Coronavirus (COVID-19): Press Conference with Roger Shapiro, 10/07/20

You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Roger Shapiro, associate professor of immunology and infectious diseases. This call was recorded at 11:00 a.m. Eastern Time on Wednesday, October 7th. 

MODERATOR: Dr. Shapiro, do you have any opening thoughts or remarks you’d like to share with us today? 

ROGER SHAPIRO: Hi, Nicole. No, I’m all set. No opening remarks. 

MODERATOR: OK, great. First question. 

Q: My question to you is Maine just recently announced that they are going to be reopening bars, and I know, you know, there’s been a lot of states that are are taking this tack. And, you know, I should note that Maine is trying to have bars function more like restaurants. They’re putting in all these rules to prevent mingling amongst people who are not part of the same group. I don’t know how successful that would be, but I guess I was wondering what you thought about bars reopening in general, how it relates to the risk of the spread of COVID and whether states can do successfully do measures to prevent mingling. Thanks. 

ROGER SHAPIRO: Thanks for the question. I don’t think bars should open right now. I believe COVID cases are coming up in most states and we’re going into a period where I think we have to have some heightened concern about some rise in cases all over, and I think Maine included. I think there’s pretty good evidence across the board that indoor spaces are transmitting this virus and bars in particular are probably among the riskiest indoor spaces for a number of reasons. In bars, people are mingling across social groups, as you mentioned, but they’re also talking loudly, trying to talk over music and often, you know, may not be able to wear masks in that setting. Of course, just as in restaurants. So I think bars are among the more risky settings. I think if we are trying to do the best we can to kind of do something to help restaurants and bars stay open or were open, you know, doing whatever we can in the outdoor spaces makes the most sense. I think we should have as much outdoor, you know, moving all moving activity to the outdoors under warming areas or, you know, hopefully I know Maine is going to get cold soon. But hopefully, you know, keeping things outdoors as long as we can into the fall will, of course, help matters. But I do think that we should be really cautious about opening indoor spaces, especially bars. 

Q: I have a follow up question. Could you delineate? Is there any indication that bars are riskier than than restaurants, or are they about the same? 

ROGER SHAPIRO: It’s a difficult distinction, but I think that there’s a few things about bars that make them feel more risky. When we think about people interacting across different groups, which is often the intention of bars but not always. And also sometimes the noise level raises the voices and raises potential risk for spread. I don’t know that we can point to very specific data that differentiate bars from restaurants, and often that distinction is difficult to make. But we do know that indoor dining and indoor spaces in restaurants have been associated with risk. No question about that. And my feeling is that bars are among the riskier in that group. It, of course, depends on the ventilation of the specific bar and the crowd in that bar and other circumstances. So we can’t it’s hard to make absolutes and there are maybe ways to turn bars more into safer restaurant like spaces. But I think that would be important if we’re going to contemplate this this move. 

MODERATOR: Thanks a lot. Next question. 

Q: Hi, Dr. Shapiro. I’m gonna pull you in a different direction from some of the news of the day. Based on a story I’m working on. So with the holidays coming, curious what your biggest concerns are in terms of the spread risk from you decide: air travel, family gatherings, state to state travel and back, and what you would hope that people consider. So in a nutshell, your advice for people who are thinking about traditional family gatherings. 

ROGER SHAPIRO: Thanks for that question. It’s one that’s on a lot of people’s minds right now. And it’s an important question. In my mind, when there is no 100 percent safe way for two households to get together over the holidays in any area where COVID is circulating, which currently includes the entire United States. If we want to think about ways to reduce our risk in the event that people say, I really have to go home for the holidays or this is just so important to me that it’s going to happen no matter what. I mean, there’s a few things that we, of course, need to think about. Well, the first is what are the what are the local regulations about this? And that, I think remains to be seen in most parts of the country. Leaving that aside, I would say that at in individual levels, people who are symptomatic should not travel for the holidays. So that would also include anyone who is recently had a COVID test and that test isn’t back yet. And it would certainly and we would certainly want people who are at higher risk for COVID to think much harder about any kind of travel plans or letting their families come into their homes. When you are moving on from that, there are definitely ways we can make things safer, and all of these are the standard things that we know about, you know, wearing masks except at dinner time, staying as distant as we can and and moving things outdoors to the greatest extent possible. All those measures are going to help. Some people have thought about can we test our way out of the holiday problem? Could people test prior to getting together for the holidays? Well, we just saw the evidence that testing alone certainly does not work when you think about the Rose Garden event at the White House that Amy Coney Barrett nomination and the spread that occurred despite the testing that occurred for that event. You think of that event as sort of a Thanksgiving dinner. It clearly didn’t work. Now, there are other factors that we can talk about with that events that contributed, of course. But when you think about testing, testing should probably be done in the in the context of also self quarantining for many days prior to the test,  prior to it, so that you know you’re not in the incubation period or you’re less likely to be in the incubation period. So those two things would work hand-in-hand. Testing close to the time of travel might reduce the risk that, you know, across the board and a large scale in the country, that fewer mistakes are going to be made with people showing up at someone’s house and being infectious. But it’s not going to be perfect and it doesn’t work in isolation. 

