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Description

Testing remains one of the most confusing elements of the pandemic for many people. In this Toolkit, Andy talks to diagnostics expert Mara Aspinall and immunologist Gigi Gronvall to answer your questions about rapid antigen tests – when people should get tested, how accurate they are, why they’re in short supply, and much more.

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

Follow Mara @MaraAspinall and Gigi @ggronvall on Twitter.

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Check out these resources from today’s episode: 

• Check out the CDC’s Interim Guidance for Antigen Testing for SARS-CoV-2: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-guidelines.html
• Read Gigi’s Clinical Chemistry article titled “COVID-19 Testing and a Path out of the Pandemic”: https://academic.oup.com/clinchem/advance-article/doi/10.1093/clinchem/hvab226/6382305?guestAccessKey=42b74d06-49a8-4972-9183-7583cd3edbc1
• Watch a video of how to take an at-home test, as Gigi suggests, before administering one on yourself: https://www.webmd.com/coronavirus-in-context/video/covid-home-testing
• Find a COVID-19 vaccine site near you: https://www.vaccines.gov/
• Order Andy’s book, Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response: https://us.macmillan.com/books/9781250770165

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia.

For additional resources, information, and a transcript of the episode, visit lemonadamedia.com/show/inthebubble.

Transcript

SPEAKERS

Andy Slavitt, Mara Aspinall, Gigi Gronvall

Andy Slavitt  00:05

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. So let’s take a step back and spend a second on the outlook. And what we have to look forward to always unpredictable in the short term. But we had, I think one of the most fascinating episodes. We’ve had this season with Larry Brilliant, last Wednesday. And if you haven’t had a chance to hear that yet, I really encourage it, because he gave, I think, some perspective on what’s coming up in the next couple of years. And how these things tend to happen and tend to play out. And he was not all sanguine, you know, he has a lot of concerns about this pathogen, and what could happen with it. But he also has, I think, some really good words of wisdom about how we think of things going forward. Now, one of Larry’s points was, you know, this is a five-year exercise. And then you know, beyond that we’ve got some level of COVID and we have other certain pathogens and diseases out there.

Andy Slavitt  03:01

And so interesting, and it got me thinking about, like, how should we be comporting ourselves? I think we’ve been sort of a bit schizophrenic going from this is really serious. And this is scary to hey, maybe it’s over with vaccinations to oh, no, it’s not. And it’s scary again, to now, well, things may be getting a little bit better. And, of course, it’s also, as part of all that it’s easy enough to just say, you know what, I’m just gonna stop paying attention, because I don’t know how to feel. And I’m just gonna sort of take what comes and that’s sort of a natural response. And if you’re like me, you probably have all those responses at various points in the day. But I think there’s some zone which I would describe as kind of confidence but not complacency, confidence that we’re going to be okay, confidence that life can go on, that kids can go to school, that teams can play sports, and people can go to college, but not complacency, in the sense that people are still dying, and people will still die from this. Even if we get to numbers like quote unquote, the flu, like everybody suggests, which is, you know, about 60,000 deaths a year that’s a lot of people, I mean 60,000 people a year dying in nursing homes, used to horrify me before COVID. It should still horrify me.

Andy Slavitt  04:21

And you know, not complacent also means that we’re going to be periods of time over time where we’re going to be wearing masks where we’re going to be getting vaccination updates, where we’re going to be avoiding certain things and activities, and it’s going to be very conscious for us. And I think we also can’t be complacent in that for some people. It’s much more inescapable than for others. Some of us have the luxury of being able to forget about it for long periods of time, other people don’t because their nurses, their doctors. You have family members that are working in exposure to lots of people in settings that don’t have great ventilation and possibly also people who are immunocompromised, and in some other way exposed. So, you know, this sort of mixed feeling of, you know, I can be increasingly confident about the things in my life. And yet, I can’t be complacent that this is ever present here. Is that really interesting balancing act, and I’m not sure that we can all pull it off at all times. But I do think it’s important.

Andy Slavitt

I’ve always been a proponent of saying we can’t defer the things in our lives that give us meaning, our family, our friends, a good joke every now and then, our sports team, not the Milwaukee Bucks, but other sports teams. That was a direct attack on our executive producer, Kryssy Pease. Who lives in Milwaukee Bucks. So I think that’s important in today’s episode, in the context is, I think, really important, because it’s something that I suspect is going to be part of the landscape for a long, long time. And that’s rapid at home tests. And there’s lots of questions about rapid at home tests. But one thing is clear that we can give ourselves an increased feeling of safety. When we make decisions, where we’re informed by whether or not we have COVID. And whether or not we’re infectious. And so we have two experts on to answer your questions in the today’s toolkit. I love doing these toolkit episodes, love them. People, I think get a lot out of them. I you know, it’s one of those true helper episodes where we just aim to answer people’s questions, and then please, and also, there’s always opportunities for good dad jokes in the middle of these episodes. For some reason, toolkit episodes lend themselves to horrible dad jokes.

