VeiligHealth Insights to Actions – 16 Dec 2020
Our weekly question and answer session with Fred Goldstein, Dr. Luis Saldana, and Nick van Terheyden, MD on our COVID Insights to Action Discussion webinar that takes place live every Wednesday at 4pm ET. You can register here
You can also find our training modules and services available to help businesses, education facilities, and employers get their employees, staff, customers, and students back to work and school safely in the context of COVID19
Transcript
Fred Goldstein
Hello, everyone, and welcome to this week’s COVID insights to action discussion group. I’m Fred Goldstein with accountable health. And we’re so glad you joined us today. I’m joined again this week by my two compatriots or partners, as we say, and working on COVID with a number of different clients around the country, Nick van Terheyden, then Dr. Louis Sol donya, both physicians, so maybe a quick introduction from each of you, and then we’ll get going.
Luis Saldana
Yeah. Emergency position by career, and also some former reformed CIO, Chief Medical Informatics officer involved in kind of digital health and, and things and glad to be here with you today.
Nick van Terheyden
And I’m Nick van Terheyden. I’m also an emergency room physician, and a COVID, investigator and deep digger into all that is COVID. Related and the importance of how we return to work safely.
Fred Goldstein
And my background is in population health. And I try to apply those principles to this as we look at the problems we’re dealing with from the various clients we have. So this week, we decided to discuss testing. And I guess the easiest way to probably start this off is to get an introduction, obviously, there are different types of tests. So perhaps we could discuss that and then get into how universities have been using them and what they might consider on a go forward basis. Perhaps, Nick, would you want to start that?
Nick van Terheyden
Sure. So cover off the sort of basics of testing, antibody testing, which we’ll put to one side, for the moment, but that’s the one that requires you to take blogs specifically, and looks for the body’s response to the disease. So have I had the disease? Potentially, it could inform you as to whether you’ve got the disease, but both of those questions remain somewhat difficult to answer based on whatever results we get, because we don’t fully understand the inflammation that comes out of that. But there is a lot of work going on about around those antibodies. The other two basic tests are the molecular test that looks for the virus, and specifically the messenger RNA components. And importantly, the antigen test, which is looking for those little spiky things that we’ve seen everybody I think is familiar with the COVID picture, those little spiky pictures protrusions are instigators of a response, and we can identify them in the shedding from people’s bodies. Those are the the basic forms of tests. And under the molecular test, we talk about PCR or polymerase chain reaction, which is the amplification system to amplify the small amounts that we find requires the barsha involvement. And then there are some subgroups underneath that in terms of the way that we achieve this. But for the most part, testing has been done in laboratories or has to be done in the varieties of requires laboratory equipment, although there’s some changes afoot around that, using some clever technology that we have had in the past, but we’re now blind to COVID-19.
Fred Goldstein
And I know that Luis, when we first began looking at this issue back in there, right pre summer period, as these universities were working with, we’re thinking of coming back. They they were looking through a testing strategy and weren’t really sure. At that time, I think in terms of recommendations, but I believe, you know, we recommended testing. Can you talk through sort of the reasons for that. And then what tests we sort of were looking at that were available at that time?
Luis Saldana
Yeah, and I’m forever it actually is Chuck and I think a big part you touched on is what’s available at that time. I think this strategies for anybody looking at testing really has to be focused on what can you execute What can you actually get? What can you do? I think that’s that’s a big driver of what that is. At the time that we started working with colleges and universities, the recommendation from CDC at that time was not a recommending entry testing. But that was probably partly due to maybe political reasons, or, or whatever, I think the CDC at that time was really not giving current guidelines that really were effective. So we went ahead and recommended to our customers to do entry testing, with the idea that that these young folks are coming from different parts of the state, the country, the world for that for that, say, and coming to a campus where they would, in some cases be living together on campus or off campus, in dorms, fraternity houses, apartments, that type of thing. And we wanted to identify and try to safely exclude those who had COVID active COVID or were infectious from returning to campus, and ensuring that they would not infect others at that time. Because this, we felt this could lead to a kind of a quick outbreak or Quick, quick spike in the numbers when when these folks arrived on campus and, and so we actually recommended entry testing at that time it was PCR testing, actually use that whole company, which which was effective, because it allowed that to happen before they arrived on campus. And, and so that was a really good strategy that that we worked through. But, you know, I think that was very effective in kind of narrowing that funnel of infectiousness cases, kind of keep those out. And we asked those folks not to come to campus if their test was positive. I think the places that did do effective testing did some form of entry testing as well. And we’re going to do the same for the spring, we’re going to have the same recommendation, I think he could do it with with with antigen testing, I think it depends on your overall strategy. What are you going to continue to do during the during the semester or the year as well. And much of that, again, is due to availability cost there, you know, these can be quite costly, we finally started seeing the costs of these tests start coming down. And so I think that’s making testing much more available.
