The Latest on COVID Testing and Summer Travel (with Drs. Michael Mina and Patrice Harris)

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As you head out on your summer trips, how often should you and your family test for COVID-19? Andy gets practical advice from epidemiologist and show favorite Dr. Michael Mina along with his eMed colleague Dr. Patrice Harris. Using real life scenarios, they tell you the most informative times to test, explain why some people stay negative while displaying symptoms, and offer an innovative way to test and treat from your home.

Keep up with Andy on Twitter @ASlavitt.

Follow Dr. Michael Mina and Dr. Patrice Harris on Twitter @michaelmina_lab and @PatriceHarrisMD.

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Michael Mina, Andy Slavitt, Patrice Harris

Andy Slavitt  00:18

Welcome to IN THE BUBBLE. This is Andy Slavitt and it’s Wednesday, June 29th. Got anything planned this summer? Going to be traveling? Gotta be seeing friends? Gonna be seeing family? One of the things on your mind is probably the question about whether or not you should be using rapid antigen tests that you take at home. I know that we’ve got some travel, cooking, we’re going to see some friends, we’ve got some rapid tests, we’re going to take them with me, but I think we need a bit of a refresher and an update on what do these tests do? When did they actually work? What do we know about how they work with Omicron? So we’re gonna welcome Michael Mina, to the show, who has really the best and most specific advice on how and when to test. And joining him is his colleague, Patrice Harris, who was formerly the president of the American Medical Association. And she’s got a real focus on a couple of things. One is the role the physician is playing, and can play for all of us in the process, as well as helping everybody and in more equitable basis, find affordable tests. And one more thing has changed about the testing question, since we’ve addressed that last on the show, which is that we have treatments that work like Paxlovid. And so we’ll start with Michael and Patrice about those new approaches how they fit together in their new venture together, just called Emad, which they’ll talk about a little bit. So looking forward to that. You heard me, just last week, talk about four pieces of good news coming in Covid. You know, I hate saying, you know, everything’s rosy or everything’s dim, because it’s never the case. But you know, the fair question is, what are we worried about? Well, you know, Covid cases are still happening in BA4, BA5, are behaving a bit differently. So as before NBA five come to the US, we’re gonna need to learn more about that we’re gonna have an upcoming show on that. But suffice to say that, you know, one of the questions on everybody’s mind is, does the immunity that we’ve gotten an earlier versions if you’ve had COVID before, or for vaccines, how well is it working against 4 and 5? Big question, we don’t know the answer. Stuff that people are focused on, nothing to panic about. But very much in mind. Okay, so enjoy your summer get into things as you’re getting the love hearing from Michael and Patrice. So here they are.

Andy Slavitt  02:47

Welcome back to the show. For I believe his third appearance, Dr. Michael Mina. Last time you were on the show, Michael, you were at Harvard. You are both Harvard and of Twitter. And now you’re of eBan and Twitter. Welcome back.

Michael Mina 

Thank you very much. Happy to be here.

Andy Slavitt 

You’re a popular guest. I hate when the guests are more popular than the host.

Michael Mina

Well, I’ll try to disappoint.

Andy Slavitt 

Please, please do. You’ve teamed up with a miraculous wonderful person who I’ve known for a long time. Dr. Patrice Harris. Welcome, Patrice.

Patrice Harris 

Good to see Andy. Thank you. And yes, you know, it’s difficult to be on with such a popular guys as Michael Mina. But certainly, I’m very glad that I have the opportunity to work with him.

Andy Slavitt 

Well, I’m suspecting if we do a vote at the end of this episode, I think there’ll be a lot of people voting for Team Patrice, just my gut. Let’s start with some of the update on the on the 101 of what’s going on Michael. And I should say not just Omicron, but the sons or daughters of the original Omicron that we originally saw here in the US earlier in the year. The speed, it’s infectious, its lethality and how it’s meeting with the public, which has various layers of resistance to an immunity.

