this problem. It’s not that getting at the root cause of the problem, but it is a solution that we could do. And it’s not a technical one. It’s not a distribution one. It’s not even a regulation one. Like if the government was truly wanting to use this and do something, then regulation will go out the window. We can I mean, heck, we’re allowed to go to war. We’re allowed to declare martial law where the government is allowed to do all sorts of things, including say, hey, we know enough about these tests that we don’t have to declare that authorize them as medical devices. We’re in a state of emergency and these are our best choice at the moment. And so it’s just a complete lack of interest to actually tackle the virus, I think is what’s happening.

Q: And a quick follow up, if I may. The idea that these could be distributed and could be available to the average American at any point in time, on the flip side, you have some people who might say, well, they’re not as accurate. And I’ve definitely heard pushback back in that direction. And so they’re saying that’s why it’s been used globally, because it’s just easier, but it isn’t necessarily as accurate. So I wonder your thoughts on that on that pushback?

MICHAEL MINA: You know, I’ve spoken about this extensively. The accuracy is a misnomer. It’s not less accurate. There’s a very good argument to be made for these being more accurate than PCR. People worry about the loss, insensitivity. But these have almost one hundred percent sensitivity to detect people who are a risk to their neighbors. So people say, well, what if you’re not catching them? What if the PCR does a better job at catching people early on? And so that loss and sensitivity when the virus is on its way upwards and the PCR might detect somebody early, but an antigen test wouldn’t. Well, that’s not the right comparison to make. That’s thinking about this too much like a doctor and thinking of one shot, not as a public health program. By the time you get your PCR results back, let’s say it’s Tuesday and you want to know that you’re negative for Thanksgiving dinner on Thursday, if you have a PCR test, you might have to take that on Monday to be sure that you can get your results on Thursday, maybe Tuesday to Thursday. If that PCR test were to be positive that you got on Monday, but the antigen test was negative on Monday, well, you’d say, OK, well, that’s bad because the antigen test missed that person. But that’s not how we have to think about this. The virus is growing very, very, very quickly when somebody turns positive on PCR. So the better way to think about it is to ask the question. If somebody would turn positive on Monday or Tuesday on a PCR, but not get the results back until Thursday maybe. By that point, this antigen test definitely would have turned positive because the virus is growing so quick upwards and becomes ten thousand to a million to a billion to a trillion. So this would turn positive. So we keep evaluating these as medical devices. But if we evaluate them in the context of a public health program and we allow ourselves to understand the kinetics and utilize the temporality of these tests, then these are not less sensitive. They’re just not.

This is a miscommunication and it’s a lot of scientists who aren’t recognizing how to sort of really think about this in the most appropriate way in terms of the kinetics of the virus over time and how differently a rapid test can be used. We’ve shown this and that we have a preprint called Test Sensitivity is Secondary to Frequency and Turnaround Time for Controlling Outbreaks. And that is absolutely correct. There is no scenario where the test sensitivity for these becomes the issue. These always went out because they’re faster. Always. But you have to understand the viral kinetics. Some people worry about false positives. Part of this plan that I’ve put out there is that these is get evaluated, and if you turn positive on one, you immediately take a second one. But not the same one, you take a second company and those will turn falsely positive for different reasons. So you can get the false positive rate to one in a few thousand. And so all of a sudden, you have a very, very, very good test that’s as good as PCR, but it’s rapid. It gives you immediate results so that it’s not getting a test on Monday to ask if you are potentially infectious on Thursday. That’s not a good comparison. What if you turn positive on Tuesday or Wednesday or Thursday? So I would much rather be able to go to Thanksgiving dinner and say I’m taking this test right before I go to my family’s house, as an example. That would be the much better test and essentially any scenario outside of maybe hospital work where time is of the essence. And so I really want to dispel this myth that they’re less accurate. In some ways, I’m one of the reasons that that myth got started. I think back in April when I started talking about this, I gave a talk that went viral and I called them crappy antigen tests, you know, and that was really wrong. And the more we learn about them and the more I think about the best way to consider it is they’re actually extremely accurate when they are needed.

Q: Thank you.


MODERATOR: Next question.

