Chief Medical Officer and Medical Director, Team Rubicon; Director of Operational and Disaster Medicine, Carolinas Medical Center
Affiliate Assistant Professor of Health Metrics Sciences, Institute for Health Metrics and Evaluation, University of Washington
Senior Scholar, Johns Hopkins Center for Health Security, and Assistant Professor, Johns Hopkins Bloomberg School of Public Health
Dean, DeLamar Professor of Public Health, and Professor of Epidemiology, Columbia University Mailman School of Public Health
Speakers discuss the latest updates in coronavirus testing and tracing, including the science behind tests for the active virus and for antibodies, local-level testing efforts, and contact tracing strategies used to identify the spread of COVID-19.
FRIED: Well, good afternoon from New York and welcome to today’s Council on Foreign Relations virtual meeting on “Containing COVID-19: Updates on Testing and Tracing.” I’m Linda Fried. I’m the dean at Columbia University’s Mailman School of Public Health, where I’m also a professor of epidemiology and medicine.
As a reminder today, as was just mentioned, this virtual meeting is on the record, and the video and transcript will be posted to CFR.org. We have over five hundred people registered for this virtual meeting, and we will do our best to get to as many questions as possible during the question-and-answer period.
I’m going to set the stage now for a moderated discussion between now and 4 p.m. Eastern time, and then welcome your questions for thirty minutes. Let’s start with the topic, “Containing COVID-19: Updates on Testing and Tracing.”
As this audience is well aware, over 4.7 million people in the world have tested positive for COVID-19 and the number of cases is increasing at a hundred thousand a day. And the U.S. represents 4 percent of the world’s population and 30 percent of its cases, with a continuing increase of twenty thousand new cases per day, and already 1.5 million confirmed cases and up to seven million people who have been infected but asymptomatic. The New York Times reported today that there is strong evidence that prevention works and that it matters, and that it matters to catch infections at a population level in the growth phase and not wait too long.
In the course of this pandemic, our nation has learned the language of public health, and the words “contact tracing” and “testing” are on many people’s lips. Today we’ll try and explore its import and what we need to do going forward. Contact tracing, of course, is a long-used and essential public health tool, and a core expertise of our public health system at the CDC and in state, local, territorial, and tribal health departments. Contact tracing aims to slow and break the chain of transmission of a contagious disease by identifying the people who were exposed and, with testing, then identifying those infected, and using that as a basis to implement essential actions to prevent further spread. Testing offers several opportunities: diagnosis, surveillance for the rates of infection in a population, and the potential to understand who has been infected by testing for antibodies.
A few cities in the U.S., including New York, are now seeing a slow, progressive decline in new cases. This has occurred in a situation of lockdowns, population-wide physical distancing, and wearing of face coverings, with some contact tracing. But capabilities got very—have gotten quickly overwhelmed in many cities, and little testing beyond those who are symptomatic and often severely ill.
We recognize that there’s a low likelihood of eliminating COVID-19 until there’s a vaccine, and that there’s—and this is highly unlikely in the coming year and maybe more. That means that we need to recognize the likelihood of continuing clusters of infection, and that we need to turn to sustainable approaches that could enable us to accomplish all three of continued containment of the disease and protection of vulnerable people, not overwhelming the medical care system, and enabling people to return to work and school. All are needed in a package. On today’s agenda are some of the tools for prevention of the spread which work: physical—excuse me, contact tracing and testing, which allow the essential actions that follow.
With this background, I turn to our panelists to discuss what the U.S. needs to do on contact tracing and testing, what our goals need to be, and how to accomplish it. I’ll start by introducing our panelists.
First, David Callaway. David is an emergency medicine physical with a national security focus, master’s in public administration. He’s the chief medical officer and medical director for Team Rubicon USA. In his day job, Dr. Callaway is the director of operational and disaster medicine at Carolinas Medical Center in Charlotte, North Carolina, and professor of emergency medicine at Atrium Health. Throughout this pandemic he has worked as a frontline clinician in the Trauma Center and Emergency Department caring for COVID patients, as well as serving in an enterprise strategic role guiding surge capacity, testing strategy, and integration of new care models.
Vin Gupta is a pulmonary and critical care medicine physician. He has been caring also for critically ill COVID-19 patients since the early days of the outbreak in Seattle. He helped a cross-sectoral team stand up—excuse me, stand up the Seattle Coronavirus Assessment Network, the nation’s first-ever to-scale home testing for COVID-19. Dr. Gupta is an affiliate assistant professor of health metrics science at the Institute for Health Metrics and Evaluation, a part of the University of Washington. And his background in public health has focused on epidemic preparedness, with roles at the U.S. CDC’s Emerging Infections Program, the China CDC, the World Bank’s Pandemic Emergency Financing Facility, and others.
Crystal Watson is a senior scholar at the Johns Hopkins Center for Health Security and assistant professor in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. She is a leader in policy research focused on public health risk assessment, crisis and risk-based decision-making during contamination emergencies, and public health and medical preparedness, as well as response biodefense in the face of emerging infectious diseases. Dr. Watson conducts research, as well, on biodefense and health security in the U.S. federal government. She earned her DrPH in health policy and management and an MPH from the Johns Hopkins Bloomberg School of Public Health.
And now, to our panelists. I’d like to ask each of you questions related to what our goals should be for pandemic containment for the whole coming year or more, and what should be the role of testing and tracing in achieving them.
