Coronavirus (COVID-19): Press Conference with Yonatan Grad, 03/27/20

You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Yonatan Grad, the Melvin J. and Geraldine L. Glimcher Assistant Professor of Immunology and Infectious Diseases. This call was recorded at 11:30 am Eastern Time on Friday, March 27.

Previous press conferences are linked at the bottom of this transcript.

YONATAN GRAD: Thank you. My name is Yonatan Grad. I’m an Assistant Professor in the Department of Immunology and Infectious Diseases at the Harvard Chan School of Public Health with background both in research and epidemiology and microbiology, as well as clinical training in infectious disease. So, I thought I just start us off with a few comments.

So, we’re seeing cases soar in a number of places. And along with that wave of cases, we’re starting to see the death rate also go up. From Wuhan, we know that the critical care cases follow the rise in prevalence by about three weeks. So, extrapolating from that experience, I think, gives us a sense of when and where we’re going to see increased critical care demand.

I think it’s important to really underscore that we’re still seeing a huge lack of personal protective equipment, or PPE, and a continued lag in testing. And although testing is increasing in a number of places, I would say the damage from the limited testing, up until now, has already been done. In Boston, for example, as many of you have no doubt seen, over 160 health care workers have tested positive for coronavirus.

It’s not clear to what extent that’s from the community, so community spread, or spread within hospitals, some combination thereof. But either way, I think it’s a reflection that we haven’t really had the capacity to test, identify cases, isolate the cases, quarantine contact, and use all of the other measures available to us to really help slow the spread of the virus. And no matter how it actually happened, the impact on the health care infrastructure is deeply concerning. Not only must those health care workers stay at home and be isolated, but so, too, must their contacts. So that really has ripple effects through the health care system and underscores its growing fragility.

I think this is even more concerning as you can see reports from Italy earlier today that 45 physicians who tested positive for COVID-19 have died in the course of the outbreak there. And in The New York Times, there is a report of a nurse in New York City who recently died of COVID-19. So, I think really, we need to worry and think about how this will play out across the US and the concern for how this will really challenge and risk collapse of our health care system. And that it’s not just about those with COVID-19, but really about those with all other illnesses who won’t get the care they need either because they’re afraid to come to the hospital or because the hospital doesn’t have the staffing or availability to care for them.

So again, I think this underscores that, in many places, we don’t know where we are on the epidemic curve. We need a lot of testing. I would say from the perspective of social distancing, we really need it to get us time for a number of things. I want to try to enumerate them – one, to improve our critical care infrastructure and expand capacity; two, to get the PPE we need; three, to get testing really ramped up dramatically in many places; four, to do surveillance, we need to understand where we are in the epidemic curve – and that can be from data, both from hospitals and from clinical labs, and also serological data to understand where the virus has been and what fraction of the population has been infected; five, to help understand which social distancing efforts were valuable so we can start to think about what approach to alleviating social distancing would be best – and if we need to implement it in the future, how best to do so; six, to train and establish teams to do contact tracing. I think the current infrastructure for contact tracing in most local public health departments is far overtaxed, particularly compared to the number of cases we expect with or already see with COVID-19.

And then, of course, the last would be time to work on developing therapeutics and vaccines. So, I think this is really a critical time to continue with social distancing to help address each of these issues so that we can develop, both locally and more broadly, the responses that each of our communities need to help limit the collapse of our health care system and the risk to the population at large. And so, with those introductory remarks, I’m happy to take questions.

OPERATOR: We do have our first question.

Q: I was just wondering– thanks for doing this, first of all– I was wondering if you could talk a little bit about the local situation here in Massachusetts and what you’re seeing. And what your concerns are, if you have any sense of where we are on that curve, are we a week behind New York, or are we definitely headed to New York, and how our hospitals are coping? Thanks.

YONATAN GRAD: I wish I had more information to really be able to address that. I think that we are, of course, concerned as we’re seeing the case counts rise and particularly seeing cases among health care workers. How far are we behind New York? I think it’s very hard to say, in part, because we’ve had such limited testing. It certainly is ramping up here. So, we can focus on trying to identify cases among those people who are presenting for care. But for the past several weeks, testing has been so limited that many people in the community who have symptoms haven’t been tested. So, I don’t think we really have a good grasp on where we are on that curve.

If, as has been suggested, many of those health care workers who are sick might have been infected in the community, then we really have to worry that we’re having widespread transmission in the community. I think this underscores the importance of continuing to ramp up testing and also starting to do both evaluation syndromicly of the population as well as serological tests so we can see, through surveillance efforts, what fraction of the population has already been infected and how that is trending over time. I think getting those data will be critical really to have a sense of where we are.

I think the risk of seeing a Wuhan or northern Italy or now New York City-type situation here is real. And we do have social distancing efforts in place. Where those social distancing efforts are effective, great, but, where they initiated relative to spread in the population, we don’t really know. So, it’s hard to say what impact we expect them to have in the near term. Again, this just, I think, really underscores the importance of getting more data so we can have a better sense of exactly what trajectory we’re on. But I would worry, given the extent – what seems to be that the extent – of transmission that we’re already seeing taxing of our health care system. And it will just get worse.

Q: Can I follow up on that for a second? You mentioned, and a lot of folks have mentioned serological testing, how would that work at this point? I mean nobody is going to doctor’s offices to get blood tests. What would that look like? How would that ramp up?