Michael Mina  04:05

The speed of Omicron and in somewhat of an expected fashion has continued to just pick up the sub variants and variants and sub variants sons and daughters, whatever we want to call them, they’ve almost we’ve essentially stopped giving them the routine names like Delta and Omicron because they’re picking up very quickly. They’re not quite so distant that they deserve their own name necessarily, but they are becoming much more transmissible and they’re continuing their steady march to evade immunological responses that are derived from both previous infections and previous vaccinations. But the important thing is that people are still getting protected from the most severe outcomes when they are vaccinated. But certainly this virus you know, the hope was that it would find out Have an optimal state earlier, I suppose, where it would stop accelerating its transmission so much, but it hasn’t quite seemed to find its optimum yet. And it seems to still have further to go. I like to think of it almost like a baby virus, it jumped into humans as a baby. And now it’s sort of hopefully past its adolescent stage of learning to learn to crawl and walk. And ideally, now it’s almost at its max speed, but it’s hard to know with a new virus how far it has to go.

Andy Slavitt 

So the brave new world that most of us are facing now, it sounds like is something that is more constant than it is seasonal, at least for now. But perhaps less dangerous if people have been vaccinated and boosted. But it’s sort of an ever present set of issues. And so we’re going to spend a lot of time on this episode talking about testing, how to make sure you know, if you’ve got COVID, and treating your COVID, if you do get diagnosed, since it’s a reality that more and more people are living with and thankfully surviving. So let’s just start at the beginning for somebody, when do you recommend people take a test following one of either the two events that would cause them to take a test being exposed to somebody, somebody calls you and says, hey, guess what, we had lunch together today and I have COVID, or feeling a symptom. They’re feeling a scratchy throat, they’re feeling under the weather, they, maybe they’re starting to develop a fever or something noticeable? What should people start to take a test and walk us through that, Michael.

Michael Mina  06:40

When somebody is exposed to the virus, the basic rules, if we go back to when to too early in the pandemic, the general discussion and the general recommendation was, you know, wait five days after exposure to test yourself, that was a recommendation that was born out of what is going to catch the most number of people who are infected, given with the expectation that they only had one test available. And that’s because that was a PCR test is hard to get. We’re in a very different world now where people have access to home tests, and self-tests on a regular basis if they want them. And so my general recommendation is, if you know you’ve been exposed, you don’t have to go right out that same day and test yourself, you’ll probably be negative, you probably will still be negative the next day. And for most people, they’ll even still be negative the day after that. But nevertheless, I would say on day two, or day three is probably when you should really first test yourself after you know you’ve been exposed. And if you’re negative test, again, 24 or 48 hours later, if you’re not yet positive by around day five, generally speaking, you’re not going to turn positive if you haven’t become symptomatic, and you’re still negative. Now, if you do become symptomatic, that’s a different story. People are becoming symptomatic very quickly after exposure today. And that’s largely a reflection of people having some level of immunity to this virus. So you get exposed and your immune system is exquisitely sensitive to detect the virus now, because you’ve been vaccinated or boosted. And so you start to get a fever, or you get congestion, you get these immune symptoms, sometimes they come on before the virus has had a chance to replicate to high enough levels, to turn your test positive. So if you’re symptomatic, my general recommendation is assume you’re infectious and infected, you believe you’re testing negative, that’s correct. Even if you’re testing negative and you’re newly symptomatic. Play on the side of safety and caution. Assume that you’re positive, assume that you’re likely infectious and test again the next day. And if you’re still negative, the next day, test again the day after that. And the reason is, it’s become very difficult because the immune system is throwing up these red flags really quickly, that it’s confusing for people. For so much of this pandemic, we’ve been told, only test once you’re symptomatic, or you’re only going to be positive and infectious if you’re symptomatic. But that’s now symptoms are starting really early before people are even potentially infectious. But we want to err on the side of caution. So if you’re symptomatic, assume and you especially if you know you’ve been exposed, assume that you’re infected, even if the test is still negative. It’s a lot like a pregnancy test used too early. If you use a pregnancy test too early, it’s not a failure of the test. It just means that you have to wait a little bit longer for the test to turn positive. And then in the case of Covid It’s because you actually have to wait for the virus to replicate enough to be able to turn even a PCR test or a rapid test positive it doesn’t happen immediately.

Andy Slavitt 

Okay, well, it sounds in some respects like a good thing. If people are showing symptoms earlier would you both agree with that, because it would seem to suggest that the stealthy spreading is less likely. Patrice, do you see it that way? Do you see these kinds of changes as hopefully reducing infection levels?