I’d like to start with David Callaway. David, you’ve said that there’s no silver bullet here. Can you tell us what our goals should be as we try to move to a new normal of containment and reopening? And what do we need to do to get back on our feet?
CALLAWAY: Thanks for the softball question, and thanks to the Council for its ongoing great work covering this topic.
I think there are a few ways that we’ve been trying to frame this problem set. So, number one, from Team Rubicon’s standpoint, Team Rubicon is a disaster-response organization, and we’ve been supporting testing with health departments and health systems—(audio break)—large and integrated health system across three states. And so we’ve been trying to address this from both the clinical care and the public health standpoint.
And so I think the first step, if we draw on General McChrystal’s way of approaching problems, is you have to assess the threat. And I view this pandemic as an existential threat to our country and our democracy, and I think it’s important to frame it that way not to create hysteria but to understand that there is no simple solution to a complex problem. And we know that the danger of coronavirus, the novel coronavirus, goes beyond its individual physiologic impact on a patient, but it also has dramatically increased the rates of non-COVID deaths. It’s crippled health-care systems and caused health practices to go out of business. We’re seeing dramatic educational and financial implications. And on a national security level, we’re seeing, you know, an increased rate of cyber issues related—and disinformation related to the coronavirus. So we need to say—we need to acknowledge it’s a complex problem, we need to say that we are smart enough to be able to address this, but we have to be more nuanced. And I think Vin’s going to talk about having the right conversation.
So once we’ve assessed the threat correctly, we need to align our efforts. And this is what I think brings us to this conversation today, is that many of us have found it difficult to understand what the cohesive national strategy is around containing the pandemic, but also specific to testing and tracing. And so the result is we have over a hundred different antibody tests, of which many have not been validated, and the results of which we don’t really understand clinically how they apply. We have RNA PCR tests that have variable sensitivity and specificity and basically accuracy. We have limitation in testing capability. And so we’ve had to try to figure out how do we use these to provide care, to support public health, and it’s been a very, very confusing backdrop against which to try to operationalize a response.
And so I think in the alignment standpoint, we need a strong consistent national message that then allows the private sector, and the health systems, and the counties to be able to come up with innovative solutions that are consistent with a national strategy. And for all the people on the line here, the messaging is critical, and the messaging in the press is critical, that this is a complex problem, but we can solve it.
And then finally, once we’ve assessed and aligned, you know, the action piece is sort of what we’re getting through, right? So you know, what actions should we take? And I think that we’re going to have some really great conversations here because we’ve got two awesome experts whose work I look at on a daily basis to try to guide our system’s response. But we know that we need a whole-of-community response that includes the government, the private sector, the health care system.
And we need to be able to have the right conversations about, you know, how do we do this? And testing is a part of it. Tracing is a part of it. We need to realize that what we’re trying to do in my mind is limit the impact of the disease until we can come up with both a cure, whether it’s plasma, and immunoglobulin, or a vaccine. And so our goal is to get there. And that’s going to take, as you mentioned, twelve to eighteen months. So I’ll leave it there. That’s the operational side, in my mind.
FRIED: So maybe I’ll move to Vin for a minute and ask, what should our goal be? Can you hear me?
GUPTA: OK, great. Sorry, I was just muted there. Thank you, Linda. And it’s a privilege to be here with Crystal, and David, and you to have this important conversation.
So I’m going to focus my initial statements just on existing gaps, and why I think we need to be having a different conversation on specifically testing. And I know Crystal’s going to dive deep on tracing. You know, on the front end of testing, you need a prescription for testing, in most cases at least. Somebody has to prescribe the test. And we’re noticing that in exurban areas and in part of chronically underserved areas where people don’t have access to health care, we talk about the racial divide, how COVID-19 is exerting disproportionate effects on certain demographics.
You know, part of the reason why is you’re seeing years and years of prevailing inequities in health care access rear its head because these individuals don’t have abilities to access broadband services on which telehealth—we’re messaging so much on telehealth as though it’s this cure-all. But to actually have a reimbursed visit in a virtual environment, in a telehealth environment, so a provider can prescribe the COVID-19 test, they need to be able to look at you in addition to speak to you. So that audio-visual component that’s built into CMS reimbursement criteria for the prescription of the test for COVID-19, by definition, eliminates large segments of the society that can’t afford broadband or a smartphone. And so we need to be thinking on the front end, who can we—how can we broaden access to health care?
And since more people are consuming health care in a first-world environment, we need to—we need to make changes to telehealth reimbursement more permanent. We need to be more progressive in how we’re thinking about what telehealth really means. Maybe it’s just audio alone. So that’s on the front end. On the back end, you know, and Linda mentioned this, here in Seattle we’ve stood up something called Seattle Coronavirus Assessment Network. I think it’s a wonderful example of what private, public, nonprofit sectors can do together in common cause to get tests to those who need it at home. And so this, SCAN as we call it, was built on the backs of many people, many organizations. But if you think about our current paradigm, now we have saliva testing that’s been approved for home use. We think—researchers out of Yale actually have shown that saliva testing is more sensitive than nasopharyngeal testing or interior anterior nares testing.