Q: Quick follow, would you consider a holiday travel and family gatherings yourself? 

ROGER SHAPIRO: Well, we’ve been talking about that in my family. I have parents who are in their 80’s and they’re pretty risk averse. I’ve only seen them one time since COVID began. And it was outdoors on a lawn separated by quite a distance. And it’s hard. I’d really love to go home for Thanksgiving. My family’s been talking about it, but I don’t think it’s going to happen. 

MODERATOR: Were you all set? 

Q: I am I missed the last couple of words there. You said the family is? 

ROGER SHAPIRO: I said my family has been talking about it, but I don’t think it’s going to happen. 

Q: OK, gotcha. Thank you. Thank you very much. 

MODERATOR: Next question. 

Q: Hi, thanks for taking my question. I was just hoping you could speak a little bit to Vice President Mike Pence. There’s some questions about whether he qualifies as a close contact. I’m curious if you think he does. Should he be at the debate tonight? And are there any safety measures you’d like to see at the debate tonight, considering that it’s seemingly going on? 

ROGER SHAPIRO: It’s a great question. I don’t know the specifics of what his interactions were with any of the many positive White House employees, including President Trump. So I can’t speak specifically to whether he qualifies as a close contact because I don’t know whether anybody has made public all of the various interactions that would make him qualify or not qualify. I think that they’re putting up the Plexiglas barrier between the candidates, the vice president’s candidates tonight, which seems like a pretty wise idea. I think we, depending on whether Joe Biden stays negative or not, I think we may have dodged a bullet in terms of having both our presidential candidates infected with COVID based on the last debate. It seems to me it’s very hard to put together the timeline for when President Trump became infected and when he became infectious. It’s not been announced when his last negative test was, but it seems to me that he was probably not infectious on the night of the debate, but probably very close to becoming infectious. And we may have narrowly averted an event where Joe Biden also became infected, although that is still true, remains to be seen because he is not yet finished with the testing process that needs to be done to make sure he stays negative. So in terms of the president, the vice presidential debate tonight, I think it makes sense to make sure we have negative test of the testing type, which would be a molecular PCR test as close to the debate as possible, and then to take all the precautions needed, such as distancing and barriers. 

Q: So you think it can go on safely?

ROGER SHAPIRO: I think you can certainly ensure it goes on safely by increasing the distance, increasing the barriers, making sure they both test negative by a PCR test today. And when you put all of that together, you reduce the risks quite a bit, and I think you can make it safe. 

MODERATOR: Thank you. Next question. 

Q: Hi. Thank you for doing this call. I’m interested in the Miami debate and your thoughts on the risks involved in holding that debate in person if President Trump indeed tries to come to Miami and be there physically for the debate. And then secondly, I’m also interested in the question of whether Florida might still have the possibility of seeing a surge in coronavirus cases before Election Day or before early voting, which begins in twelve days in a way that might materially impact voters decisions about whether to cast a mail ballot or board in person. 

ROGER SHAPIRO: Sure, let me take the first question regarding the next presidential debate. The main concern is President Trump’s infectiousness in the middle of next week. And it really depends on how severe his COVID is and that is a matter of some debate right now, as you probably know, it is unclear whether he is in a more moderate category or whether he really tipped over towards severe disease, which would be suggested by the fact that he received the dexamethasone for his illness. Patients with more mild or even moderate disease, maybe 10 days, they may be often rendered noninfectious in about 10 days just by the natural course of the illness and the immune control. That would be expected for most individuals. And and that would make it reasonable to consider a debate in the middle of the next week. However, people with more severe disease can remain infectious for 20 days or even longer. And that is a real possibility in the current situation. And it might be made even greater by the fact that President Trump received steroids, because steroids are very helpful in reducing mortality, especially late in the illness. 