Patrice Harris  10:14

Possibly. And I think that’s the good news. It’s always about the evolution, evolution of the virus. And Andy, I think, you know, I’ve always said this virus gets an A plus and doing what viruses do, which is constantly change with the mission to infect others. And as Michael talked about, now, people are, you know, getting staying asymptomatic perhaps, for a little longer and wondering if after exposure and wondering if they are positive. And so I think that, that is certainly the case. And it’s all the more reason to sort of stay on top of opportunities for testing, and stay on top of the changes, because as Michael said, now, you know, we are recommending something that’s different than he recommended 6 months ago. And it’s important that we continue to get the information out so that people get tested at the right time, and we can reduce the spread.

Andy Slavitt 

Michael, I want to just make sure we establish in people’s mind, the framework that you should have in the correlation between the rapid antigen test result, contagiousness? Are they the same thing? I’m positive, therefore I’m contagious, I’m negative therefore I’m less likely to be contagious. Were there absolutes? And where’s it just really still too murky to tell?

Michael Mina 

So, I want to, I will address that at what I wanted to also do is go back to the question you asked, which is, is it potentially a good thing that people are becoming symptomatic earlier, potentially, really early after they’re infected? They’re starting to show symptoms, and it’s almost like a red flag that your immune system is waving to say, hey, over here, I might be infected, even without knowing without having a test yet. And I think in general, yes, this actually brings this virus closer to what we’ve always seen with viruses, which is, you know, probably a reflection of people having existing immunity, which for the most part, any person who’s lived to be four or five years old, has seen most of the viruses that they’re ever going to see in their life. They’ve seen them at least once, if not multiple times. And that’s why it was a surprise when Covid, When SARS-CoV-2 started circulating, one of the most difficult things to contend with, but that we all became comfortable or not comfortable with but we all became used to was pre-symptomatic transmission. And that was massively difficult to deal with. Because how do you know when to test if you don’t have any symptoms yet, you don’t know if you’ve been exposed, and you’re already at high viral loads. So now we should actually not look at it as a negative thing that people are becoming symptomatic, before they test positive, we should understand, A, this is the natural course of things, we want our immune system to recognize the virus and throw up signals before the virus grows up. And we want to use that to our advantage to be more on the more conservative side to say, hey, I might not be positive yet, but man, my body’s telling me I might be sick. And I’m going, you know, try to take precautions, even if I haven’t yet tested positive. And hopefully we get to a point where we might have symptoms and the test never turns positive. We actually want that because then and this gets to your next question.

Michael Mina 

Then, if we can have our immunity so active and create a fever response, which helps suppress the virus, create congestion helps clear the virus, things like that. Maybe we get to a point where we have a good enough immune system that the virus doesn’t win that tug of war, the virus never grows so high that it turns a rapid test positive, and we never become highly infectious. That would be the best outcome over the long term. And our immune system is there to help with that. The question you just asked is a really good one to clarify. What is the relationship between symptoms, and as a test mean, you’re contagious are not contagious. I look at it this way. To be particularly infectious, you need to have a lot of virus in general, although as we have more and more infectious virions with the sub variants, you need perhaps less and less amount of virus to still be infectious. But nevertheless, you need a good amount of virus to be able to infect other people. And you also need a very similar amount of virus to turn a rapid antigen test positive. And study after study have continued to show very high correlation between these self-tests and culturable amounts of virus, meaning can you take a swab out of somebody’s nose and put it on a petri-dish in a lab and see that it actually has live viable virus that could have potentially infected another person, there’s a very high correlation between the two. And in general, what we see is when people become infectious, they might become infectious 12 hours before a rapid test turns positive, the period of time when they’re most infectious, the vast majority of the time they’re infectious, the rapid test will be positive. And then the rapid tests will generally turn negative within a day or so on either side of no longer having culturable virus. So it’s actually a very, very good reflection of when your infectious is these rapid tests.

Andy Slavitt 

Got it. So if you had the wisdom, in perfect timing to take a rapid antigen test at the exact right moment, and continue taking it until it became negative, what I hear you saying is, you might face a half a day to a day on either end, where you could be infectious during a negative result, but that you have in the main otherwise, the correspondence is pretty tight, you got a positive test, you’re infectious, you have a negative test, you’re not infectious. That’s right.