So imagine a scenario where we sub out nasal testing, which is currently a part of SCAN, for saliva testing. We can get universities back online for the fall. We can get large employers back online in person if we build in a cadence of at-home testing built on saliva, have USPS be the muscle behind it for home delivery, FedEx, UPS, you name it. But there is a paradigm here that could work to get us to mass testing. But we just need to start thinking outside the box and start operationalizing things that we’ve demonstrated proof of concept quite well, I think, here in a place like Seattle, that’s scale up more broadly to the country. I’ll pause there.
FRIED: Do we have—Vin, thank you. Do we have the tests, so the antigen infection confirmation tests, that we should be banking on? And what will it take to get them to scale? David’s talking about needing a nationally unified approach. What do we have to mount?
GUPTA: One of the challenges here is that the landscape of testing is rapidly changing. So, Linda, to your point, there’s the direct antigen test that just got UA by Quidel, the biotech Quidel. And that’s a different assay than the saliva test developed by the Rutgers scientists, which is very similar to—the sample collection kit is actually very similar to what Ancestry.com commercializes. You spit in a tube; you have PCR test. It’s actually an isothermal PCR assay that’s run on that saliva sample. So very different modalities. But I think the common—the common denominator here is that we are simplifying testing. So that can be done at point of testing. So what does that mean? That means it can be done by a user at home. It’s simple enough that it could potentially be done by a user at home.
The U.K. just is nearing approval of a saliva-based test where you spit into a detector and you get a result within ten minutes. It’s like a pregnancy test, but for COVID-19. So once we get there, and if the price point’s right, we’re talking about mass testing hopefully with the type of sensitivity and specificity that we can, you know, really bank on so that we’re giving people the right answers, that’s the scale, that’s the type of paradigm we have to be thinking about. And I think this is going to be a very different conversation in two months once these point of care tests actually go live.
FRIED: So we’ll have to be asking questions about how accurate and how reliable they are. Understanding nothing’s perfect. But could that support a kind of national strategy to understand where we’re at and how to—how to actually understand where to target additional solutions at a population level?
GUPTA: I think so, because you know, right now we’re—if you go to—one of my favorite sources of truth is covidactnow.org. And what they use is a metric that we should all be sliding, which is what’s the positive testing rate for COVID-19? If it’s greater than 3 percent, we’re too narrowly focusing our testing to those that we think are going to be a priori positive. If it’s less than 3 percent we think there’s adequate distribution. We’re testing a combination of positive—or symptomatic, we think they’re going to be positive, and potentially asymptomatic individuals we think they’ll be negative. That’s a nice metric with how distributed are these tests.
You know, Linda, I think to your point, if we’ve only tested 3 percent of the American population, how good are the metrics that—I mean, how—to what degree can we actually rely on the data that governors are basing their reopening strategies on. We’ve only tested 3 percent of the population. How could we possibly say that a state has met phase one as outlined by the administration, which is that caseloads are actually coming down. It just don’t make sense. It’s not internally consistent from just a science standpoint. If we don’t know what’s happening, how can we possibly claim to have that knowledge on caseloads?
FRIED: So thus far I believe that what we’ve done is use scarce testing to diagnose individuals who are really sick. And who you guys are taking care of in the hospital. The second phase is people who might be symptomatic. We’re not really there yet in terms of mass testing. That’s probably an understatement. And then the question is, going back to David’s point about a national strategy, Crystal, can we really manage to protect people’s health and get back to opening society at the same time? And what would that take?
WATSON: I do think that’s possible. I think we’re seeing in other parts of the world that it is possible. There are countries that are managing this fairly well. They’re able to reopen. Some places like South Korea never fully closed. And so I do think that we can get to a place where we can manage the virus to an extent where we can reopen more safely. And really kind of protect against large outbreaks. So what we’ve had up to this point in this country is—because of the lack of testing—is this large baseline of undiagnosed, unrecognized spread of the disease. And so we need to get to a place where we are finding a vast majority of cases, and then we are able to identify them, trace their contacts, put those contacts in home quarantine, and break chains and transmission. That will drive down the rate of transmission across the country.
And so we should be—we should be able to manage this on a case-by-case basis because we’ve seen that that’s possible elsewhere in the world. And if we can do that, then when we open up more fully we won’t have that unrecognized spread. And even if we do have an epidemic—say, in a nursing home or other facility where we have a congregant setting—we’ll be able to identify it much more quickly and stem the spread much more quickly, so it won’t grow into a population-level epidemic. So I really do think that there’s—we can do both. This is not a dichotomy. This is not do we shut down and ruin our economy or do we open up fully and let this burn through our population. There is this really broad middle ground where we can get much better at managing the virus.
FRIED: So what would it take to do contact tracing and testing at the scale that’s needed to handle this pandemic? And do we need a national approach?
WATSON: Yeah. So as you mentioned, I think we need to—at a bare minimum, we need to be testing anyone with COVID-19 symptoms. Not just people who are sick enough to go to the hospital but anyone even with mild disease. That’s just a baseline. We also need to test contacts of cases. We need to test much more frequently, as Dr. Gupta said, in workplaces where you may want to prevent outbreaks, and people aren’t able to physically distance to a great extent. So we need to have that capacity in place. And we also need to scale up our public health workforce.
We have kind of disinvested in public health for decades now. And we’ve lost a lot of public health workers. Even then it may not have been enough to tackle this problem, but now we really do need to scale up in an emergency way. And I think my colleagues and I have put forth a number, a hundred thousand new contact tracers around the country that we think need to be hired to do this work. And that’s based on other experiences around the world, some initial efforts in this country, as well as kind of the level of transmission that we have here.
