Coronavirus (COVID-19): Press Conference with Thomas Tsai, 07/10/20


You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Thomas Tsai, assistant professor in the Department of Health Policy and Management and an affiliated faculty member of the Harvard Global Health Institute. This call was recorded at 11:30 am Eastern Time on Friday, July 10. 

THOMAS TSAI: So, a few opening remarks from our work at the school, as well as the Global Health Institute. This morning, the New York Times released a dashboard of state testing threshold, which was a collaborative effort based off of our prior work through the Harvard Global Health Institute. So, I think that really highlights a few key points I wanted to open with today, is that a lot of our metrics are unfortunately heading the wrong direction. Despite an increasing number of tests, our test positive rate continues to increase, which means that the number of cases appear to also be increasing as well. So now we’re seeing over 60,000 cases a day. Test positive rate nationally continues to rise. And it’s about a nine percent test positive rate again. So instead of heading the right direction, which is closer towards a less than three percent, we’re heading back to where things were in March and April with our test positive rates continue to rise.

The second point we wanted to make today is also to realize that as a lot of the states, especially in the South, are seeing rising cases, rising hospitalizations and rising deaths, I think this is also an opportunity to go back to where the country was in March and April, where there was a collective action to focus on how do we help out New York City, where they were seeing a huge burden of disease in March and April. So I think in some ways, this also highlights that we need to kind of instead of looking at the South and some of these states and saying they open too soon is how do we actually not just, you know, take the energy we had focused on New York, but now focus on Los Angeles, focus on Phoenix, focus on Houston, focus on Miami, and think about, you know, getting volunteers down to these areas, getting PPE down to those areas as well. And then the last point I wanted to close the opening comments on is there’s been a lot of discussion in the media and conversations around the country around despite the rising number of cases, the hospitalization rates seem to be flat nationally and the mortality rates seem to be flat. But if we dive a little bit deeper into the data, what we see is for the states as part of our dashboard, which are in the red zone, which is greater than 25 new cases per 100,000, these red states are actually seeing hospitalization rates that have doubled over the last two weeks and mortality rates are increased by 35 percent from just two weeks ago. So now the narrative is no longer a national narrative, but one that is state by state. And some states are doing really well. But some states have rising hospitalizations and rising deaths. It’s important to now really understand the data in terms of its local context. So, I’ll stop there and happy to take any questions about the work that we’ve been doing at the Global Health Institute.

MODERATOR: Thank you, Dr. Tsai. OK. Looks like our first question.

Q: Yeah. Hello. Thanks for doing this. My first question is just to ask about, do we need to test flu patients for COVID-19? And the most common question nowadays, is COVID-19 airborne?

THOMAS TSAI: Thank you for those questions. I think we need to be testing a lot more broadly for COVID-19. And a lot of hospitals around the country have protocols in place where every patient that’s admitted is now being tested. We used to use the word screening. And during the early days of the pandemic, that meant screening for symptoms. But now, really the main screening test is an actual nasal swab or viral test directly. So, we can actually see if patients are coming in who may be asymptomatic or pre-symptomatic carriers for COVID. That’s incredibly important for the hospitals because they have to know what the risk of exposure to other patients and to health care workers are and also where to place patients in special isolation wards or as part of the general inpatient floor. So that’s an incredibly important screening modality that a lot of hospitals around the country are now implementing to protect both the health care workers as well as the patients themselves. 

The second question around, you know, whether the virus is airborne or not. You know, there’s been a lot of discussion the last several days and weeks, and the World Health Organization has changed its definition of the COVID-19 and the coronavirus being able to be spread as an airborne disease. In some ways, it’s a little matter of semantics whether the transmission is droplet versus airborne. I think the fundamental takeaway is that we all know that the transmission of COVID-19 can happen through an airborne means, so from coughing, from sneezing, and there is emerging data that indoor environments where there is high frequency, high duration of contact and close proximity with other individuals. These are all risk factors for the transmission and transmission from surfaces with medical and public health terms, which means fomites is less of a driver for transmission. That really argues, and I think this may be a theme for today’s conference, is that we’re back to where we were in March in lots of ways about reinvigorating the public health measures that work. That includes wearing masks to minimize the risk of any airborne transmission, whether via droplets or even smaller sized particles, as well as good physical distancing and hand hygiene.

Q: Can I have one more question, please? What are the infection risks for a large assessment? 

THOMAS TSAI: Sorry, do you mind clarifying what you mean by a large assessment?

Q: Yeah. You know, these times there are many calls regarding a mask. This a lot of people are feeling like a little bit concerned that there’s infection risks for a large assessment. 

THOMAS TSAI: I’m not quite sure I understand the question. Do you mean what’s the general risk to the general population?

Q: Yeah. The existence of a large number of people in certain place to make to take COVID-19 tests. 