Andy Slavitt  06:45

So, you might get a couple of those creeping in. But I want you to know that if you don’t like the jokes, they weren’t my fault, they were forced out of me by the context of the conversation. But in truth, I think you’ll also learn as I did from this, some very surprising things about like, how these things work, and what constitutes a good test and a bad test and when to use them. So some really not intuitive and helpful things. And then we finish up by talking about the elephant in the room, which is the major shortage. And you’ll see that one of the guests and I have been working with the White House directly on trying to how to address that issue. So that you get a little bit of inside baseball as well. It’s kind of all the things that make in the bubble episodes good, when indeed they’re good. You’ll probably notice they’re not all perfect. But this one’s a good one. Okay, here we go.

Andy Slavitt 

Welcome officially to the episode about sticking things up your nose. Yes, I’m talking about rapid testing, which is an ongoing and fundamentally important part of COVID today, and probably living with COVID in the future. And we have lots of questions from you for this toolkit. And so we’re going to ask this question is a two really wonderful people, you’ll hear them as me refer to them by their first names, unless they tell me otherwise, then I can find a more professional way to relate to them. But Mara Aspinall, someone who I’ve just recently gotten to know because we’ve been on some phone calls, with the White House together, talking about rapid testing. She’s a professor of practice at biomedical diagnostics at Arizona State University. She also advises the Rockefeller Foundation; you may have heard our episode with the CEO of the Rockefeller Foundation earlier. So really incredible resource, one of the country’s best resources, when it comes to understanding these tests and how they work. And Gigi Gronvall, who is at Johns Hopkins, and is a senior scholar and an associate professor in the Department of Environmental and environmental health and engineering. I can’t even talk today at Hopkins, Bloomberg School of Public Health. Thank you both for being here and playing this sticking things up your nose game with us. By the way. I want to start with this. That that one long, swab, the one that you had to stick all the way, like deep into your nose. That is painful, isn’t it?

Gigi Gronvall  09:15

Yeah. But I have not heard of any tests that that people routinely get any more that needs to needs that, everything out of it. Yeah, no brain swabs.

Andy Slavitt

Thank god. Oh, that was awful. I actually had to do one of those the other day, when I was out of the country coming back into the country. And all they had were those long swabs and I experienced it for the first time. Man. That’s why I’ve got to know me pretty well.

Mara Aspinall 

Yeah, although it’s important to recognize that some of the kits still have a long swamp, but it only needs to go into the front of your nose. So just because has a long swab doesn’t mean you need it to tickle your brain.

Andy Slavitt 

Okay, well, I wish someone would have told the person who stuck it in my nose knows that. But thank you. Let’s start with just the basic definition and understanding because there’s so many different types of tests, and maybe Gigi you can start by helping people understand what the difference is between an antigen test, a rapid test, a rapid antigen test, a saliva test, a PCR test, which I think many folks have heard of, help people just with the definition of what we’re talking about.

Gigi Gronvall  10:29

Sure, so there are different there, it’s a confusing topic, because there are lots of different kinds of tests and the words, you know, rapid apply to multiple different kinds of tests. So, there are tests that look for a genetic material of the virus, and then there’s, and that’s what people are usually think of the PCR tests that you had to send to a lab. And then there’s the faster tests. And these are usually rapid antigen tests, which look for viral proteins. And so they are and they take about 20 or 30 minutes, it gets a little bit more complicated, because there are some rapid tests that look for genetic material of the virus. But those two basic kinds of tests are what most people are going to experience.

Andy Slavitt 

Got it. And so if you’re going into a Walgreens or CVS, or going out to Amazon to buy a rapid home test, those would be antigen tests, not PCR test, is that correct?

Gigi Gronvall

Right, if you’re doing it at home, like an Abbott, BinaxNOW test or you know those are going to be rapid antigen tests, and I take about 20 minutes, 20-30 minutes to read, and to determine if you have COVID or not.

Andy Slavitt 

Okay, so maybe let’s start out and maybe I go to you, Mara. Can you tell folks if they use a rapid at home antigen test, what the differences are, besides the fact that one is looking for a protein and one is looking for genetic material, but what are the differences and how they should interpret their results? What are the differences in what you’re learning about? And what are the pros and cons of those tests?

Mara Aspinall  12:14

Sure. So as Gigi said, the PCR test is looking for the genetic material, virtually all of those tests are completed in a central laboratory. So you can take your sample at home. But the analysis is done in a lab. So those take 24 to 48. And sometimes 72 hours to get back to you. They are highly sensitive. Meaning if you even have a little bit of virus, it’s going to say you’re positive, they’re highly specific, as well. So they are very useful and very accurate. The antigen tests are typically now done at home with the small kits, they look like pregnancy tests, but instead of testing your urine, you’re testing fluid from your nose or material from your nose, we’ll talk about that I’m sure. And those tests are less sensitive. So there is a small chance that you might get a false negative, and an even smaller chance that you might get a false positive. But you get those results very quickly when you want and you do that entire process yourself in your home.

Andy Slavitt 

Okay, so the advantages sound like it’s quicker, you can do it yourself. You can do it at home. You didn’t say this, but I think the application is probably cheaper than something you’ve got to send away to a central lab and have people look at it.

