Toolkit: Testing, Testing, 1, 2, 3
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This toolkit episode is all about testing with Michael Mina, Harvard infectious disease specialist and laboratory director, and Robby Sikka, who helped develop the SalivaDirect test with the NBA in partnership with Yale University. Andy asks these experts your email and voicemail questions about the new wave of tests on the horizon, their reliability, how they work, when to get tested, plus some potential new creative at-home tests. What would you name an at-home sewage test? Tell Andy on Twitter!
Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.
Follow Michael Mina @michaelmina_lab and Robby Sikka @robbysikka on Twitter.
In the Bubble is supported in part by listeners like you. Become a member, get exclusive bonus content, ask Andy questions, and get discounted merch at http://lemonadamedia.com/inthebubble/
Check out these resources from today’s episode:
- Here’s the article about saliva-based testing from the New England Journal of Medicine Dr. Sikka mentions in the episode: https://www.nejm.org/doi/full/10.1056/NEJMc2016359
- Learn more about the SalivaDirect test here: https://salivadirect.org/
- Read the CDC’s answers to frequently asked questions about wastewater surveillance for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/wastewater-surveillance.html
- Check out this article from The New York Times that provides a more skeptical look at daily, at-home COVID-19 testing: https://www.nytimes.com/2020/09/06/health/coronavirus-rapid-test.html.
- Listen to a recent press conference from the Harvard T.H. Chan School of Public Health with Michael Mina: https://www.hsph.harvard.edu/news/features/coronavirus-covid-19-press-conference-with-michael-mina-09-04-20/
[00:47] Andy Slavitt: Welcome to In the Bubble. This is Andy Slavitt. We’ve got a toolkit episode today about testing. So testing is a big topic of conversation. I think we tend to think of it as a problem because we haven’t had as much. But I think this episode may convince people to look at it as an opportunity because the power of what we could do when we have a lot of tests is pretty, pretty high.
[01:11] Lana Slavitt: Yeah. More availability of testing will provide a lot of freedom.
[01:19] Andy Slavitt: Yeah, I’ve learned a lot about this along the way, which is exactly what you said, which is frequency. Being able to get things out frequently would just give us more freedom to do more things. So I think taking the lens of not what are we going to do to end the virus, but what do we do to get back to normal life? It feels like testing is a big part of that equation.
[01:40] Lana Slavitt: Well, it would be nice to get back to normal life sometime soon. Not that I don’t love spending all my days and all my hours with you.
[01:47] Andy Slavitt: I thought you did. In the meantime, let us introduce our guests for the show. We are very excited to have Michael Mina, who is an epidemiologist, immunologist and physician at Harvard School of Public Health, runs a major lab and he is at Harvard Medical School. And he’s done all that, and he looks like he’s about half my age, which is annoying. But he’s great. He’s great, gives great explanations. But more importantly, he’s doing some amazingly cool stuff. Robby Sikka is here in Minneapolis. He is the vice president of basketball performance and technology for the Minnesota Timberwolves. Why would that be important? Well, he’s the only licensed physician of any NBA team, and he’s taken it upon himself — I should say the Timberwolves were the team that had the first death of anyone in the immediate family of a player, their star player. And Robby has been like a dog on a bone trying to get more rapid saliva tests out into the country. And he’s being successful. He is on his way. And we’re very close to being able to do that more. And so we’re going to read your voicemails and your emails. So let’s ring them both up.
[03:14] Andy Slavitt: I think that what I would love to do today is just help people do two things: one is understand the fundamental basics of how this stuff works, as simple and short an explanation as possible. And then I think people are secondarily, they’re curious, like, why the hell haven’t we figured this out? And I think just a short explanation if other countries that are better? Then most things that people want to know are like what’s going to change? When is it going to change? And then that’ll be the fun part. And we’ll read through emails and voicemails. And the idea is to give people a simple, straightforward and as clear view as possible. And I think to build some momentum that, hey, the future is coming. Things are going to change. Things are going to get better. And so I’m just going to tell everyone now that we have two very cool experts to help talk about testing today. One of them is Michael Mina. And he is at a small school called Harvard, where he is — what are you in charge of, Michael?
[04:21] Michael Mina: I am an epidemiologist and an immunologist. I’m in charge of the laboratory that I run, my research lab, but I’m also one of the heads of molecular virology diagnostics at Brigham and Women’s Hospital, which is one of Harvard’s main teaching hospitals.