THOMAS TSAI: So, what I think you’re getting at is you know, so the way to kind of put all the data together is that there is not a single intervention or single test that is the silver bullet or the miracle cure. No, we’re still in the same basket of interventions that we have now that we did earlier in the pandemic. So that means each of these interventions can lower the risk of transmission by a significant degree. And taken together, that’s how we can actually reduce the most amount of risk for transmission. So, in the community, that means avoiding large gatherings. That means taking precautions by wearing masks universally, you know, physical distancing of over six feet, minimizing any sort of close contact. And also, I think testing can play an important role. You know, what’s unfortunate is our conversation has now gone back to the way it was in March where we were letting the scarcity in the supply chain drive some of our recommendations. Now, you know, that’s why in early March, some public health experts were recommending to not wear masks in the community, not because it didn’t work, but because we had to preserve them for high risk populations or frontline health care workers. Now that the production has improved for masks, there is near universal consensus among public health researchers that wearing masks can help. Testing plays a role in that. But similarly, now we’re also seeing again, like we, as you know, are repeating ourselves from a few weeks or months ago, now there are actually testing shortages once again in specific jurisdictions. And then the time it takes for the test results to come back is starting to get longer and longer, with some commercial labs taking over a week to get the results back to individuals. So, it’s not enough to you know, testing is a means to an end. The end is to beat the pandemic. It’s important to test, but testing alone may not be enough in areas where there is a high burden of COVID-19, which is why in the Harvard Global Health Institute dashboard are suppression metrics of COVID-19, we’ve color coded the risk level for those areas where the new cases are greater than 25 per hundred thousand. That may mean coupling a testing strategy with contact tracing, you know with the potential need for further shutdowns.

Q: Thank you so much. Thank you.

MODERATOR: Thank you. Next question.

Q: Hi. Thanks so much for doing this. I have two unrelated questions. One is, there’s new results out today. I don’t know if you’re familiar with them suggesting that Remdesivir is very useful. I’m just wondering kind of what your thoughts are on that on that drug in particular.

THOMAS TSAI: I haven’t actually seen the new results about Remdesivir today, but I think from the prior studies that have come out, Remdesivir is useful in reducing the duration of hospitalizations and the duration of symptoms. So, you know all of these new therapeutic trials have come out, none of this is a silver bullet that’s going to make the coronavirus go away. They’re all about against risk reduction in the clinical side means reducing the duration of symptoms, reducing the duration of a hospitalization. And for these steroid trials, reducing the risk of mortality in severe cases. But it still means really good supportive care for patients in the hospital who require that level of care because of their COVID-19.

Q: And then unrelated. Do you have any advice? You’ve been through a surge in Boston in your own hospital. Do you have any advice for folks in the South and the West who are just heading into that now? 

THOMAS TSAI: Yeah, that’s a great question. You know, I can speak as an individual living in Boston, but also as a physician. I’m a surgeon at Brigham and Women’s Hospital and I have an active clinical and surgical practice. On the first part is there is an incredible degree of individual responsibility. I think there is a sense that in some places that the virus is going to run its course and there’s very little that individuals can do. But what we’ve learned in Boston and a lot of other states who have been through an earlier peak of the pandemic is that good public health action is built on the backs of thousands of individual efforts and actions, and that means that everybody has a role to play themselves. When you break a chain of transmission, you’re not just helping a theoretical person halfway around the country, you’re reducing the risk of infection, of your friends, family, colleagues and other loved ones. So, you know, the advice to the individuals in the states that are seeing this is that, you know, that you can beat the pandemic. You know, it happened in New York. It happened in Boston, it happened in Detroit. But it means that everybody needs to take this seriously and that everybody has a role to play in beating the pandemic. That means following the guidelines, wearing masks and getting tested and also following good social distancing. 

One thing I’ll mention is that we had looked at some data on cellular mobility in Florida. So, in the early days in March, what was fascinating was that individuals in Florida started staying at home about two weeks even before county level orders or state level orders that mandated it to shut down. So, you know the public understands how serious the disease is, and I think it’s important for individuals to understand the gravity of the pandemic for their own families and not just wait for the guidelines officially to come down. But in some ways, a lot of this is just about following common sense. 

As a clinician, it’s important to understand for a lot of these hospitals that these capacity shortages are very, very real. And we’re seeing that play out in the hospitals in Houston, in Arizona and Florida, for example. And the whole goal of these crisis standards of care, which are triage mechanisms to ration scarce ICU beds and ventilators, the whole point is to not get to a point where we need to use them. That’s why hospitals have to plan, have a plan A, B and C about how to create excess capacity. And that may mean in some hospitals, once again decreasing or postponing elective admissions, in order to free up resources to deal with the surging pandemic in their local areas.

Q: Thanks so much, really helpful.

THOMAS TSAI: Of course.

MODERATOR: Next question.

Q: Hi. Thank you so much for hosting this. I similarly have two questions. The first is, can we dig a little bit further into why the United States is not meeting its testing targets? Specifically, what are the problems with the supply chain right now? And how do our issues with that compare to other countries? I’ll let you answer that and then I have a similar other question. 

THOMAS TSAI: On the first question about the supply chain, the issue is that it’s now very local and that the bottlenecks have become very local. Early on, we were focusing on a shortage of the nasal pharyngeal swabs. But now, as there’s been increased number of tests from assays from different manufacturers, they all used different reagents, different cartridges. So, the supply chain in some ways with the availability of different assays, has actually become more complex with specific reagents for different machines. So, I think that’s been one challenge is now it’s not just a national shortage. You have very specific shortages in different areas. So, in some ways, it’s a distribution challenge for the supply chain. 

And that really argues as to why we need a coordinated strategy. And if there is a lack of that on the federal level, this is where regional compacts or collaboratives across states can really help to address these shortages. Again, I feel like it’s a little bit of like Groundhog Day where we’re kind of repeating ourselves every, you know, every few weeks or every few months where we’re back to the situation early on where, you know, states are trying to outbid each other for supplies. Now its local hospital systems are competing against each other for supplies of reagents and for tests. 