Q: Thanks so much. I actually have a quick question, and I apologize if you’ve addressed this elsewhere and I missed it, but I’m just curious. Have you reached out to or had any contact with the Biden transition team?

MICHAEL MINA: I know that the Biden team is aware of a lot of what I’ve said.

Q: OK, thanks.

MODERATOR: Do you have any other questions?

Q: No, I’m good, thanks.

MODERATOR: OK, next question.

Q: Hi there. I actually wanted to ask a different question related to contact tracing. I know that at least here in Massachusetts, they’re kind of beefing up the state’s ability to do this. And I wanted to just ask your opinion, given the testing rates and also the rates at which tracers are actually able to reach cases and their contacts, how valuable is this as a use of our resources right now in the pandemic?

MICHAEL MINA: My colleagues, a lot of them will disagree with me. But I get the feeling that that’s because a lot of people just aren’t maybe bold enough to buck the trends. But contact tracing isn’t working. We keep putting a lot of effort into it for sure, but I actually think the insistence on contact tracing and making that a cornerstone of our response is part of the reason we’re in the problems that we have right now. We have to recognize we have to adapt. If we want to tackle a virus like this, we really have to adapt and we have to recognize when something’s working and when something’s not. I have yet to see any evidence that contact tracing does more than just barely dent the epidemic. And we in Massachusetts is a great example. And in Massachusetts, we have some of the best contact tracing in the country. We have some of the best operations with Partners in Health and other groups. We have some of the best testing, some of the fastest testing and the most expansive testing programs in the country. But even here, and we said that contact tracing can only work when cases are really low. So what we’ve seen is that we had cases really low. We had some of the best contact tracing in the country. And we had some of the best testing in the country in terms of turnaround time and even still, contact tracing failed. And so it continues to boggle my mind why we continue to try to use this strategy that is just not working now. Is it bad if it’s not stopping any additional resources away from other potential avenues, then great. Every case counts. And we know that contact tracing captures a fraction, a small fraction of actual cases. And so it can be useful along with everything else. But if it’s using up any of the resources that could go to other more efficient programs, or if it’s distracting us from thinking up more efficient programs, then I would say that it’s probably not worth it to really be putting a lot of energy.

And we all said, you know, it’s strange, we all said that contact tracing doesn’t work when there’s a lot of cases. Every epidemiologist I feel said it. We’ve always known it. We don’t do a good job at listening to what we know. We keep thinking that we don’t know anything about this virus and we just keep beating our head against the same wall and expecting that, you know, our headache will go away. No, it won’t go away. It will get worse. And so we really have to we really have to try to look around and take a very critical view of what’s working and what’s not working. And I would say that right now, with cases out of control, ramping up contact tracing is spinning our wheels. We know that there is there was a JAMA paper a couple of weeks ago that looked at contact tracing in San Francisco, another good place for contact tracing. Of eight hundred plus people that were positive, and contact traced, they only found about one hundred and twenty additional cases. So that’s good. Every case counts. But we know that of those eight hundred people, they probably went on to infect something like eleven or twelve hundred people on average. And so it’s great that they found one hundred and twenty, but they may be missed a thousand. And of those hundred and twenty that were discovered, it was probably too late. They had probably already transmitted the virus yet another round. So we’re always behind. And so I think we really have to take a very hard look at what our policies are, where we are placing our resources and decide. Is contact tracing and isolation really the best thing to rally around as a cornerstone of our response? Or should we think of new and creative avenues to use testing more efficiently?

Q: Thank you. Maybe just a quick follow up. One is, why is there this obsession with it? And two, where would you put those resources that are going toward that? And what would you do with that instead?