[04:35] Andy Slavitt: OK. So I’ll just give you an A-plus for qualification stats, because you’ve got a lot of bases covered. And Robby, spend a second on your background and why we’re talking to you today.
[04:49] Robby Sikka: So I’m the vice president of basketball performance and technology for the Timberwolves. I grew up in Minnesota and I’m a proud Wolves fan, but I come from the medical background where I’m an anesthesiologist working for a private practice group for the last six years. And my exposure to COVID is kind of a unique one in that I’ve been involved with the NBA response through the Sports Science Committee, and largely through my interest in academic research, I’ve put together an interesting work group that has really tried to stay at the cusp of technology and research and how we approach the pandemic.
[05:26] Andy Slavitt: Great. OK, so maybe we can start this way. Michael, what type of tests are there? Can you give us a little bit of a current state of affairs before we dive into the emails and voicemails people have sent in to us?
[05:40] Michael Mina: Sure. So the major tests that exist — the one that’s been primarily used by most people since this pandemic started, is the PCR test. This is a test that looks for the RNA of the virus. You could think of the RNA kind of the same way that we think of the DNA of humans, viruses like the coronavirus use RNA instead. And so one of the easy ways to look for a virus is to look for its RNA, because we’ve built up over decades, we’ve built up really good tools to do that. And that primary tool is called PCR, polymerase chain reaction. You don’t have to know what those words mean, but just know that it’s a very good tool for picking up pieces of RNA in a very, very specific manner and really looking at small, small numbers of RNA molecules. So that’s PCR. There’s also these tests that are called — and there’s a whole variety of different types of PCR, we can go into that later. But then the big category of viral testing outside of PCR and molecular tests is antigen tests. Antigen tests differ because they’re not looking for the RNA of the virus, meaning they’re not looking for the genome of the virus, they’re actually looking for the proteins, the arms and legs of the virus, if you will. And so in the same way we could technically go and look at somebody’s DNA and know that Joe Smith is Joe Smith based on their DNA, we could also look at Joe Smith’s eyes and nose and mouth and have a very good understanding that that is Joe Smith based on the physical properties of the person. So that’s more of what antigen tests are doing. They’re actually looking for the physical features of the virus. And the important thing to know is that these types of tests can be done very fast. To do PCR, you need a lot of instrumentation and things like that. To look for the proteins of the virus, you really can do it at a very fast speed and for very cheap just on a piece of paper, essentially. You can create a little paper strip test that will turn positive or negative in minutes. So those are the two major classes. And I do want to just mention the other one, because it’s been a source of a lot of confusion for people, which is antibody testing. Antibody testing doesn’t look for the virus, but it looks for evidence that somebody has been infected with the virus based on their antibody or immune response to it. And so it’s a whole different class. The important thing for antibody testing is it gives you information on somebody’s immune status and the signal stays around for months to years potentially. So you could kind of get a window into somebody’s past history of the virus.
[08:23] Andy Slavitt: Got it. Got it. And so how are we doing as a country? Where are we in the development of both of these types of tests? The PCR test and the antigen test.
[08:35] Michael Mina: So we have really built up a lot of capacity to do PCR in this country. And slowly, we’re building up antigen test capacity as well. But PCR testing has been — we started working on it in a pretty failed attempt early on in February.
[08:52] Andy Slavitt: This is where the CDC had a contaminated test, right?
[08:56] Michael Mina: That’s exactly right. There were two failings, and the major one that was in the media lot was the CDC had contaminated tests. They sent all these test kits out to all the state laboratories and then they had to retract them all, so that delayed the U.S. response in terms of testing by at least a month or so, three weeks to a month. But what was really the failing that came to light was that the U.S. network of public health laboratories just weren’t up to the task. Turns out we have so defunded public health for so long that it wasn’t even close, it wasn’t even a race, the state labs never really had a chance. And they are from a public health perspective, they are the public health labs of this country. But this really just was a tsunami of infections that overwhelmed them very quickly. So we’ve been trying to scramble and back up from that ever since then. And the country is doing a pretty good job at building up PCR-based test and molecular tools and a whole array of creative ways. But these are all laboratory-based tests. And so we’ve been building enough. We’re now doing upwards of around, you know, between 700,000 to 900,000 tests a day, most of those being PCR-based tests. And we’ve gotten to a point where we can diagnose enough people. But there’s other uses for the tests, which I think probably can talk about.