The second part of that is that’s why we have to measure key performance indicators, process measures. Pre-COVID, I worked on health policy and health care quality, and there’s a Donabedian framework where we talk about structure, process and outcomes. We’ve been talking a lot about structural measures of quality, such as the number of tests, a number of contact tracers and outcomes, like the number of positive cases, the positive rate, hospitalizations. But we really haven’t focused on as a community how to connect the dots between having enough tests to allow for a process that’s got to go improve the outcomes. So this is the stage are really going to focus on key performance indicators and a lot of the work that we’ve been doing through a collaborative effort, not just HSPH, but involving colleagues at the Harvard Safra Center and the coalition of research groups, think tanks and foundations to coalesce and converge around a set of key metrics to measure some of these processes around testing. Because if you’re not measuring why your turnaround time is so long, over a week, you’re not going to be able to improve those processes. So, to these metrics that are really important to measure, include the turnaround time, so the amount of time it takes to complete a full contact trace, as well as a turnaround time for a test results to come back. If it takes over a week for the results to come back, mathematically it becomes challenging for testing and contact tracing alone to be adequate. That’s why you have to couple that with the other non-pharmacologic interventions. 

The second metric is the proportion of tests, positives, that are coming from either targeted surveillance or from contact tracing as opposed to just symptomatic individuals. Now, a lot of states, because of the shortages in testing, again, they’re limiting the indications for testing again to symptomatic individuals. Now, we’ve moved backwards to just diagnosing COVID cases among symptomatic individuals in hospitals where we really need to be doing is getting the tests out of the hospitals out of the clinics and into the communities where the individuals are in order to test adequately and using that information to inform the suite of non-pharmacologic interventions.

Q: Just to follow up, you’ve actually answered my second question, but to follow up on the portion of my first question, why are we why is it the United States as a whole having these issues with testing supplies when other countries have been able to do that? So, is it an issue of a lack of a national coordinated strategy? 

THOMAS TSAI: Yes, I mean, the short answer is yes. And what’s frustrating is we seem to be stuck at this complacency that, you know, the 650,000 tests a day right now is OK. And think about, you know, that was the discussion back in March when we were doing 25,000 tests and now we’ve been, you know, creating research and these national testing targets, in order to help move the needle along the way. Initially, 500,000 tests per day. You know, then about a million tests per day. And we may need to do more if we are to truly suppress the pandemic. And that testing target is going to fluctuate with the underlying burden of COVID-19 cases. But that’s why we need a coordinated strategy on the federal level. And if that doesn’t exist, that’s where regional collaboratives across State Governors can be incredibly helpful. Well, we’re part of a Massachusetts TTSI task force, a test trace support isolation task force, and we’re diving deeply through a public private partnership to understand some of these local supply chain issues. 

And but, again, it is very local, you know, the challenges that one hospital system like Mass General, Brigham is facing is different than what UMass is facing because they’re running different platforms. The Broad Institute, for example, has been able to fill in the void in increasing its testing capacity. I think that’s a model that can be replicated as a public, private, you know, testing task force. That’s not just about strategic policy goals. But actually, involves industry, academics and policymakers, all in one task force to really hone in on fixing the supply chain. The model for that in Massachusetts has been the MERT, which was the Massachusetts emergency task force that was created to help manufacturers and industry repurpose their supply production lines towards making PPE. So, there’s an example of how we can do this. Now, the challenge is to take the lessons from the manufacturing process for PPEs and that collective effort and apply that to testing.

Q: Thank you.

MODERATOR: Next question.

Q: Hi, thanks for taking my question. I feel like a few months ago when it came to testing, a lot of the talk was about the importance of rapid testing when it comes to getting back to normal, for lack of a better word. Can you talk a little bit about where we are when it comes to rapid testing and maybe how far we are away from a place where we could take a test at the airport and board a plane or one in the lobby and go up to work or school even, and maybe piggybacking off of that, where do these new antigen tests fit in to that whole picture? 

THOMAS TSAI: Great. That’s an excellent question. I think, you know, that’s the goal is still the same. It’s still to get rapid testing results back. And so as part of our metrics for suppression, one of the key performance indicators that we’re advocating for is to measure the average time it takes to get a test result back, because if we’re not measuring it and it needs to be systematically measured out, every single state dashboard that needs to be front and center for the CDC dashboard, the metrics that needs to be front and center as well, because the whole goal is to use testing to, one, not just get control of the infection, and two, provide better data to inform the non-pharmacologic interventions. But three is also to rebreed confidence and being able to get on that plane or go back to school in the states and counties where the pandemic is in the green or under control with a low prevalence. So, I think that’s still incredibly important.

I don’t know why the conversation moved away from that and it’s frustrating that that’s happened. But I think that’s why we need to reinvigorate the focus on the processes of testing. And again, I think we’re repeating a lot of the recommendations from March and April, but I think it’s important to, you know what’s challenging is I think a lot of states that have figured it out in Massachusetts, New York, for example. There’s a notion that, you know, it’s settled. But again, this goes back to the earlier comments I made in the opening is that, you know, that collective energy around, you know, about the pandemic that there was in New York, we just apply that to Phoenix, to Houston, to Miami and help, you know, and help these other states, meet the pandemic now. And I think the rapid test, I think, is incredibly important for, you know, getting people back to work and back to schools. I think getting those processes right is incredibly important. There are a lot of specific manufacturers that make their rapid point of care testing mostly for diagnostic purposes. You know, Cepheid, Abbott, all make point of care tests. But the idea is how do we take that medical framework and turn that into a rapid point of care public health surveillance test. And we can’t just rely on the really overburdened medical infrastructure to do that. That’s why we have to divorce the testing from insurance and for the medical system and really move it to one of the public health community in the field.