But these are hard things to do. We’ve never done this kind of workforce scale-up for public health in this country in history. So national guidance, federal guidance on this is really essential. And so I think we need more information, we need more—we need kind of the federal level to embrace this as a national initiative to scale up contact tracing and testing. We need detailed guidance for our health departments about how to do this work, technical assistance for health departments when they maybe get stuck, and in doing contact tracing or testing. And so we’re starting to see a little bit more of that from the CDC in particular, but we need more.
FRIED: So some people would say that there are very different rates of infection in different states. And so you need different approaches in different states. What’s the rationale for federal-level leadership on this?
WATSON: Yeah, so I don’t think the approach actually changes very much. We need to do surveillance to understand where the virus is spreading. And if health departments can manage to get transmission down, which some states have been able to do that already, then there will be less need for contact tracing. But I still think we have to have that capability built up because if we’re without it and we’re not able to surge if we do have increased transmission once we open our economy more fully, then we’re going to get into big trouble. So it isn’t a different approach necessarily. It’s scaling that approach according to the outbreaks that we have.
CALLAWAY: Linda, if I might build on what Crystal and Vin have said. I think it’s important that when we talk about a national strategy I don’t think any of us think there needs to be a one-size-fit-all solution to the problem. And in fact, I think that that is absolutely not a problem that requires a network solution. And so where having a national strategy is helpful is that once it is defined you can then allocate resources against those requirements. So private—so public health systems or nonprofits can apply for grants. Federal funding can be allocated to innovative public health departments to work on things and try to solve these strategic problems. And in the military there’s something called commander’s intent, and in your strategic priorities. And then you push down leadership innovation to the lowest level.
And I think that that’s what we need to do. The problem is, for someone like me who’s not an epidemiologist and is trying to make sense of this and allocate resources—whether it’s manpower, or testing—and to address all of these different populations we’re trying to address, it’s very unclear what my system should be prioritizing. Now, we’ve got really smart people who’ve worked on it, but if you push that message out globally across the nation it’s very confusing and it’s hard to come up with a cohesive response, and it’s hard to do things like the innovative work that Vin’s talking about. It’s hard to do things like the very, very rigorous work that Crystal’s talking about, with, you know, mounting hundreds of thousands of contact tracers. So it needs to be a benchmark against what we say is a national strategy. And again, that’s partly why I frame this as an existential threat to our country, because it allows the country to focus on that bigger problem.
FRIED: Vin, do you want to add to that? Anything you want to add?
GUPTA: Thanks, Linda. And agree with everything David and Crystal have said. You know, I would even say at a very basic level we just need consistent public health messaging. You know, testing and tracing and ICU bed availability, all open questions. You know, you look at what’s happening in Brazil right now, it’s deeply concerning. It’s almost a playbook—they’re following our playbook. Just about two months behind schedule. And they have four thousand ICU beds for the entire country. And they need about—we were thinking—IHME is estimating about seven thousand ICU beds.
We haven’t developed any—there’s no pop-off valve here come the fall wave in the United States. We don’t have ICU beds. We have no more ICU beds. I was just on service two nights ago. About half of my twenty-five-bed ICU is full of COVID patients on ventilators. There isn’t much surge capacity. And so we need to be thinking about that very, very closely when we think about Memorial Day weekend, and mandatory mask policy. Why haven’t we done that? And we need—if it’s not going to come from the federal government, our state governors need to be thinking about mandatory masks. Basic things.
CDC just issued guidelines saying that you don’t have to worry about cleaning surfaces anymore, essentially. What is that? How are people going to internalize that message? Do we now need to Purell our hands now for touching a doorknob? That’s really concerning. So infection control needs to be top of mind. Mandatory masks, Purell. So I would just—I’ll pause there.
FRIED: Well, this links back to both what David and Crystal said in terms of a narrative that can help us stay the course on something that’s not going away in the next month. This is a long-term issue over the next year, if not more, of finding the right nuanced balance between preventing unnecessary infections, identifying clusters of new infections, and enabling people to get back to work and school at the same time. And a national narrative is a compelling one, but then you’ve also added that the evidence is very clear that there’s a package of public health approaches, which are time tested and work, but we have to figure out how we stay the course on those.
So one last question before we turn to the question and answer session. In addition to needing to stay the course on this pandemic, as we scale up, as we figure out the capabilities, Crystal has argued that we need to look to really strengthening our public health system for the long term. And this will not be our last epidemic or pandemic. And so how do we think about scaling up for the long-term, recognizing there will be more, Crystal?
WATSON: Well, I think we need to reexamine how we approach infectious diseases. We need to refocus our public health systems on infectious diseases, which has been deemphasized over the past several decades, some for good reasons. But this is clearly a really significant threat that we need to have capabilities in place to deal with this. So we need to make sure that we fund our health departments on an annual way that makes sense, both to do all of the good work that they do on a regular basis for noninfectious diseases, but also for a response to flu, for a response to new infectious diseases. We’ve had—we’ve seen a number of emergences over the past five years, including Zika and Ebola, reemergence of Ebola, and significant epidemics that we haven’t seen before. So this is definitely not going away as a threat. And so we need that sustained funding and attention. And we really need to think a lot bigger about pandemic preparedness.