We don’t yet know the effect that they may have in terms of prolonging the shedding of virus. So I think it still is a real unknown as to whether or not President Trump will be shedding virus in the middle of next week. 

And I think it really does need to be carefully considered and and thought through, probably in advance and not the day of, with some clear guidelines about what the plan will be. I think that if he is PCR positive on the day of this debate, that would be a fairly risky situation that might be of great concern. So that’s the first part of the question. Your second part of the question was about the rising cases in Florida? Is that correct, and how that might affect the election?  

Q: The question of what, as my inexpert opinion or take on the data from the state is that it doesn’t appear that, at least as of this moment, that we are seeing any kind of notable surge in cases after the return to I know we’ve seen in college areas, for instance, an increase in cases with college students and some transmission to older population. But what I’m looking at is whether what we’re seeing now in terms of transmission and whether we might see a notable increase, a rise in cases in the next two weeks or next four weeks as people begin to decide whether they’re going to try to vote in person and whether they have a greater risk of infection. 

ROGER SHAPIRO: Right. I think there’s always a risk of increasing cases. And I remember back in the spring, I was asked, why hasn’t the COVID made it to Florida and why are the cases so low in Florida? And, you know, the answer at that time was well just wait because it’s coming everywhere. And in fact, that was the case. So it’s really impossible to say that anywhere in the country will not have a rise in cases in the next month or so. And I think there are disturbing trends throughout the country right now. You know, and particularly we know that the upper Midwest is being hit very hard. But many other places, including New York City and others, have seen an uptick in cases. So you can’t say that Florida is in any way out of the woods or in no risk for an increase in infections. Having said that, I think everyone who is voting needs to think hard about how they want to vote and whether they were going to vote in person. I think it’s more the more Americans who vote in person, the better. And I think we can find ways to make voting safe in person by, you know, keeping lines as low as possible in the polling places and keeping lines outside to the extent possible, making sure everyone is in masks and making sure we take all the usual precautions that we take when people go grocery shopping, for example, or to other [places] for a temporary period of time.

Q: Thank you very much. 

MODERATOR: Great. Next question.

Q: Hi there, yeah. Thank you so much. Just the kind of big picture question as we head into deeper into the fall in the winter and all the concerns about an uptick in cases that you’re talking about. How do you- what areas is this, I mean, you made it seem like everywhere may experience this,  I mean, can you just help us [00:18:42]understand [0.0s] the progression of the outbreaks in the country right now and the places you’re most concerned about? 

ROGER SHAPIRO:  Sure. You know, a lot of people talk about the COVID outbreak as a wave that’s going across the country. And you’ve probably heard many people say, well, we’re still in the first wave. I think a better way of thinking about it is a wave that went into a pool, and in that pool, it’s sloshing around in the water and wherever it hasn’t been yet, it’s going to go because it’s just like sloshing around in a wading pool. And that’s what the country essentially is doing. So the places where it hasn’t been, it will go. The places where it has already been, it could go back because we don’t have anything close to the herd immunity. And in terms of the antibody levels that we we expect people to have from even with seven point five million cases already in this country. And so it can keep going back to places where it’s been, and it will go to new places. Where that’s going to occur really depends on what the response is at a public health level in each place. I think places that don’t have mask orders are going to be hit worse. I think places that are opening up bars and restaurants are going to be hit worse. And I really believe that we need to take the public health considerations into account and try to minimize, you know, where this wave will slosh over throughout the country. And every local area of the country should be taking that into account. 

MODERATOR: Do you have a follow up? 

Q: Just one quick follow up, I guess, which is there’s been a lot of discussion about the growth in rural America. Do you think that there’s anything different about how we should be approaching the pandemic in these parts of the country as opposed to, you know, metro areas? 

ROGER SHAPIRO:  I think the same rules apply. But I think the problem has been that in places where the epidemic has not been, it’s easy to get complacent and to say, well, there’s talk about this illness, but I haven’t seen it where I live. 