Fred Goldstein
Finally, and I know that some universities essentially set up their own labs, and began to try to do this or work with the Broad Institute work, but others had to go find vendors. How did that work? You know, what, what do we see with these companies in terms of their ability to deliver these tests and volume, get the information back in time, etc. From the return perspective.
Nick van Terheyden
I think it was widely varied. I mean, I if I was to sort of pin one specific thing on probably one of the most important issues is turnaround time, the utility of a test declines almost exponentially, in my view, with the duration it takes to get the information back. So any test that takes longer than Well, let’s start at 14 days, but it’s probably less than that based on the quarantine restrictions, becomes useless, what’s the point in testing somebody and waiting 14 days for the result if you’ve quarantine them. So, so turnaround time is essential. And the challenge with that is both the shipping, so you in many instances, you’ve got to get it and you’ve got to get it in a transport medium that meets, you know, transportation requirements does require special handling any of those kind of things. And also will hold or keep the sample appropriately maintained before it actually enters into the laboratory system. So that’s part one. And then there’s the actual laboratory processing time, which is what we’ve seen some of the clients do is, you know, bring the lab locally or an apartment with local labs, that distributed mechanisms so that you can get a faster turnaround time.
Fred Goldstein
Yeah, I think we really were able to identify some companies that could ship these tests out to individuals at their homes, or wherever they were going to be before they came back, as well as supply some for the campuses on site. And then those individuals were able to take those tests, ship them back, get the turnaround fairly rapidly before they came back. And the other key piece of that was obviously the ability to exchange that information with the university so that they would then know we’ve had 10,000 of our students and 7000 have tested to date These are 3000 we still need these the ones that have got it done, everything’s completely done and track that and I think place have gotten pretty good at that system. Now. At Although we did identify some problems, obviously, with the US Postal Service in some cases or things like that, where some of the other shippers might have been better, and as people look at it, they may want to look at that. We know that from the holidays right now, just getting mail around is difficult. So from a testing perspective, clearly something but you mentioned something else. And perhaps Louise, you might want to touch on a little bit. Some of them actually, we’re bringing groups on site to do some of that as well. And companies they identified who could come to their campuses.
Luis Saldana
Yeah, and I think Nick touched on something you touched on it as well about the turnaround time. And one of the things that we thought was important was to in the in the negotiations in the contract, have a service level agreement, to write for them to guarantee some priority, and some no guarantee that turnaround time, I think that’s that’s an important consideration as folks look at testing if they are considering that for a college or university or even a business, that you look at a service level agreement for a turnaround time to to make those, you know, make those actionable as far as that goes. Yeah, there’s many ways to solve this. Certainly, I think we’ve all seen in my city, we have drive up testing, so you can do drive up testing, you know, the thing about they got to remember is that that the advantage of the at home test is you don’t need PP, when you have any form of test, even drive up testing, or you got to go line up to get a swab. The folks that are taking those samples have to be wearing personal protective equipment to keep them safe as well. And so I think that’s, that’s a big consideration. And the same with what he talked about getting your own lab. Those are, those are pretty big undertakings. But I think if you can look at it financially, if those financially makes sense for college or university to bring in, you know, it’s the typical buy you buy this or, or you make it yourself, you know, do you do it yourself type of a decision. And I think that’s that’s really tends to be very much of a business decision of what your capabilities are. Mm hmm.