Michael Mina  16:07

And it really comes down to so a lot of people, we’ve decided to put a lot of weight, and a lot of focus on those early hours. But that’s almost, it’s a misconception because people think that of course, they must be testing at the earliest hours of the infection when it’s just on its way up. But it’s really just a very small window of time. And so yes, there’s going to be some people who if you test and you find that you’re negative, maybe you’re in between, you’re just on the way up, and you haven’t yet tested positive. If you test the next day, you’ll probably be positive. But that’s a really short window of time, the vast majority of the time that you are positive and that you are infectious. These rapid tests are really good because they give you an immediate result that says yes, you’re infectious right now, don’t go see Mom, don’t go to the nursing home, you know, don’t go to church, whatever it might be, you are infectious, you should you should take the appropriate steps, there is going to be a 12 hour window, for example, at the beginning that you might be a low level of infectiousness, and the test hasn’t yet turns pop, turn positive. And then on the back end, there might be a 12 to 24 hour window of time, where you might no longer be infectious. And you are still remaining positive for a very short window of time on the rapid test. And that’s just because the viral factory in your body has to get a chance to kind of turn off turned down. And but 12 hours, that’s a pretty good window where it’s just kind of a washout period to then allow you to kind of reenter back into society.

Andy Slavitt  18:05

So we live in this world where we know we’re living alongside the virus, it at least as for now, you know, what are the best things we could do, we have the best tools we have just knowing whether or not we’re infectious? Because we want to do things like travel, see our families, see our kids, see our grandparents, go out to the occasional dinner or to the occasional movie. And so we’re going to test. Patrice, can you talk about kind of some of the use cases that that we’re seeing travel, maybe your kids are coming home from college, you’re going to visit somebody, and how to incorporate testing, and people should be incorporated testing into this part of their life.

Patrice Harris 

You know, Andy, I’ve been thinking a lot about testing and the fact that, you know, testing is just foundational as far as I’m concerned because it allows us to act right and we can act in in many ways it gives us information. And the use cases I think are myriad. Let’s start with travel. There are people we know now and I have some international trips planned and we know currently the CDC requires a negative test for re-entry into the United States. But I hear from so many colleagues and friends who are traveling domestically and want to know whether or not they should go to a meeting or go to visit family and friends if you know whether or not they are positive and so they do so not only to meet regulatory requirements, but also because they are just not interested in spreading the disease or not interested in traveling and being sick. So, travel is certainly a use case. From the very beginning. My father just turned 87 and he was living in a senior residents, and I remember early on, it was important for me to know my status before I went, not only because I did not want to infect my dad, but I knew he was living in a facility where there are a lot of seniors and we know that seniors are high risk.

Andy Slavitt  20:18

So let’s go say you’re going to visit your dad on a Thursday. When do you take the rapid antigen test to see your status?

Patrice Harris

Well, I think is individual and Michael might talk about specific windows of time whether or not you’ve been around other people, for instance, I just came from San Diego. So I knew I was at higher risk, I was on a plane, I was around other people. And so I tested as soon as I got back home, then I will test a couple of days, before going to visit my dad now I am able to do that. So again, it depends on the activities that I’ve recently been involved in.

Andy Slavitt

So, 2 days before would be your protocol. And, Michael, if you were, you know, our 20 year old was coming to visit us. And he’s in college and around all kinds of kids that all kinds of people, if he’s coming home to visit us, when should we tell him to test to keep us from getting infected? When he gets here two days before? What’s the best answer?

Michael Mina 

The most informative test, the absolute most informative test is the one used right before the thing you’re trying to do. So if he’s coming to visit, and you’re saying, look, we need to make sure that we’re not going to get infected. Frankly, the best test is the one that’s used right before he walks through the door. And there needs to be some expectation. So for example, if he flew home, and it was around a lot of people, party last night, whatever might be, you know, he comes in and that day, his negative tests right beforehand. But I would say there’s a very good chance you might have gotten exposed in transit, for example, so you probably want to test, you know, again, if he’s got no symptoms, two days later, perhaps you know, the two days after that, if you’d been really careful. And by that point, again, like once you’re four or five days post potential exposure, you’re very unlikely to turn positive if you’re going to, and, but the one right before the event is the most informative one, doing a test three days before, doesn’t give you any more information than five minutes before. But certainly, if it’s an extended stay, then then two days into the stay as well. If you don’t know if you’ve been exposed, but you just want to take precautions.