Well, it will come. And I think what we’ve seen is that in places where they you know, maybe early on there was more fear and more measures in place, then they didn’t see cases. They may have loosened things up and now they’re being hit. And that may be the case in North Dakota or other parts of the north, the Midwest and the upper Midwest that are being hit so hard right now. But it also is just part of the natural progression as this moves across the country. So I do think that the same measures need to be in place everywhere. And it’s just a matter of of of making that happen. 

Q: Thank you. 

MODERATOR: Great. Next question. 

Q: Thank you for taking my question. So there was a study published Monday in the journal Clinical Microbiology and Infection from staff at Tours University Hospital that says even mild COVID-19 infections can make people sick for months. So my questions are, what else do we know scientifically about these so-called COVID long hallers? And what does that mean for our treatment and recovery strategies? 

ROGER SHAPIRO: Right. So we are learning more all the time about the long term effects of cozied. I think we know the most about people with severe illness. And just like people who have other severe illnesses that require ICU stays or ventilation, mechanical ventilation, we know that there is a long term effect on their health and that recovery can take weeks and months to occur. We are learning more about the effects among those with less severe COVID. And I think it’s still hard to say what all the effects will be. And to some degree, it can depend on someone’s age and other comorbidities. But people have described, you know, the brain fog of COVID or other kind of longer lasting fatigue. 

And I think we’re still really getting a better handle on that. How it impacts the management of the epidemic, I don’t think it impacts at all because we don’t want anyone to get COVID. But it might add more weight onto the scales of people who say, well, it’s mild disease and it’s not such a big deal, and, you know, I don’t really care if I get COVID. Well, it may in fact, be that this this lingers on for a while, even if you have milder illness initially. 

MODERATOR: Do you have a follow up? 

Q: Yes, please. And I’m sorry if this sounds basic. But are there other viruses that leave us with these lingering symptoms like COVID-19, or is this a unique aspect? 

ROGER SHAPIRO:  I don’t think it’s unique. People have known for years that some viruses such as Epstein Barr virus, which causes Mono, can have a long lasting effect. We know that other infections, for example, Lyme disease, which is a bacteria, not a virus, can cause a long lasting effect. And one of the reasons it may cause that is because it has a pretty high immune stimulation and there may be an immune response that gets out of maybe dysregulated a bit from these type of illnesses. And so COVID is a great example of a disease that has dysregulated immune responses, and it may take a long time for people’s immune systems to settle down once they get COVID. Not everybody, but certainly some people. And so that is probably in part responsible for the lingering and long lasting effects. But again, I think more research needs to be done to get at the nature of the exact nature of what’s causing it. But that would be my best guess. 

Q: Thank you very much. 

MODERATOR: Next question. 

Q: Thank you. As you know, the Red Cross is testing all blood donations for antibodies for COVID. And they say that nationally it’s been about two percent since June. And in Kansas, where I am, also about two percent in more recent weeks, they’re finding like four percent of donors in Kansas have the antibodies. I’m wondering, you know, what do you think my readers should know about, like, what to make of that statistic? 

ROGER SHAPIRO: I think it’s an indication that the virus is increasing in parts of the country. I think that antibody levels are a way of tracking where the virus has been. You know, we know about antibody pretty quickly into the course of illness so, you know, there might be a small delay, but especially within a week or so, you should basically see that this reflects where the community, excuse me, within a short bit of time, the antibodies will reflect that you’ve been infected, and so those showing up in the blood supply is a pretty good indication of the amounts of infection in any particular area of the country. And so I think it’s one way of tracking where the virus has been and perhaps preparing for it in slightly less real time than other measures we have, but preparing for increase in cases. 

MODERATOR: Do you have a follow up?

Q: Yeah, I wonder then, so two percent then, is that a very depressing figure? If, you know, for those of us living in Kansas, it means the pandemic is, you know, we’re in it for the long haul because so few of us have had it so far?

ROGER SHAPIRO: Absolutely. I think when you when you look at these figures, you realize how far we are from herd immunity. And I’m sorry if I didn’t address that aspect of the question head on before. 

But that is absolutely what this says. And we need, you know, upwards of 60 percent, you know, positivity to achieve herd immunity. The figure varies. But it’s a big number. And two percent is not very high. I know the WHO just came out with an estimate that maybe up to 10 percent of the world has been infected, which seems like a big jump up in the estimate from prior, and it’s based on modeling less than direct testing. But even at that number, we’re still so far from achieving herd immunity that it’s just not something we can depend on. And we really need to create immunity with a vaccine rather than depend on herd immunity. 