We are making vaccines at a pace that we have never achieved in the past. It’s amazing. The scientific advances that have been made in the last few months are incredible. But I still think we could do better. I think we can work more—put more resources toward platform technologies that will help us be able to go from the discovery of vaccine into mass production in even much less time than we’re thinking is going to happen for this pandemic. So there are a lot of areas of focus that we need to really take much more seriously going forward, but I think we need to start there.
FRIED: Very good. Thank you.
Well, it’s 4:00. And, operator, I think we’re ready to go to the question and answer part of this session. So at this time, I would like to invite members to join our conversation with your questions. This is a reminder, of course, that this virtual meeting is on the record. And the operator will give us instructions on how to join the question queue.
STAFF: (Gives queuing instructions.)
We’ll take the first question from Maryum Saifee. Ms. Saifee, please accept the unmute now button.
Q: Thank you. COVID has exposed deep-rooted structural inequities, with communities of color disproportionately impacted. How are we ensuring testing and tracing are accessible, particularly reaching the communities that are most impacted?
FRIED: David, would you like to take that?
CALLAWAY: Yeah, absolutely. Maryum, thank you for the question. It is a super important question. So our health system, North Carolina, Georgia, and South Carolina—so Atrium Health does about $2 billion in uncompensated care a year. We’re one of the major catchment hospitals in the region, the safety net hospital. And what we—what we saw is exactly this. We have torn off any of the façade about health inequities that existed. And so specific to COVID, what we’ve done is we created mobile testing teams. And so we pushed out testing sites into nine different locations in our community, and then that’s still on some of the limitations that Dr. Gupta talked about. (Audio break)—implementing mobile roving testing teams based on years of data that we have in terms of social determinants of health and high social vulnerability index.
So we put these units into these neighborhoods in partnership with churches, local businesses, local leaders, in order to increase the testing rates. And personally, my subterfuge was hopefully when we capture these individuals we’re then able to bring them into the health system, identify why they weren’t getting care before, and start providing these services. And what we found is that with all-commers our positive test rate was about 7 percent—7-8 percent. But with—especially Hispanic communities and communities of color in Charlotte, our positive rates were about 14.8 percent. And so that meshes with a lot of the existing disparity that we’ve seen in other access to care. So that’s one way that we’ve addressed it here.
And then what we’ve also done, and multiple other systems have probably done this as well, is we’ve waived the cost of the test. So we’re not filing insurance and we’re not charging for the test in the vast majority of these communities.
FRIED: Crystal or Vin, do you want to add anything?
WATSON: I think with contact tracing it’s really important to have community leaders involved in contact tracing, working with health departments, but also that contact tracers themselves come from the communities that they want to serve and that they represent. So we need people who have empathy, and knowledge about the local conditions in each neighborhood, in each community. And so I think that can help greatly with both making people comfortable with interfacing with the health department, and getting the information from them that is needed to help them, both if they’re a case to be comfortable and access care, as well as if they’re a contact to understand what they need to do, and to get the resources from public health that they need to stay home and quarantine safely.
So I think those are two big steps that can be taken for contact tracing. And there’s some really good training that my university actually released a couple weeks ago, a free training on Coursera that gets into some of this in very specific detail and provides some scenarios that a contact tracer might need to walk through with their contacts in these cases. So.
FRIED: Vin, do you want to add anything?
GUPTA: Just to amplify David’s points. You know, there are those examples, and David’s great work is an example of an inroad here that we need more of. And the fact of the matter is, I mean, I don’t know what David’s experience has been on the inpatient side, but the majority of individuals I’m caring for right now in Seattle are migrants or are African Americans from the other side of the mountains, so eastern Washington, that get flown here for advanced care. But they’re communities of color. And we are so focused on that initial spot test, as though that’s the only test you need, but most of the individuals that are essential workers on the non-health frontlines need cadence in testing.
And I don’t know about you, but I haven’t heard anything from the CDC or from (our ?) government about what’s the adequate repeat interval for testing. And that still requires a provider to be on the proximal end of that. So you still need durable health care access. So now with many millions going off payrolls because of unemployment this is a huge problem. And we need—that’s where federal leadership is critical. You can’t expect states to do it. Obviously, employers could do it to a certain extent, but if people aren’t employed what are we going to do here? So that really requires messaging and guidance. We need guidance on repeat testing. We just don’t have that.
FRIED: Thank you.
Operator, I think we’re ready for the next question.
STAFF: We’ll take the next question from Hari Hariharan. Mr. Hariharan, please accept the unmute now button.
Q: Hi. Thank you for taking my question. There’s considerable optimism in the market right now about a sooner than expected vaccine. Would you care to comment on whether this optimism is warranted? If not, what do you think is a more realistic timeframe? Thank you.
FRIED: Vin, would you like to take that?
GUPTA: Sure. I think the optimism is warranted because I think we all need a dose of good news. So I’m not surprised that we’re hanging our hats and our hopes on some very, very early signals on, say, remdesivir, or the studies on eight individuals that were tested out of this Moderna phase I trial. But it’s important to emphasize that the results were early. So what do we know about that Moderna vaccine? We know, one, that it’s based on technology that’s really novel. We don’t actually have a commercialized vaccine that is based on injecting the genetic footprint, the MRNA, into a human being to see if there’s an immune response that then gets—that is developed. What we typically do is we weaken a virus and inject it into a human being—this is very high level—and see if then they develop an immune response. Here we’re testing very novel technology for the first time to see if it works. So that’s number one.