Mara Aspinall 

Right now, the tests are anywhere from $15 to $25, either for one or two tests in a box, those rapid antigen tests that you get at home. If you’re getting a home collection kit, where you’re collecting at home and sending it to a lab, those are significantly more expensive, typically $50 to $100. But the challenge here is many of those PCR tests that are done in a community center are still paid for by the federal or state government. So you have people saying that I could go to a central location and my test is paid for, or I can buy it out of my own pocket at the Walmart or Kroger’s or target. And that’s why people sometimes talk about the antigen test being more expensive, even though dollars for dollars less.

Andy Slavitt  14:38

Good subtlety explained. Now, I’m gonna ask you a trick question, which I know you know the answer to, but it’s tricks down in question, which is, is more accurate necessarily mean better. So you said that a PCR test was more accurate. In other words, if you have any amount of the virus in you, it will be to detect it and say you’re positive, whereas some people call that the gold standard and implies that it’s better. Then there’s this rapid antigen test, which sometimes you might have some of the virus and it may not detect it, which sounds worse. But is it worse?

Mara Aspinall 

It’s a great question and a really important nuance. And my answer is, it’s not worse, a test of any type is better than no test, first of all. And second of all, what antigen tests do is to see whether you have enough protein shedding in your body to be infectious. So if you’re taking that test before you go visit your great grandma, or high-risk people, the antigen tests are not only good enough, they are strong, and they work well. And you get that result very quickly. The downside of the PCR being, quote, more accurate and more sensitive. If you’re like my cousin in New York, he tested positive with a PCR test for 44 days after he had recovered from COVID. That was too sensitive and not useful.

Andy Slavitt  16:10

And just to give us an idea of those 44 days, approximately, how many days would he have been infectious for?

Gigi Gronvall 

Less than 10.

Mara Aspinall 

I would say the first ten, exactly.

Andy Slavitt 

Okay. So I think this is really important because a lot of the questions that have come in are comparing these numbers 90%, effective versus 60%, effective, 70% effective, etc. And what you just said, when you could substitute the word accurate for effective is that whether or not there’s a trace of the virus present isn’t necessarily the most important question. What is the most important question is, am I infectious? Because if I don’t feel sick, and I can’t spread it, then who knows if that tree really fell in the woods, right?

Andy Slavitt  19:28

Let’s go to our first voicemail. This one comes from Simon.

Simon 

Hi Andy. This is Simon from Baltimore, Maryland. Thank you for all the work you’ve done and continue to do to get us all through this pandemic. My question is on the accuracy of rapid tests. I’ve seen some tweets and other information out there that they’re up to 95% accurate, but others suggest that they may only be 50% accurate so What’s the real answer here? And how do we use that information to best apply rapid tests to the broader population? Thanks again.

Andy Slavitt  20:13

Okay, so it’s a home team question Gigi. And we already heard kind of Mara, talk a little bit about this. How would you enter Simon’s question?

Gigi Gronvall 

Sure, I’ll just build on what Mara said, because it’s, you know, what happens when you get infected is you have this virus, it’s making a gazillion copies of itself in your notes, right? And in the rest of your respiratory tract. And the beginning stages, because the PCR test has this amplification step, it’s able to detect really weak signals. So if you had perfect testing, the whole time, you were getting infected, those beginning stages of you getting infected, the virus is making copies of itself, this, the PCR test would detect it faster than the rapid antigen test, the rapid antigen test doesn’t have this like amplification step, it can’t see those very, very weak signals. So but you’re not infectious at those really early stages, either. It’s only when you have a lot of virus in your nose, then you have a lot of virus in the air around your nose, and you and other people can breathe it in that you know you have a problem. And that is where the rapid engine test is really good at detecting when somebody is, you know, has COVID. And so you know, the accuracy of the test goes up and down, depending on where you are in this infectious cycle. And so when you’re, when you’ve got a ton of virus in your nose, in your eye with the most danger to those around you, that is when the, the rapid antigen test and the PCR test are, you know, almost as good as each other in detecting the virus is just as you know what the curves the tails of the curve, that the PCR test is much, much better at detecting COVID.

Andy Slavitt

Gigi, are we able to put a number on it, if we were measuring how accurate the rapid antigen test is, at detecting your virus during the time period when you’re most infectious. Is there a percentage that we would put on that? How would we look at that?

Gigi Gronvall  22:16

Well, the studies that I that have been done have found them to be comparable when people are infectious. And so that is, you know, the highest level of you know, in the high 90s of accuracy. But that’s not the entire time that you would be infectious. Like Mark was saying you will test positive for PCR potentially weeks after you’re recovered.

Andy Slavitt

So maybe this is the explanation for Simon, when he says some people say they’re 95% accurate. Some people say they’re 50% accurate. It sounds Mara like they could both be right. Depending on what you’re measuring. If you’re measuring during the most important period, it may be that that 95% sounds right. If you’re measuring it during perhaps a broader period of time, then maybe that 50% number could be closer to right. Is that the right way to look at it?

Mara Aspinall 

I think that that’s exactly right. And some of the terms people use are positive predictive value. If you have a positive result, what’s the probability that it’s true? That’s 96%-97%. negative predictive value. If you get a negative, what’s the probability that you’re truly negative 95 96%. So the rapid antigen tests are pretty close to as good as we can get on infectiousness, but they’re not quite as perfect on being infected.