MODERATOR: Next question. 

Q: Hi, thanks for taking my call or for taking my question. I’d like to ask you to zoom out a little bit and look forward to 2021. What are the main factors or unanswered questions that might shape what the pandemic looks like next year? Could it “end”? And what might help that or delay it from happening? 

ROGER SHAPIRO: Thanks for the question. I am glad to get a chance to say this because I feel like many of my answers have been on the pessimistic side. But I feel like as we head towards 2021, we can actually start to think about some optimistic scenarios. And in particular, the hope is that we will have a vaccine that is proven to be both effective and safe by early 2021. The timeline is clearly something that’s under a lot of discussion these days. But I think it’s realistic to think that by December, January, we would have both efficacy and safety data for the first vaccines that have gone into phase three trials with the remaining vaccines that are in phase two trials coming out shortly thereafter. And once we have the safety and efficacy data for a vaccine and if we show that it works, I feel like over the first six months of 2021, you know, that vaccine or a vaccine or multiple vaccines will start to be deployed to it for, you know, in in a complex way across the population, you know, starting with probably, you know, frontline workers and moving to the most vulnerable. But those are all decisions that are going to be carefully considered. But I believe that by the summer of 2021 there could be a substantial portion of people who have received the vaccine in this country. And that’s going to really, I hope, help reduce vaccine hesitancy among the rest of the population. And as the vaccine becomes available to the rest of the population and they see so many people who have already received the vaccine safely, I hope that we’ll start to see really good numbers in terms of vaccine uptake and the availability of the vaccine to the general population as we get into later in 2021. You know, the timelines are currently totally unknown. But, you know, I really am hopeful that 2021 could be the year where we vaccinate a substantial portion of the world. And that is really the most optimistic aspect of, you know, everything about COVID. You know, if we move away from vaccines and you think about other scenarios, will we have better treatments? I think that the most promising treatments are the monoclonal antibodies. So you’ve probably heard about the monoclonal antibodies this week because of the fact that President Trump received the Regeneron product. And these are really like super antibodies and really targeted to COVID, and although they are completely unproven at this point, and as you all know, it’s not gone through rigorous quick clinical trials yet. There is there’s optimism that this could be kind of a temporizing measure that might help their sick patients. We know also that steriods work quite a bit better. We have antivirals such as Remdesivir that work already. Will we get more antivirals? Possibly. That would be also another tool we could use to keep people alive. But while we’re waiting for the vaccine. So I am optimistic on a lot of fronts, but particularly on the vaccine front going into 2021. 

Q: One more follow up question in terms of sort of non pharmaceutical interventions, are there, I guess what do you make of sort of the country’s ability to practice social distancing and maybe increase some of the lockdown measures if cases are on the rise as we head into the winter months? Are there, I guess, have we sort of collectively learned things from our experience over the past several months that might help sort of this winter be better than last winter and spring? Or might we return to kind of more severe lockdowns if cases keep rising?

ROGER SHAPIRO: Well, I do think we’ve learned a lot. And one thing we’ve learned is that the combination of measures that we can deploy, that if they include mask wearing, social distancing to the extent possible, and if we add to that, you know, other measures like increasing the availability of rapid testing to bolster the you know, the existing recommendations…I think those work and I think we have shown in many settings that we can knock the virus down with those measures. Full lockdown is a last resort, of course. And none of us can say that it won’t be necessary in some circumstances, as unappealing as that is. But we know that it works. And I’d also just like to point again to the success of many countries, particularly in Southeast Asia, where you can see that even without full lockdown, but with very, very high mask wearing in the population and very high testing, countries like South Korea, for example, have done a very good job keeping the cases and the severity of the epidemic low. But across Asia, if you look at Japan, they wear masks, but they haven’t done any of the other testing measures. They’ve also kept cases on the lower side. There’ve been a few upticks since the initial successes. But not to the extent that we’ve had in in both the US and now what we’re seeing in Europe. So I actually think that we should be looking to Asia for some of the measures that we can do. And I think that those could keep us out of full lockdown if we’re if we’re really smart about the way we practice it. But it starts with mask wearing. That’s the first thing on the list. And it’s probably A, B and C. 