[10:19] Andy Slavitt: Got it. We’re saying that there’s different types of labs. There’s labs that are state laboratories. There are labs that are in hospitals. There are commercial laboratories. So it’s important to note that those things operate a bit differently. Robby, what would you add and how would you talk about the form and function of these tests relative to the types of needs we have as a society?
[10:41] Robby Sikka: This is a really large country. So when you’re talking about 300 million-plus people, and we’re doing a million tests a day or just under that, that’s just not even close to being able to test, trace and isolate. We’re not close to being able to reach capacity. So we need to have all sorts of testing available, whether it’s antigen testing, PCR testing. We just need more of it. And one of the real challenges here is the price point for PCR. Testing is really expensive. And as Michael very eloquently said in describing the testing methods, PCR testing largely has to go to a lab. There are lateral flow assays and there are other options for PCR-based or PCR concept tests that are things that maybe will eventually be able to be consumer-facing tests. But the reality is we need cheaper testing out to the masses. We need to be able to screen populations. And when we talk to hospitals, we need to talk about their capacity.
[11:42] Andy Slavitt: Well, let me let me let me stop you there. When you say to screen — because I want to make a distinction. OK, someone’s sick. They have coronavirus. They need a test to confirm they have it. That’s somebody with a symptom. That’s one type of test. That’s one need. Second, you mentioned screening. And I wanted to explain what this means. You’ve got a population where this virus spreads asymptomatically. And so there is a question — and this was a CDC controversy quite recently — about what is the benefit of also testing people that don’t have symptoms. So you can understand where the virus is spreading. And then there’s probably a third category, which is I am not in that category, but I might want to do something. I might want to visit my grandmother in a hospital. I might want to enter a basketball game. I might want to go to a party. I might want to get on an airplane. So I want to know myself. I may not be screened for public health purposes, it’s not because I have a symptom, but it’s because I want to want to do something.
[12:43] Robby Sikka: Yes. And those are all different avenues for screening, all different populations and different types of screening. It could be for schools, it can be for work. It can be to visit family. It can be for a lot of different things. And we have to have screening tests for all of those scenarios. And that can mean PCR, it can mean antigen testing, but it needs to be cheap. And it needs to be affordable and accessible in a way that you’re also not waiting for your results for days. It’s got to be faster.
[17:55] Andy Slavitt: OK, so let’s dig into some of the questions. I think the baseline you’ve given us is we have some kind of big, heavy, expensive tests that work when people are sick, but we have other needs and other purposes. So let’s start with one of the other purposes. And I’m going to play a voicemail.
[18:14] Caller: Hey, Andy, this is Jeremy calling from New York. I was wondering when we can expect to get more reliable spit testing. I am pretty tired of having that long swab shoved into my brain. Anyway, thanks for the great podcast and keep up the good work.
[18:39] Robby Sikka: Yeah. So Saliva Direct, a group that we’ve worked with over the last few months with the Yale team and the NBA, putting together just a very unique open-source protocol. Around September 15th, you will start to see Saliva Direct be accessible and different parts of the country. And we’ve had over 200 labs and over 10 different countries reach out about saliva testing. This is going to be something that as you go into October, you will start to see more and more saliva testing, and a move away from swabs, particularly nasopharyngeal swabs.
[19:15] Andy Slavitt: Are saliva tests as good as nasal tests?
[19:18] Robby Sikka: There’s an article that came out in the New England Journal of Medicine from the Yale team that did describe that lower limits of detection for saliva testing are as good as traditional swab-based testing. We’ve looked at over 4,000 samples in the NBA population in our study, and we found that the negative predictive value of saliva for asymptomatic screening and for detection is as useful as nasal or pharyngeal swabs.
[19:45] Andy Slavitt: OK. So starting around the middle of this month and carrying forward these tests will be more and more available. There are other saliva tests on the market. There are other saliva tests being created. Will they meet some of the purpose — the least limited purpose you described — of lower cost and more readily available results?
[20:04] Robby Sikka: Absolutely, and it’s going to be something that you hopefully don’t have to go to a healthcare worker or go to a clinic or go to a hospital to get tested. Because what we don’t want to test, every patient is in a medical setting. We want to be able to test in the community so that people can move on with their lives and they can resume whatever the new normal is.
[20:21] Andy Slavitt: OK, so, Michael, I’m going to play a voicemail for you around another type of test.
[20:28] Caller: Hi. My question concerns at-home tests and when those might be available. And also the reliability of quick tests, specifically, if those are useful enough, if they’re not as reliable. Thanks a lot.