Antigen tests, I think, can play an important role. I just haven’t seen them widespread yet or mature enough. I know Dr. Birx on the White House task force has been a big proponent of antigen tests and antigen tests have been used in other diseases like hepatitis and not the same sort of medical situation. But there’s definitely a role to play. So, I think this is really the next few days or weeks as a call to action as our cases are still growing out of control and in more and more states is, you know, it seems like we’ve sort of moved on. And I think it’s important that we don’t move on and we sort of double down on a lot of these research efforts and the scaling efforts that had started in March and April, but seemed to fizzle as some states have done better and some states have not. Now, is it take the learnings from the states that have done well and that energy and apply it to the states that need help now.

Q: What do you think is needed to get it to that point, to take it from that sort of medical framework that you discussed? You know, these point of care tests are available, you know, in the hospital for a quick diagnosis. But I mean, is it is it more public private partnerships? I mean, is it more money? What needs to happen to make these more commercially available? 

THOMAS TSAI: Yeah. So, what we’ve been hearing for some of our collaborators on the task force is that for a lot of the biomedical startups, you know, there is a challenge because there’s inconsistent messaging about the demand for tests. So, it’s hard for a diagnostic or lab testing company to repurpose their supply lines for COVID testing if we’re hearing inconsistent messaging about how important testing is and what the need for testing is from different governors and different mayors. And that’s why the coordinated strategy, both federally, is important, but really on the state and local level, because they need to know that there’s going to be a demand there. 

On the policy side, I think that points to a couple of different solutions. You know, there was a ton of energy around using the DPA, the Defense Production Act, to secure demand, as well as supplies for production of PPEs. You know, in some ways we’ve sort of moved beyond that conversation, but I think this is a time to revisit that for testing purposes. So guaranteeing that demand. Another policy proposal that we’ve been working on with a group of collaborators is the idea of, you know, prepaying for tests or a voucher program to make sure that, we are separating the need for public health testing from the, you know, the medical infrastructure of having to have a doctor or physician order the tests for a clinical indication that has to then be approved and reimbursed by insurance in the back end and performed by, you know, CLIA certified diagnostic laboratories. These tests are not being done for diagnoses, they’re for public health screening and for contact tracing. And I think that’s where a program like a voucher program could be very powerful to direct funds, to essentially prepay for tests. And then that way, you know, testing sites can stand up and know that there’s funding available for these tests out there that are effectively sort of pre-paid.

Q: Thank you so much. 

MODERATOR: Next question.

Q: Yes, Dr. Tsai, thank you. I have two questions as well, kind of piggybacking off of what you were just talking about when it comes to rapid testing or testing in general. Can you talk about the false positive rates and the liability of these tests? Is there concern that that’s having any kind of significant impact on your models? 

THOMAS TSAI: There is varying degrees of false positive and false negative rates for all the different tests. Some of them are, especially for the point of care tests, you know, the Abbott one comes to mind, it’s not just intrinsic to the test technology itself, but in some ways to how the tests are being processed and the reagents and then cross contamination for some of the point of care type of testing. So that is a potential concern. The consequences, though, I think have to be sort of weighed with the tradeoff of the false positive is. You know, for COVID, it doesn’t mean that you’re being subjected to a different suite of pharmacologic interventions. So, you know, you’re taking medications or undergoing procedures or tests that then have their own potential side effects. So maybe, you know, adding complications or risk unnecessarily. The main intervention from a positive test for individuals that are either asymptomatic or pre-symptomatic is to stay home or be more vigilant, really around wearing masks and physical distancing. So, you know, for all of the false positive rates for the tests, it matters what the consequence of that false positive is. So, I think that’s something that’s important to consider. They haven’t factored entirely into the models because it’s unclear the exact type of test and not broken down into the projection models, the underlying rather case data is not often broken down by the specific tests. So, it’s difficult to extrapolate the false positive rates since we know we don’t have that data for the aggregate numbers for positive cases in the county or state level. But that is an important point.

Q: And my other question is, as you’re breaking things down by state, we’re hearing here in California of issues with people being able to get tests. Can you talk about where the state stands and what kind of impact that has on the data in terms of being able to get an accurate idea of what’s playing out? 

THOMAS TSAI: Yeah, definitely, and I think the challenges that just as the supply chain bottlenecks are very local, the supply and demand mismatch is also very local. You have counties where there’s a very low burden of COVID cases, but there’s an excess of tests that are available. And you have counties where it’s the opposite, where there’s a, you know, skyrocketing cases and not enough tests. So, you know, speaking of these second order metrics that we all need to be measuring now. One thing we were discussing this morning actually on one of our conference calls is in manufacturing. We have, you know, occupancy rates or utilization rates for a machine or for a production line. For a lot of the lab sites, whether the public health or commercial is to be able to at least publicly measure what their utilization rate is, because if we know there are areas where there’s a mismatch of availability to demand, that may prompt public health officials and the local county level or state level to help redistribute or at least reallocate where their mobile testing sites need to be based off of where the supply and demand is. And I think that’s where mapping the risk levels down to the county level can be incredibly helpful to guide some of these local decisions about how to allocate what is unfortunately now becoming a scarcer resource, which is the availability of testing.