Q: Thanks. 

MODERATOR: Next question. 

Q: Hi. Thank you for doing this, Dr. Shapiro. My question is regarding the the news this morning that the Patriots had a third player test positive, this player being one who played in their game Monday. And I’m just wondering about the logic of the NFL going ahead and playing this game, even though they were doing rapid testing as well as PCR testing of their players. But it was they put him on a plane two days after or three days after Cam Newton tested positive. So my questions are two, one about the logic, and then if you can just, you know, kind of explain to the general public once again why somebody just because that testing is not foolproof, that that people can test positive throughout the period of incubation, even after they’ve tested negative. 

ROGER SHAPIRO: Sure. Thanks for the question. I saw this on the news this morning, and, you know, you’re talking about my Patriots. So it was a real blow to see another one of our all stars go down to COVID here. But I will say that that it’s not a surprise that the NFL is having some positive tests. 

I mean, there are so many players and associated coaches and and assistants and managers and the like as part of the whole NFL. That and the fact that they are not in a bubble like the NBA was. You know, we definitely anticipated that this would happen and we saw it happen with Major League Baseball, which had, you know, has managed to muddle through their season despite some of these same issues, you know, shout out to the NBA. They really did this in an amazing manner, but also recognizing that the NFL could not probably could not put themselves in a bubble in the same way. I’ll definitely address why testing does not solve the problem. So if you think of any close contact, a starting your clock, you know, you have a close contact with a COVID patient. You’re at risk for developing illness over a course of 14 days. So you go immediately and get tested, as all of the NFL players are doing. And you’re negative. So if you’re negative on day one, you people might think, oh, great, I’m negative. But yet we know that the incubation period for the virus is five days on average and can go out to 14 days. So any time after that first negative test that the virus could be coming up and up and up in your body to the point where it becomes detectable by a test and it would first be detectable by a PCR test and later be detectable by a rapid test. If the levels got high enough. 

So at any time that it reaches the threshold for infectiousness to another person. And that’s a complex discussion in and of itself. But certainly we think about when it’s detectable by the test, you’re almost certainly infectious, then you’re putting others at risk. And in any unless you are testing every day, or let’s even take it further, every half a day. I mean, if you test negative, you are probably not infecting others. But any pinpoints of time from the point of that negative test to your positive test, you maybe infectious. And so that’s why the CDC recommends that even if you test negative, you still need to be in isolation for 14 days after a close contact. 

MODERATOR: Do you have a follow up? 

Q: Yeah, just real quick, so we kind of did see this, as you mentioned, with baseball. So is this maybe a lesson to the NFL that even if you are doing these rapid testing and the testing, that if you do have a player who test positive, his close contacts need to be isolating for those 14 days, that there are no shortcuts around that? 

ROGER SHAPIRO: That’s a that’s a tough one to answer exactly. If someone tests with a PCR on the day of the game, for example, they’re probably at much less risk of infecting anyone else, because on that day, at that moment, they are unlikely to be infectious. And so, you know, given the resources of the NFL to do much more real time testing, I think it might be possible to have to help allow the players to play despite contacts in the with the team. But this is a complex conversation that I think requires a real balance between, you know, do we want to play sports and how can we keep them as safe as possible? You know, there’s going to be some level of risk by playing. And I think that’s why the NFL offered players not to play, the option not to play if they chose that. I don’t think we can make it 100 percent risk free if there are cases around and there were contacts. But I think we can improve the chances that spread can be minimized. 

Q: Great. Thank you so much. 

MODERATOR: Next question. 

Q: Thank you so much for doing this call and taking my question. I was hoping you could talk about a little bit about our current understanding of immune responses during a COVID infection. We’ve heard a lot about the sort of 7 to 10 day window being critical for some patients to determine if they’re going to be severe cases or not. Can you tell me about, you know, what do we know, what is happening? You know, in some of those cases that it become severe. What what goes wrong? What do we know so far? 