Number two, what we do know is that that candidate vaccine actually in animal models prevented viral replication of COVID-19 in the lung—in lung tissue. So that’s helpful, because that tells us, OK, maybe it does prevent infection when exposed to it. The phase I trial in humans said: Is this safe? Is this a safe vaccine to give individuals? And are they developing antibodies to COVID-19? The answer to both those questions was yes and yes. But it was an N of eight, so let’s keep that in mind. The big question is, do we have a combination—are the animal model findings on preventing infection when exposed to COVID-19, are they replicable in humans? And does it remain safe? And does it remain that everybody develops antibodies?
That’s phase II. Are the antibodies that hopefully everybody develops when exposed to this virus—or, to this vaccine candidate—not only does everybody develop vaccines, that’s question one. Is it then safe? That’s question two. And then, does it—when those individuals are exposed to COVID-19, are they fighting it off? So that’s the big question. Are we going to intentionally expose them to COVID-19? Are we going to hope that they potentially get exposed to COVID-19 naturally, and then fight it off? That’s the key. That’s the key bottleneck here. And we just don’t know. So these results are early, and that’s why you’ve seen, I think, the initial optimism on Moderna. If you look at the evaluation stock price, it went very high and now it’s coming back down to Earth. I think people are realizing that it was—it’s cautious optimism, but we shouldn’t get ahead of ourselves.
FRIED: Crystal or David, do you want to add to that?
WATSON: I’ll just add that we need the large safety studies, because sometimes safety signals don’t show up in these small studies with just a few people. But in a large population study, then you can see if there are—if there are problems with the vaccine. So we really do need to pay close attention to those large safety studies as well, because we don’t want to—what we don’t want to do is roll out a vaccine to millions, perhaps billions of people, and then find out that there is something really that makes it unsafe for a certain percentage of the population. So that’s really important, and a step that we can’t skip in this process.
CALLAWAY: Just very briefly, to build on what you both said, so I was with Secretary Azar just right before this. He was visiting our health system. And he seemed very optimistic about the amount of money they’re investing in vaccine development. But I’ll just go back to the national strategy piece. If we articulate that our national strategy is testing and tracing to get us to a vaccine and to treatment, then it allows us to know how we allocate funds, and it allows us to build processes around it.
To Crystal’s point, one of the things that I think has been the biggest problem in the last two or three months is we had very rigid FDA—(audio break)—and then our response was just to get rid of them all, more or less. And I’m sorry, I’m being a little dramatic. But to really just, like—(audio break)—smart, modern regulations, adherence to the scientific process, and then maintenance of a standardized way of relying scientific information. And if we do that, then I think, you know, we put a person on the Moon. Like, we can come up with a vaccine and we can save lots of lives. But we have to be intentional about it.
FRIED: Thank you.
Operator, I think we’re ready for the next question.
STAFF: We’ll take the next question from Karen Alter.
Q: Hi. Thank you very much for this.
I’ve been talking to colleagues in Germany. And they just have a very different public health reality over there. And when I think about the United States, I worry about a few things. I worry that we’re such a mobile country and there’s no way to stop people from traveling across state borders. I worry that our physical size as the population is so dispersed. I worry that—it’s hard for me to imagine we could get up 80-90 percent vaccination levels, if that’s what’s required for herd immunity. I don’t know if that is what is required. But it’s so hard to get—can we even get 50 percent of this country vaccinated? And I worry that we have no sick pay, so that people could have some symptoms and could go out. And all of that makes me really skeptical of this idea that we could have this, you know, testing, contact tracing in a management kind of way in this country. But I’m not an expert. So I’m wondering if these kinds of things make you worry, and what we can do about them.
FRIED: So, David, you started with the worries. Do you want to help us out on that?
CALLAWAY: Yeah, Karen, thanks for the question.
So my daily work is—I’m a crisis guy. So all I do is worry. So everything that you just mentioned I think are very valid—(audio break)—through this. But again, if you listen to what Crystal and Vin have said, you know, there are—you know, there’s historic structure and there’s historic processes that we generally know work. And then we’ve seen a lot of innovation that are worked around these problem sets, specifically—you know, if you look at mobility and the dispersal of the population, I mean, Vin’s discussion about home saliva testing can address a lot of that, because if you get it at the right price point people can test at home, with frequency. And if you create a reporting mechanism, then it doesn’t matter if they move from Seattle, to Denver, to Charlotte. There’s a cadence to their testing. They understand why they’re doing it. And then there is a coordinated response to how we track it. Now that’s a complex problem, I understand.
To your last point about sick pay, I agree. We need to modernize our HR policies, and our sick leave. And, you know, one way of looking at it is we just—we just crippled our economy and put twenty million people on the unemployment rolls. So we can either have a blunt instrument like that, or we can have a more nuanced roll where we say, you know, part of your social contract when you test positive is you go on fourteen days isolation of quarantine, never mind if you’re sick or not, and we will cover your costs or we will cover, you know, your sick leave during that period. And it does require innovative thought, and it requires federal government—(audio break). But I have to be optimistic that—(audio break)—make some of those changes.
FRIED: Crystal, what would the national strategy need to be to address the questions that were just raised?