Andy Slavitt  22:36

Got it. So, Patrice is gonna say with her dad, or dad’s gonna come stay with her visit her for a week, the first test is won’t necessarily be enough if she wants to be very careful. you’d recommend another test two days later. And if she’s still negative, she should feel pretty good. Yes. I want to talk about what happens now if she tests positive. And Patrice, I want to start with you. It’s physician issue you’ve thought this through. And I want to get into a few minutes to […] he does, but I want to just lay […] groundwork is perfectly laid first. So somebody tests positive. And they now know that there’s these highly effective therapies out there, including one that’s most effective at least today. Called Paxlovid. Under what situations in what circumstances should people think that getting a Paxlovid treatment is right for them?

Patrice Harris 

We know that right now. Certainly those who are at higher risk for developing severe disease, hospitalization, or high risk to die from Covid should absolutely consider Paxlovid. Consider one of these oral medications. They are approved for anyone 12 and over and of course, we know high risk over 65, if you have a chronic medical condition, if you are immunocompromised. And so, I encourage everyone who tests positive, to contact their primary care doctor or health professional to be evaluated, to see if they meet the qualifications for this treatment that can again prevent a progression from severe disease and death. What I want to make sure people hear is that you know we had at the very beginning of lack of equitable access to testing. And we want to make sure we highlight opportunities for treatment for Covid and make sure that there’s equitable access to that testing. So we don’t want people to have to worry about, do I meet the criteria? I would say that if you test positive use whatever our to read these are available to get evaluated. We know that speed is of the essence and all of us do this, we wait, maybe I’ll feel better. I’m not sure I can’t get to the doctor today. But speed is of the essence here because you have to take this medication is effective when you take it within five days of symptom onset. And of course, the earlier in the course of the disease, the better. So that is the key take home message as early in the disease process. As soon after you test positive as possible, please get evaluated for this medication.

Andy Slavitt 

But that’s not fair Patrice, because I’m a procrastinator, which is not fair to me.

Patrice Harris 

Most of us are procrastinators. And that that is, you know why we want to get the word out because we do wait, we wait, we have something else to do. We’re not feeling maybe I’ll feel better. And I think that’s a shift in our thinking. You know, Andy, the same thing is the case with Tamiflu, right? For flu, but all of us wait, but I think the take home message is don’t wait. Because if you are at high risk, you know, the consequences are dire. And here’s a medication that’s highly effective. We want everyone who’s eligible to be able to get it.

Andy Slavitt  26:12

One of the greatest tools of survival. And at least in my case, and people I know has been marriage. Present, I have gotten someone who tells me hey, dummy, don’t wait. Take the test, go to the doctor. Michael, tell us about how what we know about Paxlovid. How it’s working. It’s been under EUA. Now for a number of months. It first it was just at low volumes. Now there’s a lot of volume, what are we what are we learning about whether its effectiveness access the time works, how well it works, whether it bounces back how it keeps people out of the hospital?

Michael Mina 

Yeah, so certainly the data on Paxlovid continues to look really good, especially from the metric of our people not going to the hospital. Paxlovid is I look at it as one of the game changing tools that we have in this pandemic, one of the things that actually enables us as a species to start moving into what we might call, some people are calling it an endemic phase, I think that kind of conflates two different issues, but a virus that we can start to live amongst. And that’s where once we have a treatment that is going to keep those who do get infected and do become symptomatic out of the hospital and away from the most severe consequences, including those consequences of long Covid, then we start having a tool that actually allows us to change and reconsider the whole risk calculus of this pandemic. So, I look at a drug like packs limit, which is you know, in the trials was 88% or 90% effective to keep vulnerable individuals out of the hospital and those were notably unvaccinated individuals, we can expect that the mechanism of action is orthogonal to vaccines, meaning if somebody’s going to get sick and still go to the hospital, even though they’re vaccinated, the drug is still like almost in all accords going to work for that person as well. There’s not going to be some random interaction between the vaccine and that kind of makes this drug work less well. So we know that it’s probably going to work for all shapes and sizes of people all vaccination status is to keep those who would otherwise end up in the hospital out at very high rates. There’s been a lot of concern recently in the media, and especially in social media, around rebound after Paxlovid. And that’s certainly a consideration that we are actually working on here at eMed running a clinical trial to look at Paxlovid rebound using our platform. And we have to understand how frequently does that occur? Is it associated with severe disease. So far, what we have been able to glean from anecdotes and media reports, things like that is that people don’t seem to be going to the hospital if they have rebound. And this probably makes sense. It’s because people if you’re having rebound, you’re able to kind of defeat the virus with the help of the drug. And then what happens is few days later to a week later, so sometimes the virus comes back. And ideally, you’ve already had some priming of your immune response. And so it’s going to still do a good job at getting immunity is still gonna be able to ramp up eventually and stop you from the most severe consequences. So, I think that in general, the drug despite rebound, and we will figure out eventually how frequently that happens is still keeping people out of the hospital.