[20:45] Michael Mina: Yeah. So the antigen test, which is really what that question is referring to, these are tests that are sufficiently simple to be used at home. I want to make a distinction, just because there’s been so much confusion out in the public about it. And that’s that we have to separate out the mode of collection from the mode of testing. And I think Robby just did a good job at describing that. But just to be very concrete, the collection could be either a nasal swab that goes way back into the back of your brain — not literally. It could be a front nose swab, which largely is called a nasal swab. And then there’s saliva. And so each of those have their benefits and tradeoffs. But that’s the collection. And then the testing is either laboratory or point of care or even at home. And so we’re gonna start seeing this at-home tests, I think, in the near future. They haven’t quite gotten to at-home yet. But Abbott, for example, this is a major company that makes a lot of lab tests. They just came out with what they call a BinaxNOW assay. It’s essentially a cardboard test. Does the whole test on a piece of cardboard in 15 minutes. These are called lateral flow assays. They work very much like a pregnancy test in the same way you’d essentially put some of your saliva on one of these tests, or you put a nasal swab that you can do yourself. It’s like a Q-tip they put in the front of your nose and then you put it in saline, and then you drop drops of that on to these test strips. And they’re little pieces of paper essentially, maybe in a little piece of plastic. The sample will flow over the piece of paper, and if there’s a virus in it, it will make a line turn red, for example. And so these are called lateral flow assays. They look just like pregnancy tests. And in fact, the technology is extremely similar to a pregnancy test. So these could be done at home. They could be done at the school. The approval that this test just got is for asymptomatic people to be used in the doctor’s office, for example. But it’s really going to very quickly be used what we call off-label. And that means it’s going to — in fact, Health and Human Services just brought it out the other day and pretty much all out advocated for the broader use of these tests. And so I think we should start to see them. And that’s really the first major step that needs to happen before home use.
[23:13] Andy Slavitt: So I would go to CVS or I would get on Amazon and I would say I’m going to buy a whole bunch of these pieces of paper we have at home, and then either think of a tasty food and drool a little bit, or use a Q-tip and put something on here. And it will tell me whether I have Coronavirus with what kind of accuracy?
[23:37] Michael Mina: Sure. So this has been such a topic of conversation. What’s the accuracy of these tests? Accuracy, I want to make clear, is it’s a function of what your target is. The way that I look at these antigen tests, these really rapid tests, I actually look at them as transmission indicators more than I look at them as true medical diagnostics. And the difference here is if you’re a doctor and you have a sick patient in front of you, you want to know if there’s any shred of evidence that this person has coronavirus. These tests probably wouldn’t be it. But if you’re trying to create a public health platform that stops the transmission of the virus, you really just want to know who has a sufficient amount of virus in their mouth or nose that they might be able to transmit it. And these tests will be very accurate, hopefully somewhere around 95 percent sensitive, to detect people who are very likely to be transmitting the virus to other people.
[24:36] Andy Slavitt: Just just to put that in context. That sounds higher than what most people are hearing about tests. I think people in the popular press talk about 80 percent and then all kinds of exaggerated claims. And I worry that people change the denominator slightly or the description slightly to say, well, it’s 90 percent of some other thing. So just to keep it really basic, if I were to do one of these tests right now and I have Coronavirus, what’s the percentage chance that it would tell me that I have coronavirus?
[25:08] Michael Mina: Well, it depends on where in your course of infection you are. In this case, you’re absolutely right, it’s always changing the denominator. My denominator in this case is people who are most likely to transmit the virus to other people. And that’s because if you’re likely to transmit it, you’re also very likely to have very high amounts of virus. But if you have a very mild infection that might not be particularly transmissible, we’re not quite sure of what that sensitivity is. But if you’re, say, a super spreader or something like that, it would probably be very, very accurate to find you very quickly.