WATSON: So I think that we need to commit to some policy change here, as David was just saying, particularly around leave. I think that we need national funding. We need support from Congress to do this. There’s been proposals that not only would help departments get funding to hire and support contact tracers and the surrounding work, but also to provide people with funding when they need to stay home for fourteen days in quarantine. I think that’s a policy choice that we could make. These are all choices. And our system is a little chaotic by design. And so we’re not going to look exactly like other places in the world. But I do think we can take lessons from other countries that have had success with this. It takes some imagination and probably a commitment to public health that we’ve never made before. But I think it’s possible. It’s just a choice that we need to make collectively and that our leaders need to make in Washington to make this happen.
FRIED: Vin, you want to add anything?
GUPTA: You know, I’ll just emphasize I think the question is very well-put, and I agree with it. That the—which is to say, the only way out of here is broad public cooperation. And the one thing I’ll message on is just mandatory mask policy. Culture, societies that—in which masks are a daily part of life—I’m thinking Japan, or Hong Kong, where there’s broad adoption of it, 80-90 percent for example of a population wearing it in public, on mass transit, et cetera. You’re seeing that these are geos that are a puddle jump away from Wuhan. But both Japan and Hong Kong have been relatively spared of the worst effects of this pandemic. And there’s one reason why, not to draw—make correlation necessarily causation here.
But we’re seeing computer scientists out of Berkeley and other studies suggest that it’s the simple act of complying with a mask policy that has diminished transmission of COVID-19 by twelvefold. So that we can move from a scenario where R0, where the reproductive rate is quite high, to one in which it’s quite low. And we can move towards containment, and quarantining, and contact tracing, to the points that Crystal is referencing. But without that broad public cooperation, if you’re seeing security guards in Michigan getting killed at the entry of a Family Dollar store trying to compel shoppers to wear masks, if that’s where we’re at as a society then, yes, I do think that you’re—the premise of the question is true. There’s going to be a lot of skepticism and doubt that we can marshal the response we need. But sometimes it’s the most basic answer is the best answer. And I would start with mandatory masks.
CALLAWAY: And just to—you know, I would take it one step further. And I would say it is your civic duty and it is our civic duty to wear a mask. I mean, all duty is balance between freedom and responsibility. (Audio break.) It’s not the government’s—you know, I live in the Southeast of our country. And so every part of our country’s a little different. But our message is not the government’s going to force you to do it. It’s: It’s your civic duty. It’s your community duty to do the simple things to save your neighbor’s life. And I couldn’t agree with you more that, you know, we need to do the simple stuff, and we need to do it well and consistently.
FRIED: So you’re suggesting that the public health approaches are actually altruistic and you’re also, I think, all suggesting that we don’t have to choose between public health and the economy. We actually need one for the other, and that could work.
Operator, I think we’re ready for the next question.
STAFF: We’ll take the next question from Valentina Barbacci. Ms. Barbacci, please accept the unmute now button.
Q: Sorry. I clicked the wrong one by accident. (Laughs.)
I wondered how we might—this is a bit of a provocative question, not intentionally but it’s a real issue within the health care sector for those providing the tests. So I wondered what your thoughts are on how we might handle the layers of corruption, both at an international and national level, that ultimately—and also the lack of availability of biobanks for validating tests submitted for approval, which ultimately prevent, and are preventing, the most accurate sensitive and easy to use tests, specifically self-tests, from getting approved by health authorities. I mean, that those tests are not ultimately able to be produced and produced at scale in an efficient and effective manner to handle the pandemic early on. We’ve seen this with HIV and we’re now witnessing it with COVID-19. I could give specific examples, but I’ll end my question there and be grateful for your comments.
FRIED: David, did I see your hand up? No? (Laughs.) So I’m going to turn to Crystal, if you can help us with this.
WATSON: So handling the corruption is a tough question. I think in—so handling the lack of cohesive narrative and guidance at the federal level in the U.S., we’re seeing these coalitions of states come together to try and coordinate their action and pool resources and coordinate supply chains. So I think that is one option. There are ways around trying to create a more cohesive response in the absence of federal leadership. But it’s a really tough question. And I’ll leave it to, I think, Vin or someone else on the testing specifically.
GUPTA: Thanks, Crystal.
What I would say is we need—there is a set of guidelines, the International Health Regulations, IHR, that were developed in 2006, after SARS. And the world basically operates as though those don’t exist. So rules on data transparency, on data sharing—so if you’re seeing a certain strain of COVID-19 in Wuhan in November of December, whenever the first incident case was, the world knows it in real time. Also, it means we don’t do travel bans, so that we can encourage data sharing and not the ill effects of an economic quarantine, or what have you. There’s a lot of—countries naturally want to keep their borders open. They worry about the economic impacts of saying: I have an epidemic. Everybody’s going to stop traveling here. We need to encourage data sharing. We need to encourage free flow of the movement of people and technical expertise, even in studying a pandemic in the early stages, so that we understand what’s actually happening.
And so what does that broadly mean? That broadly means we need the WHO actually to be better resourced. And this is the Council on Foreign Relations, so I’m going to make a pledge for multilateralism and strengthening multilateralism in the WHO and giving it an enforcement mechanism so it can sanction and fine countries that are not adhering to the IHR. If this was done, if the WHO’s technical guidance that was released on January 13 to all countries about what are the—you know, testing guidelines, testing guidelines that were then adopted by South Korea but not adopted by us. If there was a way in which we could elevate the WHO, give it an enforcement mechanism, and make sure that people are complying—countries are complying with the IHR, I think you’re going to see less willingness to ignore technical guidance that some countries adopted, and they’re doing quite well, and others like us, we didn’t adopt—I think because of an inherent arrogance—will pay the consequences for that.