ROGER SHAPIRO: Sure. I’ll try to keep it brief. It’s a complex immunologic discussion. But what happens when somebody gets into the later stages of it and they develop severe disease, is that their immune system really fails to lock onto the virus. If you want to really simplify it down, you can think of it as almost like a mismatch, the immune system cannot lock on and control the virus. And so it keeps trying. And it keeps trying and it keeps trying. And through those efforts, it harms the body. And that excessive inflammation that we see in late COVID patients who have severe illness is it represents the body, an attempt to try to control this virus. But it cannot lock on in the right way. The virus, the immune system starts with something called an innate immune response, and then it moves on to an adaptive immune response. Around the 7 to 10 day mark, and when that adaptive immune response doesn’t work well, when it can’t lock on, that’s when we see the worst of the problem. And so, you know, we really have learned quite a bit about, you know, the immune responses to this illness. And they are challenging. But I think we’re also learning, you know, the right strategies to address this. And so, for example, that’s why we would favor strategies that use antivirals to the extent that we have effective antivirals early in the illness. And we would use steroids to try to tamp down the ineffective immune response later in the illness. 

MODERATOR: Do you have a follow up? 

Q: Thank you very much. That’s helpful. Just to follow up with that, is it could you, I guess I have two questions. Talking about the sort of tamping on the inflammation later on in the disease when things may be going awry, is it dangerous to to try to tamp down the immune responses earlier? As you know, we saw in president Trump’s treatment, he gave he received dexamethasone pretty early in his infection. You know, in relation to this, you know, dangerous 7 to 10 day period, could that you know, are there any other implications to that in terms of sort of long term immune responses? 

ROGER SHAPIRO: It’s a great question, and it’s one reason that many people have scratch their heads a little bit about why President Trump received the steroids so early in the course of illness. And I think we do have some learning still to do on this as to whether someone with severe illness early in the course would benefit from steriods in the way that we’re quite sure now that people a little later in the illness do benefit from steroids. So there’s no question that is that there is concern about using steroids in someone with mild illness. The recovery study, that is a major randomized study on this that came out of the U.K. showed that there was clear benefit to those with severe illness, you know, 20 percent mortality reduction and those mechanically ventilated even higher in the 30 percent or so range. Whereas the patients who did not meet severity criteria by oxygenation, so had a higher oxygenation when they were given steroid, there was a suggestion of worsening of outcomes. So there’s no question that we really think of steroids as helpful in severe illness and generally at a later stage in the illness, when it’s the immune system that’s dominating the pathophysiology, that it’s the over exertion of the immune system, the lack of a coordinated response that is causing the problem. So what we do is we try to just knock that all down and are there risks to it? Yes, there’s always risks to using steroids, but they are far outweighed by the benefit of removing that sort of abnormal response. 

Q: Thank you so much. And I had one other question, but if you need to move on to another, to other people’s questions, that’s fine, too. But I was going to ask about your current understanding of protective immune responses after an infection, how long they might last if there’s any sort of movement on that front in terms of our understanding. 

ROGER SHAPIRO: I’ll give a short answer, which is just stay tuned, because I think, you know, we’re still working on that question. 

Q: Thank you so much. 

MODERATOR: Next question. 

Q: A follow on what we talked about before, I imagine you’ll need to qualify this answer based on scenarios, but where do you think we’ll be in, say, a month from now on, the number of daily new cases across the country? 

ROGER SHAPIRO: So if you look at the trends right now, they’re ticking up in October, really late September and early October. Many areas of the country have started to tick upwards. And it’s not shooting upwards like New York City did in April, you know, or to that degree. But we’re seeing these sort of slow upticks. If those trends are to continue, I mean, we could be at, so right now, you know, it ranges daily for, let’s say, 40,000 cases per day in the United States. It’s sometimes higher, sometimes lower. But I mean, I think what I’m seeing right now is a trend moving us more towards 50, 60 per day in the United States. If we don’t do anything to take measures, if we take no measures to stop this trend, to reverse it, I think kids are going back to school, you know, some states are opening restaurants and bars, and I think those are factors that we have to think about. You know, I think we saw some change in the epidemiology as college students went back. One thing we’re seeing, for example, is a lot more testing being done in many areas where there’s a lot of college students because there are protocols in place to test all those students. So you have to kind of, you know, look through the total test results and look at sort of new test results for individuals. And there is a there’s definitely a little bit of an uptick when you look at the kind of first positive test for an individual in the country if you look over the last couple of weeks. 

Q: You made me think of something else, I may test your patience here, and so I apologize. But the divergence in case counts and death toll, could you speak briefly to what’s happening there and how that might continue to change moving forward? 