[25:40] Andy Slavitt: Rob, you’ve got a question that’s coming via email from Kelly. “If we really need to test on a massive scale, how will that affect the labs we have for processing now? Do we need more labs”
[25:55] Robby Sikka: It’s a good question. And I think it goes to some of the stuff that we’ve already talked about. We need labs to understand that they are running at capacity. They are testing as much as they can. Tests like Saliva Direct has a positive impact on the efficiency of the lab, but more importantly than that, we need to start screening the community to avoid having spreading and to reduce our hospital population. To reduce the viral burden in the community, we need to screen more. The public health folks will tell you that we need to screen, the lab folks will say that, you know, we’ve got a test hospital, folks. We need to find a better balance of how we test the community. And I think Michael was alluding to this earlier. The test cadence matters more than the sensitivity of a pure test. The more we test, the more often we test, the better these tests will perform, and the more likely we are to pick out positives and reduce the spread in the community. And I think that’s something we can all get behind. But we have to test more and more frequently. And that’s going to mean that we have to test asymptomatic individuals to avoid hospital burden and having people who can spread the virus more.
[27:02] Andy Slavitt: OK, so here’s a voicemail for you from Carol.
[27:07] ccc: Hi, Andy. If you think you’ve been exposed, or you’ve been in a situation where you could have been exposed, I understand you should get a test. If you get that test, say, three days later and you test negative, should you get tested again five days later, 10 days later, 14 days later, or do you just wait and see if you have symptoms? It’s a little confusing to me about the period of testing and how, when and how often you should get tested. Thanks a lot. I appreciate your thoughtfulness and your service.
[27:39] Robby Sikka: That’s the situation we’ve been living in, because when do you test? And those are those complicated situations where, you know, I typically tell someone if you’ve been exposed, your job right then and there is to stay home and to minimize your exposure to the community. And until we have more and cheaper testing available, we don’t want to go and test everybody. But we’re getting to that point now where we should test you and we should test you more often. So let’s experiment and let’s figure out how we’re going to figure out that test cadence, because we can figure out how to ramp up and go test everybody in a small segment of the population. We also don’t know how to ramp down. So if there are no cases, we don’t want to be in a situation where then we ramp down and we have more cases and we’ve got to ramp up again. We have to have a consistency that’s out there that this just becomes part of what we do. We test to go into certain situations, to go to a game, to go to school, to go to a restaurant so that you can limit the viral burden in the community. So to answer your question succinctly, even though that was a long answer, I would stay home for a period of probably five days, minimize your contacts. And then at that point, if you develop symptoms, I would certainly get tested. And if you don’t, before you go out, I would consider getting a test before you clear yourself at probably five days after your exposure.
[28:57] Michael Mina: To clarify that it’s because there’s this period called the incubation period. I think a lot of people are confused about this. If you get exposed today, there’s almost no point in going and getting a test tomorrow, just none. You’ll be negative even if you’re positive. During the incubation period, you have to let the virus grow enough so that even the PCR tests can detect it. So the best window, as Robby is alluding to, is a five day period, maybe a six day period if you want to be conservative, and then get a test. A lot of people remain asymptomatic. The symptoms alone won’t necessarily be able to tell you that you’re negative. But if you do it before five, five days or so, you’re very likely to just do it too early. And this is really similar actually to a pregnancy test, again, actually. If you become pregnant and you go and take a test two hours later, it’s not going to show they are positive. You have to wait a couple of days.
[29:48] Andy Slavitt: Interesting. OK, so stay home for five days, then go take a test. Do you need to take another test at the end to make sure that at the end of 14 days that you are no longer carrying the virus? There’s been some conflicting reports. And I will tell you that we have had a situation here where we had someone in our household who had coronavirus and kept testing positive for weeks and weeks and weeks and weeks and weeks later. He had no symptoms. They were telling us at the time, you need two negative tests before you can let him out of his prison cell. He wasn’t in a prison cell, he was in our basement with a computer and everything. So he was fine. But we came to find out later that maybe we didn’t need to wait so long. Sorry. And wait for two negative tests.
[30:35] Robby Sikka: Well, I think that those are interesting scenarios because, one, the more you test, the more you will have false positives and false negatives in the community. So you better be prepared to handle some of those situations. Those are complicated situations where you have to be able to communicate and figure out how you’re going to move forward. We’ve developed a lot of tests that have really good specificity. So if you’re positive, you’re more than likely positive. But what that means in terms of your infectiveness versus your infectiousness, that you don’t spread it to people. We need to understand and I think this is one of the points that Michael’s made. If you have the virus and you have low levels of that virus and you’re not spreading it to people, you are not as much of a risk to the community.
[31:23] Andy Slavitt: Sure. So at 14 days, can people go out?