Andy Slavitt 

Got it. So someone has a question that Lynn asked the question, wondering, she’s been told that tests also show positive results. If people have multiple infections like the flu and strep. That seems pretty easy to dispense with. Is that true or not?

Mara Aspinall 

It is not true. Rapid antigen PCR do not show positive for the flu or strep or anything else. I will have a little bit of a trivia point here. They will show if you have SARS‐CoV‐1 but I don’t think SARS‐CoV‐1 is circulating in the US or anywhere else in the world, so you can feel confident that the test is only testing for COVID-19.

Gigi Gronvall  24:21

If that’s the case, you should definitely isolate and not be around other people, too.

Andy Slavitt 

It’s a good trivia, but someone’s lying to you, Lynn. Okay, here’s an email from Erica. So my eight-year-old son tested positive for COVID through a Malin PCR test. While we were in the UK this summer, as rapid tests are so easy to get there. We had a package of seven tests and he tested negative on everyone. How could that be? It makes me doubt the benefit of rapid tests. Okay, Mara, this sounds like our detective work can give Erica the answer here.

Mara Aspinall 

Absolutely. So first, let me say this a lot. We don’t know about the progress of infection in kids at the stage. And I will comment that pre-Delta kids seem to have a cloak of invincibility; they were not getting sick. Now in the Delta world, kids seem to have a higher risk of developing COVID. Even though the vast majority of the cases were mild, I think no offense to the folks in the UK, my husband is from the UK. But it’s important to know what kind of rapid tests you use, there some more much less reliable than the ones in the US and have been pulled off the market. To be fair, the newer tests are much higher sensitivity than the older ones, and the earlier ones. So we’ve talked about rapid tests, and we’ve talked about the challenges here, I think it’s quite possible that your son had a mild case was not at any point with those seven tests, shedding enough virus to be detected by an antigen test. And that means it was too mild to transmit to others.

Andy Slavitt  26:08

So here’s what it sounds like we’re saying, Erica, your facts are right. But your conclusion is wrong. In the following sense that you concluded that made you doubt the benefit of rapid tests? And of course, why wouldn’t it because you get a positive from one which is supposedly the gold standard and negative from others. But it may turn out that it’s actually the PCR that was less relevant. And that what you really wanted to know, could your son play with other kids? Could your son, infect other people, unknowingly? And the fact is that what we’re hearing from our experts today, is that the antigen test giving you a no was in fact, the most important answer. Okay, we’ve got an email from Colleen, what’s the best next step after a positive test result in somebody who’s asymptomatic? Should you then confirm it with a PCR test? And then if that PCR test is negative, can we trust that the positive antigen test was a false positive? So this, again, is a question from Colleen under the premise that assumes that you’re going to get more false positives out of an antigen test, rather than what we know, which is that you’re less likely to get a positive result. But let’s go back to the core of that question, Gigi, which is, what’s the right best step when someone gets a positive from an antigen tests? What should they do next?

Gigi Gronvall 

So the first thing that I would do is, you know, it depends a little bit on the circumstances. So I mean, I think if you know, if the person test positive with the rapid antigen tests, and there’s no reason to believe that there’s any problem with the test, or how you did the test, then I would you know, if somebody was asymptomatic, that’s why the CDC recommends following up with PCR. So you know, but I would assume that if you tested positive right away, that you should isolate, you know, I would assume that it’s correct. And then if it turns out that you know, you’re asymptomatic, you want to follow up test, you don’t want to quarantine for 10 days, you want a confirmation, there’s nothing stopping you from getting a follow up PCR test. And, you know, there are going to be cases in the margins where you’re going to have these false results. But for most people, that’s just not the case. You know, it’s going to be the unusual ones that you hear about for sure. And that, you know, people will remember and tell others around them. But for most people that positive on the rapid antigen test is, you know, a true positive and they should not be around other people, especially unvaccinated people.

Andy Slavitt 

And Gigi there’s that second test in the box, if I get a positive, I’d be staring at that second test going. You know, maybe I should take that second test, just to be sure. Is that a bad idea?

Gigi Gronvall 

I mean, I think that’s exactly what I would do. But let me tell you what the box says that you should do so the box it tells you that you should take the test no sooner than 36 hours later. And the tests are meant to provide greater accuracy, especially if you’re asymptomatic. And that is why you have those two tests. But I probably you know, human nature being what it is, I probably would you know, use several tests to get that confirmation before I believed it. But it also depends a little bit on how available the tests either as well. I mean two tests per 25 bucks. You know, your curiosity could be stated pretty quickly.

Andy Slavitt 

So let me tell you about the story. True story. The year is 1997. My wife and I got married at 1996 and Lana says to me, hey, I think that I might be pregnant. So we go to the drugstore, very excitedly, buy a whole pregnancy test. And there’s two sticks in that little box. So I’m very eager. She’s very eager. She goes into the bathroom, she comes out. And a minute later she shows it to me. And it’s got a pink little line, which shows that she’s pregnant. And what did I say? Take another one. Take another one. How do we know it’s not lying to us? That’s how crazy I am.