ROGER SHAPIRO: Yes. Were seeing lower death rates in this country, which is really fantastic compared with, you know, the spring. And we, you know, we can attribute that to a few factors. I would say the main two things that are making death rates lower in this country are that it’s a younger demographic who are becoming infected in general. 

And we are not seeing the wave of patients from nursing homes, the elderly, as we saw in the first part of this epidemic in the spring. And so I think we’re seeing a more generalized population epidemic that is clearly going to have a lower fatality risk for their cases. 

And then the second aspect of lower death rates, too, is because of our improved ability to treat patients in the hospital. So we now have better techniques for managing their illness from ranging from how we position them when we intubate them, giving them steroids, which is probably the number one thing we’re doing that’s reducing mortality, and also giving remdesivir, which was not shown in trials to reduce mortality, but it reduces hospital stay. And it’s possible that in larger studies it would have an effect on mortality. So when you put all that together, we may be, you know, 40, 50 percent better at keeping people alive than we were in the spring. 

Q:  Thanks so much for that. 

MODERATOR: OK. Next question. 

Q: Hi, can you hear me this time? 


Q: OK. Awesome. People who find out right now that they have the COVID antibodies, should they still wear masks and social distance? Because we don’t know enough yet about the, you know, what the antibodies mean. And then I wonder later, when people are all getting the vaccine, will they be able to reliably relax mask wearing and social distancing? 

ROGER SHAPIRO: Well, I think you answered your own question, as you said, as you asked it, in a pretty nice manner. I do think we don’t know enough about what the antibodies mean to say that somebody should not wear masks. And I think it’s just too complex right now to, you know, have people wear a sign around their neck saying, I’m not wearing a mask because my antibodies are positive. It’s just complicated. And I think until we know what the antibodies mean it’s just better for everybody to wear masks. And again, remember, people are wearing masks to protect other people primarily. There may be a small amount of benefit to the individual wearing the mask, but for the most part, you’re protecting people around you. So, you know, less is known about whether someone who has had the illness once and maybe has antibodies. Could they get a very mild case a second time that they don’t even notice? What makes them infectious? We don’t know enough about that. And that’s, you know, sort of yet another reason to wear mask. 

MODERATOR: Do you have a follow up? 

Q: Well, yeah. Then I just wondered, will we know enough about immunity later when we’ve rolled out the vaccine so that at that point we can know, like, OK, I’ve got the vaccine. I don’t need to social distance and wear masks anymore. 

ROGER SHAPIRO: That’s where the studies come in. So I think, well, yes I should rephrase that. That’s in part where the studies come in, because the studies will help us understand, you know, what someone’s risk of getting ill are after the after they receive a vaccine. And we [inaudible] a bit from that in terms of their risk of infecting others. So I do believe that that’s going to be in play. But then the other factor that will be important is as we get to high enough vaccine levels, the herd immunity will actually just lower the amount of virus that’s circulating in the population. And so there will be just less virus around us. This is our hope once there is a very high level of immunity in the population. And so the issues around it become moot as we get more and more people vaccinated. 

Q: Thank you so much. 

MODERATOR: It looks like we have just a couple more minutes. A follow up question?

Q: Hi, thanks again really quick, I want to follow on that question. Can you talk a little bit about protective immune responses and just basically about how they might differ or hopefully be better when you’re comparing a natural infection versus a vaccine? How could a vaccine maybe better protect you than a natural infection or not? Can you talk about that a little bit? That would be great. 

ROGER SHAPIRO: Well, I actually don’t know if we can even speculate on that yet. I think there’s just still lots that we’re learning. The early data from animal studies and from the phase 1-2 studies from vaccines show very good neutralizing antibodies for most of the data that we’re seeing so far. So that’s really good. How that’s gonna compare to natural infection and how long it will last compared to natural infection is absolutely something we’re still studying. And I think it’s just going to have to be studied in it in real time as we go through this. Most of the vaccines out there are two shot formulations. There’s one that’s a one shot formulation based on neutralizing fighters but I think there’s more to learn about what would be needed in terms of any future boosters, etc. 

Q: Thank you. OK. 

MODERATOR: Dr. Shapiro, I think that’s our last question. Do you have any final words you like to share with us before we go today? 

ROGER SHAPIRO: No, but thank you for the questions. It was a very interesting and well thought through group of questions that were being asked. 

This concludes the October 7th press conference.

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