Fred Goldstein
And then as you think about this, we had the pre testing for those. And then we saw different strategies on an ongoing basis for testing during the semester. Some campuses chose not to do random screenings, others chose to do only symptomatic testing. Where should we be falling out? And that what are your thoughts around the, you know, adding that either random screening in a large scale or even just a sampling,
Nick van Terheyden
I’m going to call out Louise’s point earlier, which I think is essential here. You’ve you’ve got to do what you’re able to do. And I think that’s one of the problems I heard. Recently, the numbers associated with the cost of testing in one particular college was just an istat. I mean, it blew my mind how much money they had to spend. And if you don’t have that money, or you can’t justify that cost, you’re sort of limited. In an ideal world. The visual that I have is I sort of walk around with a little paddle that says, virus free virus free and then it flips at some point when suddenly it’s not sure anymore, you know it all the time. And you know, that would require some level of testing. Obviously, that’s unobtainable. You know, and there’s a spectrum in between that. And we’ve seen all variations of that you sort of described them, I think surveillance testing, from a population standpoint, especially when you look at a population that you have some control over and have some impact on and, you know, present themselves in your community that you can sort of influence behavior, extraordinarily important to do some level of it, and preferably, as much as possible, be at 5%. You know, something larger than that, that says, we’re going to try and look for those instances of people that don’t present with symptoms before they’ve spread the disease. And you know, those are both asymptomatic and pre symptomatic. And that’s especially true in the younger age group, who tend to present or don’t present a tool with any symptoms. We have a large number of folks who went into quarantine as a result of positive testing, who ultimately never had any symptoms. Well, we never would have caught them if we hadn’t tested them or found them either, you know, one way or another.
Fred Goldstein
And as you think about moving into this next semester, obviously, you know, as you’ve both hammered home, it is about the resources The university has does it it Is it really limited? Or does it make sense to not screen or test students before they come back? Just because no resources?
Luis Saldana
Well, I think you have to look at the prevailing diseases out there, the viruses into your community, if you have widespread community spread disease, you really need to screen as many folks out, you want to reduce that burden, to not perpetuate the virus spreading. But Nick mentioned to you about the pre symptom vaccinations Max, and that’s what makes this unique challenge is just that group, if we were just talking about cinematics, it would be easy, you just test symptomatic, they can be tested probably in the community or whatever that that may be available. But the challenges identified those that are actively spreading the disease, but may not have any symptoms, and those that that that’s been responsible for much of what we see in our communities, but but in the light of the amount of virus we have in our communities right now. My sense is you have to do some form of screening, testing, entry testing, to really try and reduce that burden, have those folks isolate in place, if they have a positive test, they should stay, they should stay in place and not be traveling, wherever they are, and, and or have the resources, you know, to, to help support their, you know, their isolation and things as well. So, so that, I would definitely say that’s the case, again, I think we’re in a very different situation. Now, in the spring that we were in the fall, in terms of the availability of testing is much, much more, there’s a lot more companies out there. I think the last couple of days, we’ve seen two direct direct consumer tests happening. So so maybe there’s a way to leverage direct to consumer even at that, that’s probably not the case for, you know, coming into spring, it may not be that broadly available. But I think that’s where we’re going is that where you’re trying to leverage those, those resources for rapid testing, I think we’re seeing more and more rapid testing in the communities.
Fred Goldstein
And I would add that while they always talk about this issue of, you know, university doing the testing themselves, and obviously those with the resources have tended to do that, and paid quite a bit of money to get testing services in there is the option of asking individuals to get a test and report that back as some way to, for those that may be have less resources to be able to fund up that kind of an operation.
Nick van Terheyden
And the other thing that it you know, in terms of the context of what’s going on, and availability of testing, the other data point that’s changed dramatically from when we first had is, the virus is exploding, the presence or the prevalence of this disease is so high, when you look at the risk factors, or the the statistical probability of somebody getting infected and coming to college way, way higher, in my estimation, now, or, you know, potential unless something dramatic happens in the next few weeks. And it doesn’t seem that way, we’re going to have very high levels of people coming from, you know, disparate parts of the country and have a higher risk. So it’s even more important at this point, because the prevalence of the disease is so much higher.