Andy Slavitt 

We talked about accuracy these tests. And that’s tricky enough. But I think you’ve done a great job explaining how the accuracy works and what to do in the situations where you get a positive or negative result. Now, we had a number of questions for people about how in what situations they should be using these tests. So here’s a question for Randy. My wife and I are wondering how best to use the fast test. I am retired and she works at the University of Massachusetts Amherst. We’re both fully vaccinated and all of our grown kids as well as our close friends are. I see a lot of potential uses for them with our families for school aged kids. Not sure how to use for us, maybe traveling. We are very careful. Can you help us? So, Mara will just say what do you say are some of the good uses that Randy and others could think about? If they have a story of rapid antigen tests.

Mara Aspinall  34:59

Well first, it’s great if they have a store of them right now. But you know, it’s a personal decision. For me, whenever I go out, I went to a baseball game a few weeks ago. And I did a test three days later. So I was out and amongst people, even though it was mostly outside, so I think that the best time to do it is in that two-to-three-day window. After you have gone out with a lot of people, and especially before you’re going to say, a whole another group of people. I think the biggest mistake people make when traveling is they’re going to go visit their family, they get off the plane, and they immediately take a test, because they’re worried about the plane. There is no test that’s going to be accurate, sensitive, specific in any way useful. Right after you get off that plane. You need to wait at least two days even in Delta, that’s the best way to use these tests.

Andy Slavitt 

Okay, so you wait two days afterwards. It’s interesting because you went to the baseball game, but you didn’t take a test on the way in. You took one on the way out, some people would have said they would take one on the way. And now is that because you already knew based upon the last time you took a test and your prior exposure that you were you were still negative?

Mara Aspinall  36:19

In my case, yes. I hadn’t been out of the house for 10 days.

Andy Slavitt

Good. Okay. So that makes sense that you wait two days, then you take a test. Now, if Randy is inviting people over to his house for Thanksgiving dinner? Should Randy get people take a rapid antigen test before coming over and exclude them if they test positive?

Mara Aspinall  36:45

Well, I think first of all, we haven’t talked a lot about vaccination. And I think that that’s an important consideration here. If you have a fully vaccinated group of people that is generally being careful, then one rapid antigen test, a couple of days before you get together at Thanksgiving would be belts and suspenders. If you’ve got unvaccinated people, I think you need to be much more aggressive either to test beforehand and possibly test twice beforehand as the box says, to ensure that you’re not introducing that. So whether it’s unvaccinated people coming or unvaccinated people and in Randy’s house it’s a different protocol with a different level of concern.

Gigi Gronvall

And that’s not the only thing you should be doing too, I mean, you should also in addition to testing and vaccinating, whoever’s eligible, you know, you could do a lot to increase ventilation and wherever you are, either have things outside or increase you know, the heppa filtration inside and you know, make the air healthier to breathe.

Andy Slavitt

Gigi we give no extra credit. Sorry, your extra credit points are not existed. No, thank you, that’s a good point. Now, I per one, Mara am terrible at analogies. So I have never in my entire life worn a belt and suspenders at the same time. I think it’s a foolish look, I think you look crazy. So are you saying that being vaccinated, having this test is a good idea or a bad idea, and I’m being silly, but what I’m really trying to say is if someone’s vaccinated and careful, and asymptomatic, sometimes taking an antigen test and getting a positive result may give you information when you’re very unlikely to be infectious. And so you may be excluding yourself, for no reason, that would be a bad version about suspenders. A good version about suspenders would be Hey, you didn’t catch it with the belt, your pants are still falling down. So you needed the suspenders.

Mara Aspinall  38:58

I think that’s a perfect analogy, I love analogies. So I do think that the vaccination is the belt, the primary way people keep their pants up, and the suspenders are extra. If you’ve been home for the last two weeks, and you only went on a plane with a mask and you are careful, then you don’t need to test and I think that the disappointment factor is huge, and quite frankly, awkward. If you’re worried about being positive, take the test before you get onto the plane. Planes themselves are actually not a particularly dangerous place to be the way their ventilation works. And so don’t wait till that last minute and then have an unpleasant surprise.

Andy Slavitt 

Great. Okay. Here’s a question from Rick, who’s a doctor. I love this question. He says I get the question can I do a rapid test of my kid with the sniffles and if negative let them go to school all the time. And then he says all the time. Now, aside from the fact that you should always keep your kids home when they’re sick anyway, what’s the sensitivity of the various rapid test? Does this hold up for home use? Do I still need to get a PCR test if negative? I have the answers to these questions, but I think your listeners would benefit. He knows, he’s doing good for our benefit. I see yes, to test us. Then he says love your work. Okay. He redeemed himself.

Gigi Gronvall  40:30

Well, I think it depends a little bit on and the procedure, the school. This is why I mean, the kind of under question, the question he’s not asking in there is, can you trust to everybody else to follow the procedure and to, you know, not send their sick kid to school? I would say the answer to that is absolutely not. And so you do need I think that’s why it’s great to have testing programs in schools. So you have pooled testing because, you know, people send their kids to school sick all the time. And, and so I think that’s kind of trust but verify approach would be a good one there. But I have used rapid antigen tests a lot for my son who can’t be vaccinated yet. And, you know, because if he has allergies, or whatever does other things that go around, I want to check. And I haven’t ever tried to get them a PCR test where it wasn’t required, like it was required before I sent him to sleepaway camp this summer. But I, you know, I do use the rapid antigen tests more frequently.