MICHAEL MINA: I think the obsession with it is because we ran into this epidemic, assuming that we knew how to deal with epidemics. We had Ebola and HIV and influenza and all kinds of other things. Influenza didn’t really count because we didn’t really start contact tracing flu. But certainly, things like Ebola, contact tracing worked for in Western Africa, for example. And we just assume that we can contact trace our way out of this. That’s kind of one of the tenets of public health. And I think when this happened, people just went into the mode of what can work, and we saw it work. We saw a lot of things work in South Korea very early on. We saw things working in China very early on, but what we didn’t necessarily consider I think enough, is will those same policies work in a country where people are less willing maybe to mask and social distance? And we’ve generally seen that maybe they’re not as willing and we never really reevaluated does this plan work? But also, we’ve never seen any real data from the US or other countries that are like the US in terms of our society and culture that this can work. So I think what has happened is we just got in the mantra that this can work. And an epidemiologist went into auto mode and said, OK, this is what we’re doing, this is what’s going to work. But I mean, the proof is right in front of us. It clearly didn’t work. We have exponential growth that’s out of control. It did not work, and so I think the other options I mean, I really believe that because we just keep focusing on pounding that and trying to say that is what’s going to work, it’s detracting from our ability to be creative and think of other solutions. I’ve put out a solution with these rapid tests. I think that with the right economics in place, we could use shutdowns and partial closure closures in a much more efficient manner if we really give it a lot of thought and if we put the resources into it.

So maybe instead of putting our resources into contact tracing, we should really be figuring out how to get Americans in actual catchment, which if they’re out of work because of lockdowns and use that more appropriately. Now, I don’t think that that’s going to happen in terms of the finances from Congress. So I’m not pushing for a lockdown. But if there was a safety net in this country, then I think those other creative avenues to how can we better really spin up pool testing to do frequent testing with the lab capacity that we have today. It’s not perfect because it will still be a long time to wait and things like that, but we can become more efficient. So there’s other approaches to use besides this individual level contact tracing approach, which is sort of like trying to claw back an exponentially increasing outbreak by taking people one at a time. Meanwhile, the replication is happening faster and faster and faster than we can possibly catch people. So we just have to really take a big step back, stop this whole contact tracing bit, because this is just growing. One generation of this virus, a four-day period will catch it will, in fact, more people than all the contact tracing we could possibly do in a year. And so we just have to take a big step back, say, is that the right approach? And if not, what is? And tackle the epidemic from the picture of the big pandemic and then the cases will resolve. Maybe eventually we can get it to a place where contact tracing becomes efficient again, but it’s just not.

MODERATOR: Are you all set?

Q: Yep, all set, thank you.

MODERATOR: OK, next question.

Q: Hi, thank you for taking the time. I wanted to ask you about two things. One, you mentioned earlier, Slovakia implementing this type of testing regime or similar testing regime as you’d like to see in the US. Are there any other examples of this being used successfully out there, even, I guess, on a smaller scale, and then following up on what someone else had asked a little earlier about the Biden transition team? Is this something that you’re optimistic could be a priority in the Biden White House in the New Year, or what are your thoughts on that?

MICHAEL MINA: So the other example, Slovakia is certainly the first one to initiate it. We really came up with the idea of this mass frequent testing back in May or June, the preprint out first and then it really gained traction. Other research groups made similar models that showed similar results. And since then, we’ve been advocating for it pretty widely and I’ve been personally advocating for it to a lot of these other countries, to their leadership. And Slovakia is kind of the first one to take hold and try it. And it’s been wildly successful so far. Austria is going to try it soon, I believe. And then the U.K. is piloting it and each country is doing it a little bit different than the next. And so we have to see, you know, it gives us the variety. It gives us a good opportunity to try to see is one way working better than another way. But it will really have to be kind of country specific, what people are willing to do. For example, in Slovakia, they’re able to get people to come to a site set up all across the country and test outside of their home. I think in the US generally, people are not going to be interested in sort of participating if it’s not extremely convenient. I mean, heck, I don’t even know that I would if I had to walk two blocks down the road to get one of these tests, I’d say I’m good. I stay in all the time anyway. But if it showed up at my doorstep and I had a box of them like I do here, then I would use them, and so I do when I’m doing certain things. So I think that we’re going to see different countries do it differently, but so far, Slovakia is really leading the charge. I would have really liked for America to lead the charge. We call ourselves an innovative country. We clearly are not in this regard. And, you know, at some point, our leaders have to realize that their leaders and I think our leaders in this country have really felt like their followers without realizing that they’re in positions of leadership. And I’ve personally been on a number of calls with leaders in the country who say, well, you know, we don’t really know how to do it. We can’t do it. Our hands are tied to this and that. And I think at some point, real leadership is saying enough is enough and we have to figure out how to lead. And Slovakia is doing that. And it’s going exceedingly well, I do believe, from everything I know. There is building support in the in the president elect’s administration or at least the COVID, the people who are talking, we saw Fauci and we saw Debbie Birx start talking about it. So now we have two very, very prominent people who I think are feeling more emboldened given the election results the way that they are really saying that this is something that they are starting to support. So now we have Birx and Fauci very publicly supporting it. And I believe that this will be something that the Biden campaign and that his administration will take very seriously, and they are starting to take it seriously. It’s one of his top priorities to get rapid testing out to the people. And so I do believe that there is a strong will to do this.