[31:27] Andy Slavitt: So the 14 day mark is they conservative mark. I would say that it’s designed to account for both an incubation period and a whole course of maybe asymptomatic infection for somebody who doesn’t get symptoms. So it’s conservative. I would say that if you test negative at day six or seven — this is not what the CDC currently says, but if you have access to a test on day six or seven after exposure, I would say you can probably go out if it’s negative. But if you haven’t tested again and you’re waiting the whole 14 days and you still have not shown any signs, then in general, the recommendation, and I agree with it, is that you could start to go out. I actually really push for the use of — there’s a value that comes along with these PCR tests. It’s called the CT value and it essentially kind of reflects the viral load. And I actually think that there’s whole new guidelines that should be made that actually interpret the CT value to say to somebody, look, you’re somebody like your family member who is stuck inside for potentially a week. Some people get stuck for months in a positive state. And that’s confusing to a lot of people. So we should be able to look at the viral RNA load and say, look, this person has very low RNA amounts for weeks now, there’s no way that they’re transmissible anymore. It’s just remnants.
[35:38] Andy Slavitt: I want to talk to you both about a different type of testing, because a lot of what I want people to take away is understanding kind of the innovation that should be making us more hopeful because of the things we’ll be able to do in our lives. Someone asked a question about sewage testing. He emails “testing of sewage looks like a good early indicator of COVID infection. Could there be an at-home version? You drop a paper strip in the toilet and it turns color and tells you whether you’re infected.” Maybe we start this way. Michael, what is sewage testing? Does it work? What’s it useful for? How is it being used? What can it be used for?
[36:25] Michael Mina: Sewage testing is a very good surveillance tool that we have at our disposal. This is a particular virus that likes to grow in our intestines, and that means it comes out in our feces just some of the time. Not everyone would necessarily have a high signal of it. But it seems to be the more we learn about it seems to be a pretty common phenomenon, that people if they have this virus, you can usually detect it potentially for quite a bit longer, actually in the stool than in their respiratory tract. And that’s for a number of reasons, there’s some new research coming out that showing that the virus is actually turning up, changing the properties of these cells to turn up this thing called the ACE2, which is what the virus binds to. In any case, the virus seems to really like the gut. And so when your body starts clearing it, you essentially shut it in your feces and there’s a lot of RNA from these viruses. So you can actually start to pick that up downstream in the sewage water. The question is, what do you do with that information? And if you’re like at that outflow tract of an entire university and you start to see a positive COVID RNA in the sewage from the outflow tract of a whole university, do you shut down the whole university, you know, how do you act on it? And that’s where we really have to say, OK, this is a public health issue. This is a very powerful potential public health tool. But you have to have pretty good plans in place about how to act. How are you going to identify the people who are transmitting? It could be two people in any University of 50,000 who are leading to that.
[37:58] Andy Slavitt: Right. One of the things that I think it’s important to understand, I think about sewage testing, correct me if I’m wrong here, is that when we get this under more control, when it’s not such rampant community spread, we are still going to want to be able to catch it at the earliest possible time. And so right now we’re in a situation where, you know, you could, as you say, you could be a school and lots of people could have the virus. But hopefully we’re in a situation a few months from now, or at some point in time, when you have communities where you’re not seeing any spread. But you want to know when is the first time I should start — because I don’t want to close the bars and the restaurants and everything too early. But I want early indicators. I want to signal. And so if you’re in a county somewhere and you’re doing the sewage tests on a daily basis and you find up we just saw it again, we haven’t seen it in a month and a half, that at least can begin the beginning of a detective trail for you.
[38:56] Michael Mina: That’s that’s exactly right. And this is how surveillance programs across the globe for infectious diseases like this have generally worked. Not always through sewage, things like antibody testing, other types of testing that are not so frequent and so intrusive into people’s lives are generally used during what I call peacetime, when there’s no cases and you just want to have — risk is very, very low on an individual basis — and you just want to have a signal set up, a surveillance system set up that very frequently is monitoring for any slight signal that the virus is coming back into the community. And then you can act appropriately to deal with it.
[39:39] Andy Slavitt: What about Paul’s kind of billion dollar idea? Can you just drop a piece of paper in your own toilet and not have it as a surveillance test, but use that as your test?
[39:47] Michael Mina: Well, I have thought a lot about it. And I think it’s possible. It doesn’t exist right now, but I think given the right people working on the problem, you could have CRISPR based types of tests that potentially, you know, if they target some of the RNA from the virus, it sets off a little chain reaction. And you get a little signal.
[40:05] Andy Slavitt: Let’s workshop this. OK, we launched the product, which we call it?
[40:09] Michael Mina: Poop Direct.