Q: Are you able to say with California specifically, basically how they rank compared to other states in terms of the difficulty of getting tested right now, are they on the more challenged end or somewhere in the middle?

THOMAS TSAI: So, looking at the test positive rate in California, one thing that’s really stood out is that it’s been essentially stuck at six percent test positive rate for the last several months, actually. So what has happened in California is as the cases have increased, the testing has increased in proportion, but it hasn’t increased to a level where testing has outpaced the growth of cases and the ability to contact trace, you know, has actually gone ahead of the infection and then gotten control of it. So, you know, California is testing in an absolute sense a very high number, but relative to its population and its growing pandemic, you know, it’s still short of its targets for suppressing COVID-19. And that’s why California appropriately has, you know, a week ago instituted restaurant bans in some of these southern counties because, you know, if you can’t catch up on the testing side and you have to layer on the risk reduction of COVID-19 by adding on social distancing measures and possibly even localized shutdowns. So, I think California is doing well, but it can do better. And the key thing is really getting the tests out to the communities where they’re needed the most.

Q: Thank you for your time.

MODERATOR: Next question.

Q: Hey, thanks very much for this. Two quick questions. First, on everyone’s totally favorite drug. What’s your take on that Detroit survey on hydroxychloroquine? And my other question is about reopening schools. There’s a lot of reference to data that kids are not much of a conduit for spreading the virus, and I just wanted to get your take on how robust you see that data being. 

THOMAS TSAI: I actually haven’t seen the survey yet on hydroxychloroquine. So, sounds like I’ll be reading about it and in fact maybe later today or tomorrow, so, I’ll keep an eye out for that. So, thanks for putting that out. On the second part is the data on how transmission of COVID is among children. It’s still very much unclear. We’ve been taking a deeper dove into the CDC data that’s been reported from both commercial and public health labs in terms of the age breakdowns. And the concern, isn’t that just there’s a rising number of tests, positive or positivity rate from, you know, the under 65. There’s a lot of focus on the 20 to 40-year-old demographic from, you know, folks being out at bars and restaurants and driving a lot of transmission. But even in the younger groups of 5 to 17, we’re starting to see increased test positive rates as well. So, I think, again, I don’t know the answer to that yet. I don’t think that we have clear enough evidence on the on the transmission rates. But that’s why contact tracing is so important because, again, I think there’s a narrative that contact tracing may be futile as a pandemic is getting out of hand. But in terms of gathering the data, the way we know where the high-risk populations are or which industries are high risk, you know, or which meat packing plants are at risk is because of contact tracing. I think that’s why it’s incredibly important, especially as we reopen different industries and reopen schools is we need to be able to track that information, because the first thing that transmission is happening in schools and then going on to families and then back into the community. You know, that will be it would be important to know. I don’t think we know that yet. But that really means why, again, the testing as a means to an end. But it’s the information that we need to be able to, you know, come up with more informed policies. So, I think there’s a lot of interest in that. So definitely everybody’s that is going to be keep an eye on the rates of transmission among, you know, school age children.

Q: Great, thank you very much.

MODERATOR: Next question.

Q: Thanks for taking the question. So, we are in one of the hot spots you mentioned here in Miami. And we know we have a county government here that’s shown a willingness to act ahead of the state government. I kind of heard you hinting at this earlier that you thought it might be time to reconsider a lockdown. Well here in Miami-Dade, you know, a lot of things are restricted, but we’re nowhere near kind of like the safer at home orders that we were. There is still outdoor dining, for instance. I believe gyms are allowed to stay open right now. What are your thoughts on that, given the level of infection we’re seeing and kind of the testing capacity here being strained and also a lack of contact tracing? Do you feel like Miami is an example of a metro that should be locked down again? 

THOMAS TSAI: Yeah, that’s a great question, and that was the reason why, for our dashboard, for the key metrics, for suppression that we had color coded a risk level that green, yellow, orange, red, and for the red counties, those with greater than 25 per 100,000 cases, of which I think Miami- Dade is one of the red counties, is to not link that to a set of actions. And in the red counties, when the cases are growing beyond the capacity to test, you have to institute not just social distancing if that’s not working and you’ll consider shutting down again.

You know, what strikes me is Florida was slow to shut down but did shut down. But if you think about it, you know, Miami had shut down because of rising cases in New York. Now that there’s rising cases in Miami, it just doesn’t make sense of why you wouldn’t shut down when the cases are now in your own backyard. So, I think, you know, there’s understandable fatigue around, you know, the prior shutdown and social distancing. But now, you know, the analogy I had used earlier was, you know, the hurricane is here, you know, before you had boarded up the windows because, you know, you were the path of the hurricane. Luckily, the hurricane had diverged. For this storm, you’re in the midst of the hurricane and you know, you’re watching the hurricane, you know, flood homes on TV. But if you look outside the window, you’re that home. So, I think this is the opportunity where, you know, for decisive action and half measures didn’t work. Half measures aren’t going to work. And it doesn’t mean a permanent shutdown it means just buying time. You know, everybody understood the need to flatten the curve. The whole point of flattening the curve was to buy time. A lot of counties were back in that same situation again. Arguably in a more dire situation, if you look at the growth curve of cases in other states, this current wave and this current peak is higher than the peak that we saw in April, so I think that’s something that local leaders may need to consider.