Mara Aspinall 

I agree completely with Gigi, but I do think that the fear factor comes in nowadays, we used to send kids to school that were that were definitely sneezing. And I think a lot of people did, but I think that the standard is changing. And there is so much fear that it could be COVID, that if anyone coughs, everybody is scattering. So I think that the hurdle now for sending kids to school is a whole lot lower than it used to be.

Andy Slavitt  42:08

Can we just say, if you’re sick, stay home. We’ll agree to that. If you’re sick, stay home.

Gigi Gronvall 

I mean, I totally agree. I just think that some people, they don’t have alternative arrangements. And so they will go to great lengths to, you know, to be able to go to their job and everything else. So I mean, people have different circumstances. So they will try and game the system. when my kids were in daycare, I learned, they said, you don’t put Tylenol in your breast milk that you send in with the into daycares. Like, oh, my goodness, I never even occurred to me that somebody would do that. But yeah, people go to great lengths to get their kids out of the house.

Andy Slavitt 

So Gigi, I’ve changed my mind, I will give you extra credit for pointing out that people do live in circumstances where sometimes with a little bit of sniffles they can’t afford to stay home from work. So I will go back on my rule of nurture credit. Let’s award Gigi some extra credit. Okay, now Mara might be wondering, how much credit Do I have if JD just got some extra credit? We’ll come back to that. Okay. Next question is from Jodi with I think some very tricky little cases here. One, I’m going to give you all three that relates to taking the BinaxNOW now test. Okay. One, do you have to use both test to be effective, two, should, the whole family get tested before visiting other members of a larger family? Or can one member of each family get tested and assume that the rest of the family has the same status between the families, all the adults are vaccinated and none of the children are eligible to be vaccinated. And then finally, five of six children will be vaccinated when they’re eligible. The baby of the group is four years old. Should we continue to test once everyone except the four-year-old is vaccinated? Oh boy, this is a complicated question from Jody.

Mara Aspinall  44:02

I’ll start here, do you have to use both tests to be effective, I don’t want to get into trouble with the FDA. The box says use them for 3 out of 5 of the ones on the market. Two of them a loom and […], are going to be single tests so I’m not going to provide advice not to do it. But I know a lot of people are only taking one of those tests and having husband and wife and two kids taking tests each but use that. I will say However, you can be creative to do that. But do read the directions and use the test as directed because then it’s completely useless if you’re not doing it the way it says. Number two, should the whole family get tested before visiting. Personal decision, we do, my kids won’t see me unless I test before I see them. It really depends on where the family has been if everyone’s been home together and never been out, then fine. You can test one or two and not five or six. if everyone’s been going to school and work, I think you got to test everybody. And lastly, five out of six kids should we continue to test probably the answer is yes, but you can be a little bit more lacs about it. As we talked about, maybe just about not suspenders on everybody. If you’re at the point that everybody is four weeks past their vaccinations or two weeks past their last one. Gigi, you’re with me?

Gigi Gronvall

Yeah, I would just add that like these tests are not very hard to use, but they are a lot easier the second time we use it, and so I recommend that you know people check out the, if you have an Abbott test, go to the Abbott website, they have videos there YouTube has videos, just watch a video to see how it’s done. And then you know, it’ll be a lot easier when you do it yourself. There’s instructions. If you find them a little bit confusing, there plenty of other resources to know how to do the test right.

Andy Slavitt  46:08

All right, on three, I want you both to enter at the same time. Do you twirl the swab clockwise or counter clockwise? 1, 2, 3.

Gigi and Mara 

Counter.

Gigi Gronvall 

Are you right-handed?

Mara Aspinall 

I am.

Andy Slavitt

Both of you are counter, I think this is the way we’re going to start identifying each other now. I’m a counter. I’m counter. I also do counter. I don’t know what it is. But yeah, completely counter. Okay. Now from Amy. Hi, Andy, we plan on driving across country in early November with overnights at friends. We have three rapid test kits for each of us. This sounds like one of those math problems. And we’re driving 500 miles. The train coming at us? No, she doesn’t say that. We have three rapid test kits for each of us. Two elderly people and a dog. And we’re only testing humans. I love this question. I don’t know whether we will have received boosters, but we were each double vax to Moderna in early 2021. Should we test her right outside the door of their friends? And also what if the test is positive? We have only planned on testing negative. Okay, so they’re at their friend’s house. They’re at the front door. They got the Q tip. Should they go in counterclockwise right at the door? What do you think?

Gigi Gronvall 

I mean, all tests are a moment in time. And so the moment in time that right before you see people, that is the time when you are most concerned. Are you infectious or are you not?

Andy Slavitt 

So you say yes.

Mara Aspinall

I’m going counter clockwise and as late as possible, but do it in the car. So you’re not actually balancing this thing literally at their front door.