YONATAN GRAD: Yeah. So, I think that there are a few ways that one could imagine doing it. The first is to take advantage of what we call convenience samples, so using blood that may be stored in clinical labs. So, in a hospital clinical lab or other clinical labs, if they have maintained any of the blood that they’ve drawn from individuals for all sorts of reasons, not just for people who come in with concern for coronavirus, but, in fact, people who come in with concern for heart conditions or with a broken leg. If we have those types of samples, we can use those to start looking at what the prevalence is in that population.

Another convenience sample that might be of interest is newborn blood spots. So, as you may know, newborns have a heel stick done. And they take a couple of drops of blood and they use that to look for a number of different diseases. Those are kept, I believe, and would be one way to screen and look for the mother’s antibodies. So, you can see if the antibodies transmitted from the mother to the baby have antibodies that would indicate exposure of the mother to coronavirus at some point. So that is another type of convenience sample that might help us look at what’s going on in a population.

A third way is to take advantage of the fact that people still are going to emergency rooms, not only for coronavirus, but for other things like those broken legs. And looking at the that population, the people who are asymptomatic, who aren’t there for coronavirus-like symptoms may also be an opportunity to do serological testing.

And then the last possibility that I’ll discuss – there are other ideas out there – is doing some kind of population survey. So, whether this is something where there are people who can go to households and even collect just like a finger stick type amount of blood would be enough for many tests. So just like the drop of blood that people get for doing blood sugar checks if they’re diabetic, something like that may be one way to do a survey. I think in the UK they were discussing rolling out population surveillance through a test that they would mail to people. I don’t know the details of how they will do that, but I’m trying to find out so we can explore what other options are available here. But something, then, that would be community-based is another way to do serological surveillance.

Q: So, this isn’t an issue with the testing about running short on reagents or not having the proper test or whatever. We have the capacity to do this?

YONATAN GRAD: Yeah. I think there are questions right now about what are the serological tests that we can use, which ones will be quickly approved by the FDA? I know that many, many folks are working hard to develop serological tests. I believe serological tests have already been developed in China and Korea. So, trying to sort through whether these tests will be home-grew tests, tests developed locally by individual labs, or whether they will be ones that are available to be mass distributed, all of these are critical questions that in some ways reflect the questions that develops with diagnostic testing, just – it feels like a while ago – but just a few weeks ago. So, yeah, I think those are serious issues that need to be looked into.

I think validating multiple independent tests is also going to pose its own challenge. I think this is, yet, another reflection of the challenge of such a fragmented response in the absence of clear federal leadership and guidance. Many places are trying to do the same thing. And they need to validate and then cross-check so we know. There’s relative sensitivity of each of these tests so that we can really look at all of the data and interpret it meaningfully.

Q: Thanks that’s really helpful.

YONATAN GRAD: No problem.

OPERATOR: Our next question.

Q: Hey, thanks for taking the time this morning or afternoon – just for doing this. I’m wondering in light of the exchange or account that your colleague Marc Lipsitch gave to Deborah Birx’s comments about models and their reliability – you have done on models of how the disease will progressed, seasonality most recently, for example– do you think that the federal government – that essentially fragmented response you mentioned – is using models appropriately, is understanding how models work, is seeing the kind of modeling that your lab and many others are doing and taking appropriate actions in response to them? How are they seeing that kind of work absent the sort of data that you just asked for?

YONATAN GRAD: Yeah. I think that the concern from the comments last night is that the worry that you’re looking not seriously at what the models are saying, but instead trying to pick and choose what you want to believe. So as Marc wrote on Twitter, we were asked to urgently respond with estimates for a variety of scenarios for what we think might happen.

And I think it’s an important point that the models try to give a view of contingencies. So, for example, in the model that we had developed, and that’s available on preprint servers, we were looking at the impact of social distancing that initiated soon after an outbreak. And we looked at what happened with social distancing that was variously effective – from modestly effective to pretty effective to very effective – for different durations. And our intent with that is to help show what would happen under those circumstances in the absence of other types of interventions. That, I think, can give intuitions for what we need to prepare for.

Of course, if we develop other interventions – drugs, vaccines – those, of course, are further out but even the contacts tracing and tailored interventions to particular areas where we could improve social distancing, those types of interventions may change, of course, the projections and the trajectory. But it is important to take, I think, the view that these models are intended to be helpful in anticipating the seriousness, or the potential seriousness, of these outbreaks or of the epidemic broadly.

Q: That seems like – and I don’t know if this is what she meant even, but it did seem like that Dr. Birx was being dismissive of those conclusions. Like they asked for your range of possibilities and you offered them. And they said, well, we’re going to take the low number, basically. Does that seem like adequate and accurate interpretation?

YONATAN GRAD: That was my impression of her comments as well, yeah.

Q: Thank you.

YONATAN GRAD: OK. Thanks, everyone.

This concludes the March 27 press conference.

Sarah Fortune, the John LaPorte Given Professor and Chair of the Department of Immunology and Infectious Diseases (March 26, 2020)

Press conference with Caroline Buckee, associate professor of epidemiology and associate director of the Center for Communicable Disease Dynamics (March 25, 2020)

Press conference with Marc Lipsitch, professor of epidemiology and director of the Center for Communicable Disease Dynamics (March 23, 2020)