Andy Slavitt 

Am I wrong, too? I think this distinction rebounded something that they clearly people are starting to learn about. But I have yet to see any data which shows me that this is happening in really significant numbers. And in fact, some of the data that I have I’ve seen which has not been double blinded, verified studies, but it’s been still pretty reputable have still been, you know, in the kind of single digit range. Is that your experience?

Michael Mina  30:14

Well, that certainly the experience that you’re having of not having any good data is absolutely the case there is no, this is why we’re going down the road to actually study this, right now we’re starting the trial very, very soon. We need the data we need. And it really drives home the message, something that I’ve been trying to do since I was at Harvard, still trying to do it here at eMed is we need systems in the public health world and in the clinical world, that are constantly measuring these things so that when an aberration does occur, we don’t have to wait to start whole new trials and wait months to get results that we say let’s look back at the data that we had from the last couple of months and see if this is really an issue or if this is just social media buzz.

Patrice Harris 

And Andy yet you know something that someone that we know very well, I used to say this when we were having conversations in DC, but the plural of anecdote is not data, And so that’s been the unfortunate thing, because I don’t want people certainly want people to be informed. And this is something we should know more about and gather the data on. But, you know, when it gets the social media buzz, as Michael mentioned, then people are less. They’re more hesitant to perhaps consider pecks, low bid, and so certainly something we should think about. But hopefully, people are informed and it does not deter them from at least being evaluated for their appropriateness for Paxlovid.

Andy Slavitt  32:09

Patrice, I want to get into you and you are a for people who know public health, public health policy, who know Washington, DC, clinical immunity, community, you’re the leader of the American Medical Association, someone which is an extremely prominent role, but a physician, but you started this company called eMed. And then for some reason you hired Michael, which we could talk about when Michael’s not around. Why did you start this company? What kind of, I’m just curious what kind of leap it was for you personally, to start a company to become an entrepreneur? And what were you trying to do?

Patrice Harris 

You know, I was thinking about what I wanted to do beyond AMA, you know, what’s my next role, and there have been certain values and areas that have been important to me throughout my career. Mental Health, of course, as a psychiatrist is one of them. Health Equity is another. Another is the intersection between tech and healthcare as a physician, I have had the experience of and frustration around electronic health records, right, I think you probably won’t find very many physicians who have not had that experience. But what that did, it drove the AMA actually and me individually, to again, figure out and think through and think about how to make that intersection, right? Technology is a wonderful thing. But when it comes to health care, it’s more than it’s more important than developing a shiny new object. It’s developing technology, and it’s innovating in the service of improving health outcomes, and not worsening health inequities. And so I wanted, I was looking for opportunities where I could continue to focus on that intersection between health and healthcare and make sure that tech and innovation solve problems, right? And it was more than the shiny new object. And so this opportunity came before me, people were thinking about how to use technology. For early diagnostics. We know you know, the earlier you diagnose a condition, the greater the opportunity for better health outcomes. And so we’re thinking about that in the infectious disease arena, again, early diagnostics and again, what about that earliest of points of care, right? At home, when you first develop a symptom? We’re home can be the first point of care and of course, we know now, that telehealth is just increased exponentially in its use and acceptance, we are seeing emerging care, home health care, people talk about clinics without walls and hospitals, without walls, so I think it’s just such a wonderful opportunity to figure out diagnostics at home in the earliest phase at the earliest onset of symptoms, how we can do that, but do that with integrity, right? Because if people aren’t home, are they doing it correctly. So, we wanted to make sure we developed a platform that enhanced the integrity of early diagnostics at home, again, thinking broadly about infectious disease. But there was a problem that we saw with testing, again, the inequitable access to testing and from the very beginning of the pandemic, and I said, Let’s solve this problem. This could be our first use case. And that’s, that’s where we went.