Andy Slavitt 

Okay, and then presuming that they do test positive? I assume they’re sleeping in the car. God help them. All right. Mara, I really want you to work on figuring out how you’re going to get some extra credit to catch up.

Mara Aspinall 

Stressful.

Andy Slavitt 

It is. Now this is supposed to be stressful. Okay, because you know, the prize at the end is just enormous. Jessica, right. Jessica is trying desperately to keep her nine-month-old safe until he could be fully vaccinated. If we only allow vaccinated people to be around him, and we make sure they take rapid tests before […] indoors. How confident can I be that they’re not carrying the virus? Both of my sisters who had respectively the Pfizer and Moderna shots have gotten breakthrough infections. So be very cautious even seeing vaccinated people. What do we think, Mara?

Mara Aspinall 

If Jessica is really concerned, which I fully understand with a nine-month-old, then you do want to have people just like my kids and new grandchild, tests before you see them. It is such a sneaky little virus, and it gets into vaccinated people. So that is the best way to do it. Because the fear of a nine-month-old getting sick is just too much to deal with. So that’s the way to feel comfortable.

Andy Slavitt 

So would you pick up your grandchild if you’d been fully vaccinated, Mara, and if you had just done a test that had shed a negative, would you feel very comfortable picking up your grandchild?

Mara Aspinall 

I did this weekend. I took two tests in 36 hours and picked him up and hugged him.

Andy Slavitt 

Well, you don’t need extra credit you’ve picked up and hugged grandchild. There’s nothing better than that. It just sounds amazing. All right. I’m a physician and I still can’t figure out if I should be checking a PCR test three to five days after travel, or rapid antigen test. I’m worried that PCR is just detecting dead virus, basically a sign of vaccine success. But then the positive test would necessitate a quarantine for my kids and work which I’m not sure would really be needed. Let me ask the question this way. Since I think we’ve established how and in what ways that rapid antigen tests could be much more useful. Mara, is there a situation or what is the situation under which you would recommend a PCR test?

Mara Aspinall  50:25

When you are, have been and going into a very high-risk situation. So for me, the number one place to use a PCR test is going into a hospital for surgery. Taking that test right before you go in, nobody wants to take a risk that you might get a false negative or a false positive, the hospital can do the test very quickly, same day, it really only takes six to eight hours in a lab to do a PCR test. So you’re in that hospital, you’re getting admitted, you’re in the emergency room, you’re going in for elective surgery tomorrow, PCR test is a perfectly appropriate time to do that, you should be able to get a result quickly. And everybody will feel more comfortable that they’re getting the most effective test for that use case.

Andy Slavitt 

Got it.

Gigi Gronvall 

To me, one of the best reasons to use a PCR test is for pooled testing. So having the like my kids classroom get tested once a week, it’s, it’s great to, you know, if there’s a positive case, hopefully you catch it early enough, that you know, they can, they can be isolated. And so I think I’ve seen it work. You know, recently where, you know, there was a kid that was positive in the in the class, we don’t know, when you do the poor testing who it is, you have to follow up with individual testing. But you know, my, my child was in this room with a positive person. And they are all wearing masks and have good air and he did not get infected. So I know it’s an N of one, but I think it was pretty awesome that we were able to limit the infections.

Mara Aspinall  52:10

And I don’t know, Andy, if this is extra credit, but I’ll say there are 32 EUAs for pool testing, and many people don’t know that you can get any […], and these pools are anywhere from two samples going into the same test to 12 going into the same test.

Andy Slavitt

Okay, so final set of questions that were just a few of them. And by the way, you don’t need the extra credit, grandchild. You, Gigi, because I

Gigi Gronvall 

I have a teenager and a preteen I think you went..

Mara Aspinall 

It’s much easier with grandchildren.

Andy Slavitt 

Yes, I think it’s evening out. But I do want you Gigi to tell your kids when you’re off this, this recording that you earned extra credit points, and you expect them to do the same at school. Okay.

Gigi Gronvall 

I’m sure, that’ll work.

Andy Slavitt 

It’ll be helpful. Andy, Andy wants you to get some extra credit, see how that goes over? Okay. Didn’t work with my kids. We’ll see if it works with yours. So I better start really focused on some of this with you, Mara, because of some of the work that you’ve been doing about the availability of tests, and so forth. So some people are frustrated that they’re going into a Walgreens or CVS and are not able to find a test, they’re not able to get enough tests. Or if they if they get a test, they could only maybe get one, can you just start maybe 30,000 feet? All right, and tell us a bit about what’s going on? Why do we have not have enough tests? How many tests are being created? Are there more on the way? How many tests are available, and a little bit about some of the issues in the supply and everybody’s favorite word of the year, the supply chain?

Mara Aspinall 

Sure. I’m going to start out with America has seemed to have fallen in love with rapid tests. When they first came out in April, nobody wanted them they were on shelves, and they were advertisements on TV and nobody wanted to use them. But the combination of Delta, and the reality of the people who are asymptomatic has really changed that. And I think really an acknowledgment amongst Americans that I want what I want when I want it, which says I want that answer right now. And what that changed is this huge run-on rapid antigen tests. In my numbers, something about 125 million tests a month are out there today, and that’s increasing to 200 million. It sounds like a lot. But with people back in school, people back at work. It’s not as many tests as it seems. So what the White House has done, which I wholeheartedly endorse is they are giving these long-term contracts to rapid antigen companies and they are saying to these companies, make tests, we will buy them, and then we will work together to distribute them. So I think we will see a significant increase in tests by December. And then another big increase in tests in Q1 2022.