Q: Just to follow up on that, not only is there the case numbers higher than it was in April, but we’re actually able to track real time hospitalizations and we can see that we’re double the rates of admission and double the peak level we were at in April, so we can feel pretty confident that the rate, the actual rate of infection is much higher than it was in April. But getting back to your comments, you know, we’re seeing a lot of pushback from people in Miami who don’t even want to wear a mask, and they’re claiming that masks make them unhealthy. And I mean, are you concerned that even if the county mayor was to issue another lockdown order or another shelter at home order, are you concerned that people wouldn’t necessarily follow it or that there would be pushback in response? 

THOMAS TSAI: Call me an optimist or maybe naive, but I think people do understand, and again, I mentioned earlier on the call there was data I looked at from Tampa Bay Times, some of the reporters there were looking at the mobility data, people actually stayed at home two weeks ahead of the shutdown orders because people understand how serious the pandemic is. I think that’s why it’s important to convey the gravity of the pandemic in very clear terms. And that’s where the dashboard that shows the color-coded threat level makes that very clear. And then I think people will understand. And people in Miami have friends, family members who are in hospitals. And what really concerns me about the rising hospitalization rates that we’re seeing now is that that’s reflecting transmissions from about two weeks ago, the rising cases that we’re seeing now, the 60,000 new cases in the country, that means that in one to two weeks, you know, some of those will turn into hospitalizations as well. So, this isn’t going to blow over. You know, we’re back to where we were in March and April.

So, I think if that’s conveyed in that way, you know, people will understand. But I think the challenges, in some states, people have moved on, like their intentions moved on to something else. But I think in Miami, it’s a very clear and present danger to lives and livelihoods if a shutdown doesn’t happen.

MODERATOR: Thank you. Next question.

He would like to ask about testing, whether all states at this point should be striving to test all residents who want to test whether they’re symptomatic or not, whether they think they have been exposed or not, just anyone who wants a test?

THOMAS TSAI: I think that’s the goal. The problem is in a lot of local areas now, you have this supply and demand mismatching of local bottlenecks, of the availability of tests. But the goal is to get to a point where everybody who wants to get tested can get tested and should be tested. Other countries have been able to do this. And we just need to have the resolve to do that. But that means, you know, measuring these key performance indicators or the testing process, we can figure out in state by state or county by county where the local bottlenecks are. Is it still swabs in some places? Is it the reagents in places? Is it the availability of testing sites in different places? I think, you know, we need to shine a light into the process, and we do that by measuring how well the process is working. But absolutely. The goal is to get to a point where we can test everybody. It’s just that we’re not there yet. But, you know, again, I’m hopeful, right? We’ve moved from 25,000 tests a day to now 650,000 tests a day. So, it just shows that with concerted effort, you know, it can be done. So, I think that’s where, you know, refocusing the conversation on that part is incredibly important.

MODERATOR: Great. Thank you. Next question.

Q: Hello. OK. So, you kind of answered some of my questions along the way here. But I wanted to ask you, you know, we were one of the three sites to have this federal major testing site with a goal of 5,000 tests per day. As we’re looking at the numbers, it looks like we’re passing the per capita benchmark for our area that like Harvard has recommended and things. But the positivity rate keeps going up, even with the increased testing. And so, I guess my question is, do you just keep testing more, more and more to eventually get a bottom? Is there a bottom that you’re going to hit? Whether positivity will start trending back down and what is that number? I mean, how much testing are we really talking about? 

THOMAS TSAI: Right. The short answer is yes, we just keep testing more, but sort of to go on a bit of a tangent, you know, in the ideal situation, we would know everybody who is infected, and we would test those people. So, we’d have 100 percent positivity rate, but we’d also have 100 percent capture rate or ascertainment of all the cases. That’s just not realistic. So, we have to rely on the test positive rate to reflect how wide a net that you’re casting. And the analogy I use is, I fly fish, so I like to use these fishing analogies. But, you know, you can go fishing with a hook and bait and you can catch that, you know, that one fish it’s 100 percent, but you don’t know what other fish there are out there, so it’s important to kind of, you know, cast a wide net to get a sense of how widespread the pandemic is, especially what we know about the risk of transmission from asymptomatic and pre-symptomatic individuals transmitting COVID. 

But again, my worry is that people are talking about all these interventions in isolation and that it’s not just about, testing alone is not going to control the epidemic because testing just provides information. The testing is not therapeutic. The testing is therapeutic if people actually react to the testing results. So, people who are a positive then actually stay home and self-quarantine for 14 days. My fear and worry are that people are not doing that. You know, people used to stay home while they’re waiting for their test results to come back. You know, in some ways you’re guilty until proven innocent. Now it’s the opposite. People are going back and getting tested, but, you know, still going about their daily lives while the tests are coming back. So, you know, the way I was phrasing it is that, you know, innocent till proven guilty works really well for criminal justice, but for pandemics, it doesn’t work so well. So, we do need increased testing to drive the test positive rate down. The goal of the positive rate is not the goal in itself. The goal is to control the pandemic. The goal ultimately is a zero percent positive rate. So, I think for Louisiana and a lot of other states, it’s about testing broadly, but then coupling that with, you know, supported isolation, reinforcing universal masking and physical distancing. All these things that are needed to work together to bring the pandemic under control. Once it’s under control, then you can use testing and contact tracing to rapidly diagnose individual cases and quarantine those individuals in a supported way, so they don’t become a case that then turns into a cluster.

Q: Just to follow up, can you speak a little bit more about the accuracy of PCR testing currently, I know someone else had asked this question. I know there’s different tests, but what is the average accuracy percentage on the test right now? Because there’s all sorts of things all over the place. Tell me what you understand it to be. 