MODERATOR: Are you all set?

Q: Yes, thank you.

MODERATOR: Dr. Mina, we have two minutes left and only one question left. Do you have time for that, or do you need to go?


MODERATOR: OK. Last question.

Q: Hi, Dr. Mina, thank you so much, I’ll be quick. What would you say to leaders who are counting on a vaccine to get them out of this mess without taking many other measures? We just had the governor of Florida announce that we may get some vaccines here in this late December, but he seems pretty bent on not doing much else.

MICHAEL MINA: I think it’s a really bad idea to bank just on these vaccines. This is the same behavior, though, that we’ve seen. I mean, there’s a reason why I often say that for the whole of this, for the whole of this pandemic, the vaccine has always been one month away, right now is no different. Sure, we might actually get a vaccine to a few people or even a million people by the end of December. But that doesn’t mean that this is going to be the game changer that we need to stop spread now any time soon. And I think all signs point to this not becoming widely available, at least until early spring of 2021. We’ll start to see it ramp up more and more. But remember, seven billion people may need this vaccine. Now, we can allocate it very well. We can allocate efficiently. If we can get it to the elderly individuals first, along with the first responders, then that’s the most beneficial way to use this potentially. We don’t know if the vaccine is going to have really durable long-term effects, we have no idea. All of the vaccine results we’ve seen so far have been the short-term effects of the vaccine when the temporary cells that produce the antibodies are still floating around. But those die off after two or three months. And so it could be that all of these efficacies that we’ve seen in the 90 percentile, those are maybe really high compared to what will turn out to be at month four or five and six and seven. And so we have to be really careful about how we’re considering these vaccines. We also don’t know, is it really going to do well in the people who need it? Most elderly people don’t tend to respond to vaccines. Well, my hope is that it will respond, that people will respond well to the vaccine, that they’ll get immunity, that they’ll get enough protection, at least that they don’t die if they get infected. But there’s a lot of unknowns. And so, you know, this is a massive catastrophe that we’re dealing with. And any time we have something like this, if anyone is thinking that there’s one solution, that’s really dangerous thinking. And as we’re seeing, it’s another one of these things like people glommed on to it, just a contact trace and said, OK, you know, we’ll put all of our energy into these two things. That was probably a really bad idea, and, of course, it was a bad idea for vaccines, these were never going to be available this year in any widespread way. But people made policy around it, thinking that maybe it would be. And so I think we should probably not bank on it. Hope for the best, but really plan for the worst is very apt here. And I think it only makes sense to do that.

Q: Thank you. And if you have one minute, I’d love to fact check a tweet from the spokesperson of the governor of Florida with you, if that’s OK. He’s just kind of a bit of a denier. So he quoted an observation by Dr. James Todaro that wearing a mask outdoors is more ludicrous than wearing a seatbelt in a car showroom. This is the spokesperson for the governor of Florida, by the way. And if you just have anything to address to that.

MICHAEL MINA: Masks work. We know enough at this point this is a respiratory virus, and I would say that that tweet is dangerous. Masks cut risk. I mean, are they marginally less good or less efficient than they are indoors? Sure, because the risk is lower outdoors, but they’re still useful. Just like anything and so I would call that a false tweet.

Q: Thank you.

MODERATOR: All right, Dr. Mina, do you have any other final thoughts for us before we go?

MICHAEL MINA: No, I guess we won’t be doing this next Friday. So for those of you still on, I hope everyone has a great Thanksgiving as they might be dealing with it.

This concludes November 20th press conference.

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