So a sort of indirect answer to your question, but we need enforcement mechanisms and a stronger multilateral organization to deal with the next pandemic. And that’s the only way we’re going to get consistency across countries when it comes to testing, quality, validation.
FRIED: So we almost have the global analog in terms of the need for strengthened social compact to the community level social compact that David was referring to before, about everybody pitching in and wearing masks.
David, I can’t tell if your hand’s up.
CALLAWAY: It wasn’t, but, you know, I think Vin and I approach this very similarly. I believe that this is—I’ll just say, this is my naivete, right? I believe there’s a tremendous—(audio break)—we should fund the WHO—
FRIED: So I think I’ve lost David. Let’s move on. Operator, can we go onto the next question, please.
STAFF: We’ll take the next question from Garrett Mitchell.
Q: Good afternoon. I hope you can hear me.
Q: This is not the voice of COVID-19. This is recent thyroid surgery, which was successful.
I want to come back in a sense to an earlier question and put it in a slightly different context. There are two components that will make whatever it is we do work. There is leadership and followership. I think we’ve noted that the leadership has been weak and inconsistent. The followership problem was referred to earlier. Political scientist at Stanford Larry Diamond, talks about something called radical libertarianism. And that, it seems to me, is, in addition the virus itself, the polarization and the radical libertarianism that we are dealing with are going to make it difficult, demonstrated as recently today in both, I think, the New York Times and the Washington Post, who reported that something on the order of 75 percent of people polled said they would take a vaccine tomorrow if it were made available. And I wonder if you, A, get some sense of that in each of your individual domains and, B, whether you think we still have the opportunity to make a big dent in this challenge.
FRIED: So this sounds like a moment of saying that leadership matters. Who wants to take that?
WATSON: I can just say a couple of words about this. I do think it is a concerning trend, and the politicization of some basic public health principles and actions make it much tougher for public health to do it its job. I do think that there is—there is room for optimism here though too. I recently saw an unscientific survey by Slate that—with about six thousand of their readers. And it found that 73 percent didn’t want to eat indoors or would not go to—91 percent wouldn’t go to a movie in a theater right now if they did open. So I think there’s a mix here. And there is a danger of kind of having the vocal minority represent a lot of the popular—overrepresented in our discussions.
I haven’t seen the poll that you are referencing, but that would be very concerning. But I do think that by and large people have taken the steps that we’ve asked them to take. I think that it’s actually been very incredible and not something I anticipated at a public health researcher before this pandemic, that we would be willing to stay home and take these social distancing measures on this population level scale. I know people are getting tired of them, but I still think there is evidence that people want to be cautious and want to follow the science. And so it is a mixed bag of these surveys here. And so we do need to figure out how we better manage the messaging from public health and make sure that we can combat mis- and disinformation that’s coming out about this pandemic and the response itself. But it’s a tough problem. But I do think there’s room for hope and optimism as well.
FRIED: Thank you. I’d like to try and squeeze in one more question. Operator, can we take one more?
STAFF: Sure. We’ll take the next question from Pearl Robinson.
Q: Pearl Robinson, Tufts University, political science.
And you actually got a tour of what I wanted to ask. I am very troubled by our dysfunctional political institutions. And I’ve heard lots of very positive things talked about. But I would like to hear people who can be positive say something about what might be done about our political institutions.
FRIED: Who would like to take that? Crystal?
WATSON: I’ll let somebody else answer this one, and I’ll jump in.
CALLAWAY: Pearl, I’m happy to fall on my sword here. I think the issue, I’m just going to reframe it, politics plays a role in everything we do in public health. All decisions have political implications. I think the problem is hyper-partisanship. And, you know, this was going on beforehand. It’s been accelerated by social media. And if you look at some of the tools that our intelligence agencies and special forces use to destabilize governments, it all focuses on disinformation and misinformation. And we’re falling prey to that ourselves domestically.
So I think step one, there is a—there is a caucus within Congress called the For Country Caucus, which is a group of military veterans who have committed to a pledge of, you know, funding—or, sponsored bipartisan legislation and engaging in non-contemptful discussion. So I think that that’s one tangible example of how people are trying to make a difference within Congress. I think that for the media on this call, it’s very hard to stay focused on a complex message like this when there are so many easy things to talk about—like hydroxychloroquine or visiting hospitals within masks.
I think it’s important to keep hammering on the message that the only way we get through this is, you know, in a unified front. It doesn’t mean we have to agree on everything, but we have to—we have to treat this as though it’s a national threat to our country. And, again, I don’t mean it’s going to kill everybody. Coronavirus is not going to kill everyone in our country. But certainly if we don’t handle it right, it could kill our democracy.
FRIED: Well, on that note, I note that it’s 4:30. And I unfortunately have to conclude this meeting. I want to thank everybody for joining us today, and particularly thank David Callaway, Vin Gupta, and Crystal Watson for your wonderful contributions. To the audience, please note that this audio, video, and transcript of today’s virtual meeting will be posted on the CFR website. And thank you all and have a great day.