[40:13] Robby Sikka: I’ll have to talk to the Yale team about that one. But, you know, that team has been working on sewage tracking in Connecticut for a long time, and they actually used this to predict outbreaks in Connecticut very early on. So I absolutely see the value. I think college dorms should be doing sewage tracking because it’s a great way, if you’re not going to be able to test everyone, you’ll be able to predict outbreaks in populations like that. So it’s the perfect setting for something like that.
[40:39] Andy Slavitt: I think we’re through most of these questions, and I would love to see if we can’t bring it to a bit of a close with just a look into the future. It’s so hard for us to get out of kind of what things look and feel like today. Four or five, six-day wait times, very expensive tests, hard to be able to get them, not knowing what to do or where to go. And, you know, I’ll ask each of you to look into the crystal ball, primarily driven by the impact of what tests will bring. Obviously, there could be vaccines, there can be better therapies, and all those things to mix as well. But if you were describing a vision six months from the future, where you waved your magic wand and we had all the testing and the testing kinds, what does that world look like for people?
[41:21] Michael Mina: If I was king or president or whatever it might be, I think a way to tackle this virus, especially from a testing perspective — again, I want to caveat it by all of this will happen within everything else were already doing, which is for the time being, social distancing and masks. Well, I think only the federal government can reasonably be the buyer and producer of, say, 30 million tests a day in the United States. I would like to see these rapid antigen tests, these paper strip tests that look like pregnancy tests built so that 30 million people could use these every day. Used every few days, that would mean 90 million people could actually be participating in this type of very frequent testing program. You put these tests into all the hotspots of America. And so anywhere where there’s cases that are really emerging, you get these tests into the hands of people. They brush their teeth each morning. They put in their contact lenses. And they use a COVID test to see if they are transmitting virus that day perhaps and likely asymptomatically. If they are, then they stay home and they stay home for at least five, six, seven days, and they test a couple of other times to see if they turn negative. And that would be enough to stop transmission chains. I don’t see these at the outset as your golden ticket into an event or into dinner. These would be actually a way, that just like vaccines, they create herd effects. They actually drop population prevalence. And that means you don’t have to have 100 percent of people using them every day. You could have 50 percent of people not want to use them at all. Another 10 percent use them incorrectly. And if you just get 40 or 50 percent, for example, using them every few days, we’d see major reductions that this value called the R-naught, the R-factor, of the virus would plummet. And that essentially means that that spread in the community plummets. So if we had that kind of testing, that takes the burden off of the PCR labs, so that they can do confirmatory testing, for example. Even with a one percent false positive rate, if you had 20 million tests going out and being used every single day by Americans, that brings our number of tests from 900,000 to 20 million. And one percent false positives means we’d probably have to be doing PCR at around 200,000 PCR tests a day to confirm them. And that alone, all of this kind of infrastructure would be sufficient to repress the virus and suppress its transmission in the community. So we can actually get people to a point where you’re no longer worrying if the person next to you at dinner has a COVID infection because you’d be in peacetime, you’d suppress it so much that there’s just the prevalence goes away in the hotspots, which makes all of America safer If you’re not worrying about people bringing the virus into your community.
[44:14] Andy Slavitt: Then you’d be finding one and two cases instead of 2,000 cases at a time. OK. So how realistic is that vision you just gave, that that could be the case in a few months?
[44:29] Michael Mina: I think it’s very realistic. These are easy tests to build. It doesn’t require building huge labs. It requires maybe contracting with major manufacturers in China, for example, or even major manufacturers right here in the United States. 3M, for example, has been interested in building these types of tests. They have amazing capacity. They can build huge numbers of them. So it’s a simple technology, there’s even free blueprints online.
[44:54] Andy Slavitt: Is scalability a challenge?
[44:57] Michael Mina: It will be a challenge, but not an insurmountable challenge. I would say the pains that this country has gone through to get to 900,000 PCR tests today far exceed the pains that it would take to get antigen tests to 30 million a day.
[45:13] Andy Slavitt: Let’s hear Robby’s vision, too. When you think about where we can be in a few months as a society, what are some of the elements?