Andy Slavitt  55:16

Donna says that she paid $25 for a test kit at CVS with two tests in it, says it’s way too expensive. Mara, what are the hopes, are their hopes that the price will continue to come down?

Mara Aspinall 

I have huge hope that the price will come down both because of competition and some government subsidy. The price at Walmart and Target is now $14 for two tests for several of the manufacturers. And I hope with new people coming onto the market, the price should go further down and there should be increased availability.

Andy Slavitt 

Can you speak this is a question that came in from someone who only identified themselves as […] the causes of the bottleneck for creating more tests, and the cost what are the major contributors to the bottlenecks in the supply chain.

Mara Aspinall  56:09

without too much detail, there are seven components of each rabid antigen test. And the two that are causing the bottlenecks are the strip that’s in the middle of that test, like that pregnancy test called nitrocellulose. There are only three manufacturers in the world that make that. And then secondly, the chemicals or reagents that go on to that strip, those could take as much as six months to get enough in a factory to produce these tests. And that’s the challenge back to supply chain.

Andy Slavitt 

And is this being addressed or what’s being done to address these supply chain issues?

Mara Aspinall 

Well, two things, President Biden has said and began to use the defense Protection Act, the DPA and that is critical for some of these areas. Secondly, there are lots of small manufacturers that recognize those market, and they are creating their own supply chain. And thirdly, people are being creative, and not using the exact same process that their competitors are using. So they’re diversifying that supply chain that should give us more availability.

Andy Slavitt 

Let’s try to close on this at least step up a bit from people’s questions. Maybe like eg to just give your final thoughts on kind of how important will rapid antigen tests remained, it feels like in some regards, these tests could become part of our future, you know, even as we’re dealing with much lower levels of disease as sort of a precaution. And are there any future innovations or upcoming innovations that you see changes? You know, how, what will this look like six months from now a year from now? And more? And maybe we’ll start with you, Gigi?

Gigi Gronvall  58:00

Sure. I think something that’s really struck me for this entire pandemic is that people want this information, they really want this information. And we have, the technology has not been there for people, like we expect to have like from our Fitbit and our phone tells us health information. And I hope that this process in this you know, having rapid Ascension tests available and testing available will lead to other tests being available to you know, for flu and for other things that we are going to deal with. So that, you know, testing becomes something that is a little bit more common for people not just for COVID. But for other things, other respiratory nasties that will come our way.

Mara Aspinall 

And I’m gonna start with where Gigi left off. People want information, information is power. Everyone wants to be powerful; you get information when you test. Number two, I go with fast and flexible over slow and sensitive. So that to me puts rapid antigen tests first. But all tests work. And if you need a test, don’t get picky, get whatever tests you can get. And thirdly, six months, I hope a year from now, I think we’re going to be doing many more surveillance tests, testing the air, testing scratch and sniff testing our poop that they’re doing in dorms in the universities to look for outbreak control, not specific individuals having tests. Once we get to that point of the pandemic, it’s starting to end.

Andy Slavitt 

Great. Well, you guys have been just terrific. So appreciative. It was fun. And I think answered a lot of questions that maybe I would sum up what we’ve heard today by saying these are incredibly useful. The numbers could sometimes be deceiving. The prices will continue to drop, it’ll make it more useful, there’ll be more available. That’ll make The more useful, they are useful at a variety of circumstances. But certainly after exposure or a couple days after exposure seems to be one really useful point. And of course, there’s a variety of uses going places. It really is a really vital tool. And you’re both wonderful for helping explain these things to people and for joining us today on in the bubble. And you both get lots and lots of extra credit.

Gigi Gronvall  1:00:28

Thank you.

Mara Aspinall 

Wonderful doing this with you, Gigi. And thank you, Andy.

Andy Slavitt 

All right. Thank you again, to Gigi and Mara, I realize that you weren’t probably always able to tell who was dg, and who is Mara from listening to them. And that was my bad as a host. I think Gigi had this slightly higher pitched voice and Mara was slightly lower pitched if that helps you to go back and listen, but they both made such great comments, and they both deserve a lot of extra credit. Let me tell you what’s coming up. I’ve got a bunch of great episodes Stéphane Bancel, the CEO of Moderna, Paul Offit, who is part of the group of people advising on vaccines for 5-to-11-year old’s. Fresh off of that meeting, we’ll come right on the show and talk to us about kids. And Richard Besser, who is the president, CEO of Robert Wood Johnson, and also pediatrician and former head of the CDC. So, if you like to geek out, we’ll be geeking out, but it’ll be fun. geek out with me. It’ll be fun. Okay. Talk to you Wednesday.

CREDITS

Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produced 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 at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, most importantly, please tell your friends to come listen and please stay safe, share some joy and we will get through this together.