Luis Saldana
Yeah, I think, along the same lines of new you, he kind of mentioned this earlier, Fred, it’s data and analytics, I think that’s something we strongly recommend that it’s not only do get half testing, but you have to track testing. And you have to tap track testing results that may include tracking outside testing, as well have a mechanism to report outside test results. So you can actually actually track the positivity rate in your community as well. So I think effective data analytics and dashboards I think are critically important. Some places have not really invested a lot on that either. I think if you’re going to spend the money on the testing, you want, you want to have some insights, you want to create some insights. So you can actually take some actions on that. And especially when you can slice and dice the data to actually identify, you know, possible clusters. And we we’ve done that you know, that you have the ability to kind of break it down to a certain apartment complex or a certain dormitory or a certain it that he got to have the data and analytics to support smart support testing as well.
Nick van Terheyden
Yeah, that’s a great building on that you need to have The data on the contact tracing as well, you can’t start with just the data, the testing, but and that proves to be one of the richest sources, if you look at any of the sort of insights that we’ve gathered about the disease going forward, and other significant information coming from contact tracing, you know, huge respect for the people that go into the detail. And the same thing occurring, same opportunity in these colleges, businesses, all of those, you can’t abdicate that responsibility to the local health authorities, they seem overwhelmed and are not doing it, it becomes a, you know, local activity that requires follow up and people need to be doing and then looking at the data subsequently.
Fred Goldstein
And that really points to the whole point that testing is one piece of this, that needs to be part of a fully integrated strategy, to be able to flow that data through to have the systems and the dashboards and people looking at it, people making your calls and analyzing it. And then beyond that, how do you then make the adjustments to your plan to try to reduce the ongoing risk going forward, as you identify these individuals? So it’s really fascinating. What are you seeing now, as we consider the spring, obviously, some schools have delayed some openings for a couple weeks, given some of the numbers, others, you know, are looking mid January or so. And we’re seeing some variation in testing. I think, you know, based on the numbers we’ve looked at, in some of the reports we pulled, it looks like more universities are gonna be testing them more in the past and testing more frequently. Does that make sense?
Nick van Terheyden
I believe so. I mean, I at a minimum testing prior to arrival seems like a cool, and, you know, even take the issue of cost. You know, I think it was Fred, you made the point, you can ask your students to test prior to arrival. I can’t speak with certainty. But I think the majority of states are offering free testing, it’s accessible, there is no reason that your students, your people coming back to campus can’t access. So at a minimum, I’d also be the baseline, before you allow people to come in otherwise, they’re bringing disease to your community.
Fred Goldstein
What about the antigen test? There’s been all this talk about? Well, it’s not accurate enough at 70%, that you see all this stuff flying around the media, that obviously impacts all of our thoughts, and some of us more than others. What’s your sense on that? And how’s that gonna fit into the strategy in the spring perhaps?
Luis Saldana
Well, I think the antigen test definitely have a place in Danny, I think you’re gonna see an increase in that is when the use of antigen testing in the spring across the country, I’ve already heard Dr. Fauci kind of green that that the way to wrap up the testing is going to be with the antigen testing. And you’ve seen the by Knox now from Apple has had really good numbers in terms of sensitivity and specificity. But the idea with the antigen test, is you’re actually trying to identify infectious innovator individuals. So sometimes there’s a disconnect between the molecular PCR test and the antigen test. And, you know, I think that that sometimes alarms folks, and but the key point is that these are generally asymptomatic individuals. So so it’s hard to say about sensitivity and specificity, specificity because you’re trying to find the presence of the virus. So it’s not like the disease or that we’re trying to find here. But But, uh, I think the rapidity of the results, Nick talked about it. Generally, the PCR tests do take longer in terms of turnaround time. So these become much more actionable, because you may have an immediate result with these and the various antigen test platforms, and you could perform them on mass. I think the earliest we saw this was like the NBA, that National Basketball Association was using these tests. And the idea was, they’re using these tests for ongoing surveillance. So even if you have some degradation in sensitivity, specificity, the fact that you’re repeating in two or three days, covers that, yeah, it’ll it’ll turn positive and, and you’ll find those individuals with still a very narrow window of infectiousness. And so it still helps you to identify infectious individuals very early.
Nick van Terheyden
And I think the other thing that changed just this week, in fact, is that at least one of those antigen tests is now OTC so it’s available over the counter. It’s at the ilumi. I think if I’m saying that, right, it’s ironic, ironically, comes from Australia, but the Australians can’t buy it. Not sure I understand what’s going on there. But okay. It means that you can go and buy Your own antigen test and have it potentially in your house when you’re concerned, you can run a rapid test and you know, to Louise’s point, all tests will show a false negative if you test somebody at the wrong time. So if I’m exposed right now to the virus, and I test myself, you know, 30 seconds from now, I’m going to be negative doesn’t matter which test I use, it’s all about timing. And, you know, his point is so essential, this repeated testing, with Ollie return of information that is actionable, changes the face of the way that we deal with this.