THOMAS TSAI: Yeah, it really does vary. And it’s not just the test itself. What’s also challenging is depends on where in the course of the disease you’re being tested. There’s this great scatterplot, it was a pre-print paper, I don’t know if it’s actually been published yet. It looks like a random scatterplot of when individuals are most infectious, meaning where the viral shedding is most significant. It’s likely highest in the pre symptomatic period of a few days, one to two days before symptoms develop. But it can vary quite a bit. So, I think that’s the challenge. The overall consensus on the clinical side is that the PCR tests are very highly reliable. We’re using it to screen individuals in the hospital. You know, I’m a surgeon. Every single one of my patients I operate on undergo a PCR test to rule out COVID, you know, prior to any elective operations. So generally speaking, the tests are accurate and reliable on average.

Q: Can you put a number on it?

THOMAS TSAI: Not off the top of my head, it really, again, depends on the specific assays, how they’re being done. So, I can look into that and I can get back to you with some information.

Q: OK. Thank you. 

THOMAS TSAI: I’ll follow up with you on that.

MODERATOR: Are you all set then?

Q: Yeah. The other questions kind of got dealt with. 

MODERATOR: OK, great. Next question.

Q: Hi, Dr. Tsai, thank you for taking the question, I want to ask a more specific question, we’re seeing people lining up for tests and we’re also waiting longer for results. And last week, the state began adding antigen test results and pooling them together with their PCR test results. And I understand that antigen tests may provide faster results, but they also have some, I’ve read that they have some issues with perhaps false negatives. And I’m wondering, in your estimation, should they be lumped together with PCR test results, and what are the pros and cons of antigen testing? 

THOMAS TSAI: Yeah. I don’t know the specific antigen test that’s being used in Florida, so I don’t know the exact specificity or sensitivity rates or, you know, the false positive or false negative rates for the specific antigen test that’s being used in Florida. The best way to display the information, you know, you think about how the hospitalization data are being displayed in different state dashboards and by the CDC, you have overall hospitalizations and then proportional hospitalizations that are attributed to COVID and you have overall ICU occupancy rate and the proportion that’s due to COVID-19. So, I think our testing needs to be displayed in the same way for active disease. So, what the overall test positive rate is and then broken down by viral PCR tests, then broken down by antigen tests.

You know, there’s so many different tests out there. I think it’s important to just have both that granularity of information, but also being an aggregate way so we can look at them sort of on average. I think, you know, breaking that down is incredibly helpful. If we can do it for, like basketball games, like we can show an overall score, what are two pointers, three pointers, you know, we should be we should be able do this for the pandemic.

Q: Then just as a quick follow up. I mean, people are waiting much longer it seems, they’re waiting a week or longer which I think will reduce the effectiveness of perhaps the testing itself and I think a lot of states maybe going into this issue, what can be done when commercial labs are  saying that they’re over capacity and other public health labs really don’t have a lot of capacity? 

THOMAS TSAI: I think one incredibly important model is what’s happened in Boston is the Broad Institute, which is a research laboratory, that’s a collaboration between Harvard and M.I.T., has really stepped up to produce, fill the void and being able to produce tests. I think Eric Lander, who directs the Broad, says they can do up to a hundred thousand tests a day if needed. But, you know, the Broad isn’t the only research lab in the country. So, I think this is where that model of public-private, or in this case from academic partnership, to fill a public health need can be incredibly powerful. You know, as an employee at Harvard, I need to be tested every week to be on campus. And those tests are being done by the Broad Institute. And the results are back within one to two days. So, again, I think that’s a really powerful model that can be replicated by universities across different states to really fill in the gap by what the commercial labs are able to do. And then the other part is what I mentioned earlier, where, you know, either a voucher program or prepaying or activation of the Defense Production Act, but guaranteeing a demand of tests that creates market confidence for a lot of the startup companies and biotech companies to repurpose their manufacturing lines for testing. But I think it’s such mixed signals that it’s been challenging for the companies to be able to do so. Again, another example – I keep pointing at Massachusetts – you know, when it’s done, it’s done really well. But also, you know, from a policymaking standpoint, but also because I live here, you know, they just put out a new RFP targeted at, institutes like the Broad or startup companies like Ginkgo Bioworks to be able to repurpose either research or manufacturing production lines towards testing.

Q: Thank you. 

MODERATOR: Next question.

Q: Hi. How are you? Thanks for taking my question. We are obviously in a hot spot down here in South Carolina. I’m in Charleston County. I just got off the phone, this morning on a task force meeting with the school system, they are looking at delaying the start of school, possibly as one consideration, backing it up a little bit, however, do we have enough time to pull out of this peak right now? Is there a way for us to get the numbers down to a place where it would be safe for our kids to go back as soon as the end of August, which is what they’re considering? Right now, it’s still slated for August 18th. And that would be possibly with a in person and online model particularly. Is there a way to get kids back into school safely that soon when you’re already in the red zone?