[45:25] Robby Sikka: The hope with Saliva Direct that it can change the conversation about testing shortages to access to testing and dropping the price. We need affordable testing. And we need to have testing accessible to the masses. It’s our only way out along with masks. That’s it. And creating an open-source platform for anyone with a lab to have access to a test, it changes the dynamic. It creates a recipe that labs around the country and around the world can use. We had a forward-thinking vision at the NBA with the Timberwolves and with Yale to not just do something for America, but to do something for the world, because other countries are going to be six months, a year, two years behind here, and they’re going to be testing for a long time. This virus is not going anywhere. So we need to change the conversation. This is the first step in doing that. It’s a low-cost, affordable, accessible test that will be available to the masses. For us, we want to take a step forward as a country, and when we talked about this at our first meeting, Andy, back in May, we said this is not for the point guard, this is for the student body. This is for the population to be able to get back to school so that we don’t have a generational gap. I know your son is headed to what I think is the best school in the country, the University of Pennsylvania this fall. And I want him to have the same best great four years that I had while I was there.
[46:54] Robby Sikka: We want students to be able to go back to school. We want restaurants to be safe again. We want people to be able to go and enjoy a sporting event. And for us to be able to do that, we have to have testing for right now. And I don’t see that going away for the foreseeable future. We’re going to have asymmetries in who is immune, who has been vaccinated. We have to address these inequities in our country and really come together. And I think the reason I’m proud to work in sports is sports is the best platform for teamwork in a lot of ways. People come together to be greater than the sum of their parts. And we need our country to come together and be greater than the sum of the individuals here to really try and figure out how we are going to test our way and mask our way out of this. And that’s going to require us to remember who we’ve lost. The personal faces, the people that we have had to not be able to say goodbye to over the last few months. We’re forgetting that as we go forward, we have to remember those faces because that’s what’s going to haunt me for the rest of my life, that there’s more we could have done, there’s more I could have done. And I want to keep doing more as I go forward.
[48:01] Andy Slavitt: Well, those are two pretty compelling cases. Thank you guys so much for the time and the vision, and the hard work and the fact that you guys are both bulldogs at this. You’re not going to quit until we get there. I just realized that I wanted to in addition to the toolkit today, I wanted the country to know that while they’re seeing bad news headlines and things are scary, that there’s really great people working on this problem every day. It’s not visible every day. We only really sometimes see it to get to the end. And sometimes some of things get to the end. Some things don’t. But, you know, I’m privileged to see the work that you guys are both doing, and it’s really important for the country.
[49:05] Robby Sikka: Well, Andy, thanks. Thanks for your vision with all of this, too. That’s, you know, your vision of sharing and communicating and bringing together different voices, it’s really cool how we’ve seen scientists and the community come together here, but we need more of it. And I’ve never met half the people I’ve worked with. I don’t think I’ve met any of the people that I’ve worked with ever. I don’t know if they walk or wear pants or what, but that’s what’s great. I mean, we’re doing this all over. Zoom. Imagine how much better we can be after this, because we’ve gotten to know people who are really smart, talented, committed. I really do think that when we get through this, we have a chance to be a better country if we don’t get lost along the way.
[49:50] Michael Mina: Couldn’t agree more.
[50:06] Andy Slavitt: I hope you enjoyed that show. Keep the ideas coming. I thought those two were great and very hopeful. Here’s what’s coming up. On Wednesday, we have a new podcast coming out with Julián Castro. I think it’s going to be a great conversation about where we are as a country and the people that are affected and that are going to make things happen. We’ll get some reflections from him on the campaign trail. We have another episode coming up shortly on the west wing. And it’s going to be — I won’t give it all away, but Pete Souza, who is the White House photographer under President Obama, was there. The West Wing is up for grabs now. It’s real estate lease is coming up November 3rd. So we’ll see if the tenant is going to be renewed or a new one comes in. But we’re going to talk about what it’s like there and how decisions are made and some really interesting experiences there. We also have Rajiv Shah, who is the president of the Rockefeller Foundation, who’s devoting considerable resources and energy towards that notion that we can do better. He has written a very powerful treatise on what we can trust, and what we can’t. Anyway, I’ll let you all go.
[51:25] Andy Slavitt: Thanks for listening to In the Bubble. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen, produce the show. Our mix is by Ivan Kuraev. My son Zach Slavitt is emeritus co-host and onsite producer. Improved by the much better Lana Slavitt, my wife. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produce the show. And our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media @LemonadaMedia. And you can find me @ASlavitt on Twitter or @AndySlavitt on Instagram. If you like what you heard today, most importantly, please tell your friends to come listen. But still tell them at a distance or with a mask. And please stay safe. Share some joy and we will get through this together. #StayHome.