Andy Slavitt 

Very, very frequently, people reach out to me, and say that their biggest barrier to taking rapid tests is the cost. The people do have access, just to be clear, people do have access to some number of free tests from the government. And insurance coverage is also supposed to kick in, although it can be a bit cumbersome to cover tests. But even with that people, particularly if they have large families, or understanding and listening to you about the frequency at which people are supposed to test cost is an issue. And it’s you and I know from years of work in healthcare poetry’s even $1, even $5 can be enough to just cause someone to not pick up a prescription, or go see a physician, that plus taking a half an hour of work, or half a day of work, which is just makes getting health care and nonstarter for so many. So maybe walk us through in the case of COVID, in the case of testing treat, how someone could go about experiencing this in a new and innovative way.

Michael Mina  36:56

So, the biggest thing that I would, when we look at what are the barriers to people getting treated, I would say there’s a couple but the biggest one is certainly finding your way to a doctor. So we did create test to treat centers that were federally supported.

Andy Slavitt

I just wanted to put a definition on test to treat means that you take a test, it comes back positive, and you get a Paxlovid prescription more or less on the spot. Is that the fair definition?

Michael Mina 

Yes. So that that the only real difference is that instead of having to leave the doctor’s office and go down the road to the pharmacy that the drug is generally brought into the doctor’s office. But unfortunately, that was I think, a little bit misguided in terms of what are the real barriers, I think the real barrier that people have is getting to the doctor in the first place, is getting to get that initial diagnosis that the doctor can do it and take and prescribe them a drug. And so what we’ve been working on very hard is to create a test to treat program that lives within people’s home to not have centers brick and mortar doctor’s offices serve as the test to treat centers or the CVS sort of Minute Clinics be tested treat centers, those should exist still, but to also offer Americans a different solution, which is at home test to treat. And so that if you wake up and have a scratchy throat, you pull it a test, you get on to a telehealth visit with that test, we generate a laboratory report based on that telehealth test visit. And if somebody is positive, we now walk them straight through a medical intake form for a physician to review at no additional cost over that initial laboratory testing process. And get them a prescription of Paxlovid. Or steer them to a different, if they need monoclonal is, for example. And so we’ve tried to really reduce what we view as the major barrier, which is just having to get out of your house and decide to take off of work, just to go see a doctor that comes not just with the cost of time, but it comes with a cost of expensive, you’re still having to pay for the doctor’s visit. And that in that case. So we’ve tried to really encapsulate all of it and say how do we do this for very affordable rates, so that somebody can just have a test in their home and that is their key to the whole test to treat process from their living room sofa.

Andy Slavitt 

This goes back to I think a point Patrice you were making earlier about how important speed is, your part of the reason why I do procrastinate is because oh I gotta go make an appointment and the doctor only has noon available and then I don’t want to wait. There’s a waiting room. So just I might as well not. But if what you’re telling me is I can do this and then I can get a prescription. Is that a same day proposition?

Michael Mina 

That’s right. So the way that it works is you scan the QR code on the box or you go to to start testing. And the other big barrier was exactly what you just said, it’s scheduling it’s having to make an appointment. We don’t require any appointments, it’s on demand, we have enough of scale and capacity so that there’s never really a wait milliseconds usually. So, you scan the box and you’re on with a proctor immediately. They walk you through the whole process, and then within usually an hour or two, from the beginning of the process, you’ll actually have that prescription waiting for you in the pharmacy, sort of on your terms on demand.

Michael Mina 

So, how much will this cost be including the visit the prescription, the test, etc?

Michael Mina  40:33

Yeah, so for the prescription and the test and the lab visit and the doctor’s visit, it costs $25.