Fred Goldstein
Let’s talk about maybe a little different area on this. And Luis, you sort of mentioned this last week in our conversation, when I was talking about quarantine, and the fact that many people don’t have the resources. So at what point do we get? Do you see an antigen test that either is so inexpensive? Or perhaps is distributed? Is that what we need to distribute that out to the communities and cover the cost of that, because many people obviously, even with this, over the counter test aren’t going to be able to afford to buy that and stick in their house? thoughts on that, Louise?
Luis Saldana
Yeah, and I think we’ve we’ve kind of touched on I think, before in a previous conversation, but we’ve seen places actually do that push out massive testing, with these antigen tests, and get them out there like Slovakia and Liverpool, England, I think did this in the community to, to really drive down the level of the of the virus in the community. And I think we can do that, I think you’ll see that maybe after the first of the year, a real aggressive approach to nationwide testing. Right now we’re dealing with the logistics of the vaccine, well, I think it’s that you’re gonna have the same thing, the logistics of tests of this kind of testing, that they’re both big challenges, I think that and we’ll have to see, but I think there’s going to be, we are definitely going to see these tests, kind of get on the on the big stage now for actually driving down those levels, to where we can match it also, for the vaccine to me to be effective. You, you want that as well. So, so I think it helps us to kind of get to a lower level than, as Nick mentioned, right now, it’s such a high level, in all the efforts, you know, everything gets overwhelmed contact tracing, you know, we don’t get people in quarantine and isolation. There’s all kinds of issues that that really snowball, as we move up the curve. If we move down the curve, we can really get control of this pandemic again, and and and really start doing some nice things. And then then the vaccine can really be an effective, effective deterrent to further spread.
Nick van Terheyden
And other countries are great examples of different approaches, different methodologies with different resources, different use of testing and quarantine, shut down lock downs, there is no perfect answer. There’s always the best available option is available. Perfect almost never is.
Fred Goldstein
So we’ve got just a couple minutes. And I know we’ve also kind of like to dabble in the new and cool stuff such as CRISPR. And that testing technology, a question? Do you think perhaps, with the vaccine coming out, that maybe some of those new technologies will just hit too late, we won’t potentially need them? Or is this something we’ll always be doing on an ongoing basis with antigen tests and stuff like that?
Nick van Terheyden
I’m gonna say that this stuff is with us for for a long period of time. COVID 19 is not the first, certainly not the last, there will be other instances. And it has woken us up to the risks and the challenges and all of this is going to become raw, you know, we’ll be relevant. My only fear is that, you know, the attention span, which is tied to the money and resources diminishes too quickly and some of this withers on the vine, but pick RNA vaccines as one instance. We went under 12 months from no vaccine not even the knowledge of the virus to an available vaccine that is best not one but three for crying out loud. That’s amazing. That kind of progress applied to other diseases. Wow.
Luis Saldana
Yeah, no, I don’t I don’t think in science that any of this work is wasted. I think we saw with the messenger RNA work this was done some time back on done on this idea of Have a messenger RNA vaccine. But it was now that they kind of were able to execute that. So I think any of these technologies that are coming out now they’re new and innovative, will be great techniques going forward in different applications. And, and as Nick said, I think we’re gonna continue to have other pandemics as well, there may be another pandemic around the corner, so we better be prepared. So, so I think you want to foster that sense of innovation. And and, you know, and discovery. So I think we, we will all only benefit if we continue to do that.
Fred Goldstein
Absolutely. I didn’t mean to imply that that was a wasted effort, that CRISPR stuff is going to do all kinds of wonders whether in testing or other things throughout the next years and decades ahead. I know we’re up on the half hour. So I’d like to thank everyone who joined us and thank you, Nick and Louise, the next two weeks on the 23rd and the 30th of December, we will not be having COVID insights. But we will start again on January 6. So please look to join us then and we’ll be back at it. We hope you all have a fantastic holiday season.