THOMAS TSAI: Yeah, thanks for the question. I know I’m deeply worried by the timeline that’s available and with the rising cases in South Carolina, that’s going to mean, you know, a rising number of hospitalizations and unfortunately fatalities in a couple of weeks. So, I think that’s where being proactive on the part of the state leaders and county leaders is incredibly important, because if they’re reacting to the case data, that’s a day late and a dollar short. So, it’s really important to take proactive action and sort of it’s like any public health measure in some ways if we all want to be wrong. I want our testing targets to be totally off because the states have done better and don’t need to do as many tests because they’ve controlled the pandemic. So, I think with all the schools opening August, that that window of opportunity, I think is still there. It is closing very, very rapidly, which is why, switching gears from South Carolina that the restaurant bans in Arizona that came in yesterday is, you know, an important step. But it’s you know, it’s not enough. And if we need to flatten the curve and really in order to get schools open, it’s not just enough to flatten the curve, it’s to bend the curve down until there’s safe levels for children to be back in school, for teachers and staff to be in the schools teaching. And we all agree that’s incredibly important. But we need to get the coming level of transmission down to a low enough level where that is safe for everyone involved.

Q: Is it unrealistic, do you think, to be thinking we can do this in time? We haven’t even put those measures into place. 

THOMAS TSAI: If anything, the pandemic has taught me I don’t have a crystal ball and nobody, none of us have crystal balls. But looking at where the data are now and the trends and the data, I think it would be very challenging at this point. But again, the thing about the pandemic is that, you know, that you can change the course of the pandemic. The problem is it just doesn’t turn on a dime. You know, there’s a couple week lag in the response to the policies in terms of how that translates to the cases and the hospitalizations. So, I think that window is closing very rapidly, you know, if school was supposed to start on time.

Q: Thank you.

MODERATOR: Thank you. And a final follow up question.

Q: Thank you for taking this question. I was just thinking your message was really resounding with me that it may be time to look at embracing some of the messages that we did months ago, rallying behind the effort to flatten the curve. It feels like things have changed now with so much conflicting information, political division and a desire to resist wearing masks. And could you talk about and try to deliver a message to people like our viewers as what kind of waves will start to see this manifest in their lives and impact them if they’re not taking this resurgent seriously? 

THOMAS TSAI: Yeah, thanks for that question. I think that’s where the local reporting is incredibly helpful. I think people are fed up about hearing about what’s going on in another state, county and city. But in a lot of these hotspot counties, that’s what’s incredibly important to show the data. You know, this is what the pandemic looks like in your backyard. This is what it means for you in terms of your children’s ability to go back to school. Your ability to go back to your jobs. And your ability to visit your grandparents in the nursing home. So, I think driving home the local effect is incredibly important, too, for people to understand what it means on a local level, because then that hopefully will translate to an individual level response in terms of masking and social distancing. But yeah, I’m not sure if I answered your question, but is that it?

Q: Where will they start to see this? We’ll start to see hospitals overwhelmed and those kinds of things that will make it real for them. What are they going to see?

THOMAS TSAI: It’s already happening, you know, in hospitals in Houston. But I think it’s a very local context. I think it’s, you know, I think that’s why it’s important to kind of illustrate these local stories, because, you know, even if you’re not in Houston, you’re in the panhandle in Texas, it may not seem like it’s going to affect you. So, I mean, again, it’s too late to wait for the hospitalizations and the deaths. The whole point is to avert that. You know, we all know it’s there a lag indicator. But you know what we’re seeing the rise in hospitalizations we’re seeing now is about what happened two weeks ago. And hospitals are already getting overburdened. And we know some hospitals are instituting these crisis standards of care. And the whole point is to not get to that point. And you’re right. And you know, all the solutions that we had come up with in March, it does boggle my mind a little bit why we aren’t talking about that again, you know, creating field hospitals to, you know, recreate capacity because now the challenge is hospitals can’t just easily postpone surgeries. There’s a lot of pent up demand for health care for non-COVID patients. So, the challenge is now meeting the current need for health care on top of the rising pandemic. 

So, again, like we know what the game plan is, we just have to execute it. There is not a new game plan. There hasn’t been a new tool, a new solution, whether pharmacologic or not pharmacologic, it’s still the same bag of tools that we had back in March. It worked in March, April, May. We flattened the curve and then we actually bent the curve down. The challenge is that, you know, for individuals, for local leaders, you can’t look to a national message. You have to take responsibility for your own individual jurisdiction to flatten the curve and bend the curve and suppress it in your own area.

Q: That’s great. Thank you.

MODERATOR: All right, Dr. Tsai, I think that’s our last question. Do you have any final thoughts you’d like to close the call with?

THOMAS TSAI: I feel like it’s a sobering call.

MODERATOR: It usually is.

THOMAS TSAI: I think I need to go decompress a little bit. But, you know, I think the data are really sobering. And this is this was our message back in March. And the reason we’ve been pushing out these testing metrics and really advocating for the key performance indicators is to really offer solutions. And there are solutions. And it’s incredibly important for individuals to understand that public health leaders and policymakers to understand that the solutions are there. The tradeoffs are not easy, but we all know what the consequences of an action looks like as we’re seeing it play out in front of our eyes right now. But this is the moment for action. I think this is a moment for collective action. I think that’s what’s been missing in the conversation the last several weeks.

It’s, you know, states in the north looking at, you know, states in the south saying, well, you know, that’s because you open too soon, you know. But let’s go back to where we were in March and sort of, you know, have that collective energy about, you know, solutions that we did in March to flatten the curve. And people’s staying at home in high risk areas. So, I think if we focus on that, we can hopefully move the needle there. But again, thank you for organizing the call. And the media has an incredible role to play in getting that message out because you know that lack of a federal strategy around this. So, getting these stories out to local communities is incredibly important, especially as a pandemic looks so different across different counties.

This concludes the July 10 press conference. 

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