Andy Slavitt

So, I know a little bit about health care. And look, I think we can acknowledge $25, isn’t initially affordable by everybody. But, you know, an e-visit on its own is a $60-$70 event and prescription drug, and OpEx love it is comes without cost. But the tests are $18-$20 on their own at a store. But it is interesting that you’re able to take five or six things that individually cost people money, put it together in a package, get it to people, and so it’s worth thinking about. Let me just wrap up because we’re taking a lot of time. You know, we took in questions from people who you both were going to be on the show, I think we got a lot of them answered, when you look at some of the other viruses out on the scene now. Monkey pox, hepatitis? How are we doing? How do you think we’re gonna be doing at getting enough surveillance and enough testing available in these viruses, which seemed to have very different or I knew, I’d say unusual. They’re showing themselves up in unusual ways relative to where they have in the past.

Patrice Harris 

I’m optimistic about lessons learned. But I’m not sure we are going to then act on some of the lessons. And so as we are seeing monkey pox, and there will be other viruses. What we didn’t have in place was a coordinated testing and surveillance infrastructure in this country that I think and by the way, I’m not advocating for this one size fits all, necessarily national system, but I do hope that we think through a broad surveillance and testing infrastructure from wastewater to home testing, right, and a way to make sure there’s coordinated reporting, and it’s real time that we can then act on that. So I’m hoping that that’s a lesson learned. And we do get to a basic testing infrastructure.

Andy Slavitt  42:49

Well, I really appreciate you both coming on. And coming in the bubble today, and making us aware of updated ways we need to be thinking about testing and treating, and how the virus is evolving. And, you know, some of the issues at work, you know, I think you guys are appear to me to be an example of, I call it the next stage of infrastructure building, you know, we’re past the emergency stage of infrastructure building, and running around like chickens with their heads cut off and now saying, let’s take a step back, and what are the sensible ways to serve people to treat people to allow people to live their normal lives. I do want to say Patrice, the two of you make a terrific team. And I know that the rest of your folks do as well. Michael’s been a credible resource. He was a credible resource to me when I was in the federal government. He’s been incredible resource and working with the federal government has been very helpful in informing people and giving people the straight facts, but also just sort of pushing hard. And I think that’s exciting to see the two of you guys together. Appreciate you informing us all today.

Patrice Harris 

Thank you for having us on.

Michael Mina 

Thank you so much.

Patrice Harris 

And appreciate your work, Andy, and I’ve known one that’s for years and just appreciate your work and all of your venues.

Andy Slavitt  44:19

All right. Next up our Friday conversation, what tradeoffs are we willing to make to lower gas prices? So we have Jason Bordoff on the show. He’s the dean of Columbia’s Climate school. And, you know, are we willing to do business with MBS in Saudi Arabia? Are we willing to abandon our environmental goals and start drilling? Are we willing to get rid of the gas tax? What is it that we’re willing to do? How do our principles around climate policy, global policy, etc. Do they all just disappear overnight when we see gas prices going up? So that’s our Friday show. Monday, Independence Day, Ken Burns, I hope you tune in for that it is a great conversation is the latest documentary. One of many great documentaries he’s done. It’s about Ben Franklin. Ben Franklin actually lost his son, his little boy to smallpox and he had died vaccinated him and he spent a lot of his life then really, really pushing and promoting the idea of vaccinations kind of important when we get vaccines now available to kids zero to five. So that’ll be fun. You know, listen, while you barbecue listen before you barbecue listen after your barbecue Ken Burns is great. And he’s really great. Then on Wednesday, I think one of my very favorite conversations. It’s with Jason Kander, you may remember him from his presidential run, he is sort of had a rocket ship rise, and then a very public conversation we have about when he dealt with […], which was admitting to himself that he had post-traumatic stress disorder and what he did about it. And it’s not just veterans, but he’s a veteran. But it’s not just veterans to deal with this. We have Bill Hanage is going to be on to talk about BA5, and what’s happening to our immunity with B five relative to earlier bouts of COVID. And then a great episode that I think you’re gonna really enjoy with Scott Kirby, who’s the CEO of United Airlines. Like why would I want to listen to that? Okay, get this, we’re going to talk to him about how miserable and expensive it is to travel on airplanes right now. And I can’t imagine all the times you’ve written a letter or want to write a letter to an airline, after your that’s a great experience there. Why don’t you write me that letter? And I will ask Scott, your question live in studio that you can listen to, and we’re going to really get into it. With all the problems with air travel, you just send your question to Give me your questions for an airline CEO. It’s a good opportunity. So lots of good shows for you ahead. And I will talk to you on Friday.


Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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