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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning, everyone. One hallmark of the Omicron era we've been in since Thanksgiving is, of course, more reliance on rapid at-home COVID tests combined with less ability to get them. A lot of people already couldn't afford them. President Biden is expected to say something about this today. We'll see if he's got any new policy to address the need with 400,000 people a day right now testing positive for COVID, more than at any time in the pandemic. There's at least one person who has a right to say I told you so about the at-home testing shortage.

As a Harvard public health professor, Dr. Michael Mina, a physician, epidemiologist, infectious disease specialist, and immunologist, was a rapid test for everyone evangelists since early in the pandemic. He was first on this show to explain his idea for regular rapid testing as a way to reopen more of society back in November of 2020 before there was even a vaccine, but it didn't catch on until the Omicron crisis made everyone suddenly seem to want one.

Now Dr. Mina has left Harvard and become chief science officer with a biotech software company based in Miami called eMed that calls itself the leading provider of at-home rapid COVID-19 tests with validated results. We'll talk with Dr. Michael Mina now about how we got to this point and the options for what comes next for breaking the Omicron variant, beating it back, and living with it in our midst in the meantime. Dr. Mina, thanks for some time. Like the rapid tests themselves, I know you're very much in demand right now. Welcome back to WNYC.

Dr. Michael Mina: Thank you so much. Happy to be here.

Brian Lehrer: I guess we have to start with full disclosure. Since the last time you were here, you've gone from being a Harvard professor studying rapid tests to someone who profits off selling them, yes?

Dr. Michael Mina: That's sort of correct. What eMed does is it's actually a software company that authenticates testing. It's more to enable a test that somebody might have in their home, for example, to enable it to be useful for downstream purposes. For example, if you want to get a prescription based on a test, a doctor won't just believe that you used a test on your sofa, you need to have a laboratory report based on that test.

What eMed does is it enables reporting to public health agencies and it provides people with a verified and fully authenticated laboratory report for the test that they are using. We're not a test manufacturer, that's an important piece. We're a software company that's making the most use of these tests.

Brian Lehrer: Right. That's why that cut line from the press release from the company's website that I cited calls it the leading provider of at-home rapid COVID-19 tests with validated results. It's really the validated results part. Let me ask you a question about that because I think a lot of people are dealing with this in their own lives right now as they consider their testing options or get with just whatever test they can get.

Some at-home tests require apps like you're involved with, some do not. Why wouldn't someone prefer a test with no app? For a few reasons. For the convenience of just seeing the result yourself with no need to upload anything. Also because the app introduces another step for a potential technological error and false negative or false positive, and also over privacy concerns.

Dr. Michael Mina: Yes, the apps are different than what we do. An app, for example, is usually just some sort of reader or something that you just type a button onto. What eMed is actually doing is there's an actual live person that comes onto your screen. Essentially, you scan a QR code or you go to emed.com once you have your test. If the test says eMed on it, you can use it in this manner. A live person actually comes onto the screen and walks you through how to use the test. It's actually really good to enable people who maybe are uncomfortable using these tests at home, which is actually quite a large fraction. The population doesn't feel a lot of comfort doing these tests on their own at home.

The proctor will walk them through it, verify who they are just as a doctor or a nurse would verify who you are before they draw your blood or take a swab, for example, and help you get to the end of the test, and then verify that you read the result appropriately. The process is actually enhancing and improving the quality and accuracy of the tests used at home, whereas a lot of the apps are a whole different thing. The apps are generally just an additional add-on to many of the rapid tests that don't offer much to people beyond just a way to store their result.

Brian Lehrer: All right, that's a little background, listeners, on what Dr. Michael Mina is doing in the corporate sector now. That he's left Harvard, but he was certainly the visionary with respect to rapid tests and what the country now seems to be moving towards. Let's talk about where we are as a country with the at-home testing shortage. You tweeted yesterday, "I have tried as hard as a human possibly could to make sure we didn't get to this point." Why do you think we have wound up in this place of tremendous demand and tremendous shortage?

Dr. Michael Mina: The US took a very vaccine-centric approach, for good reason in some ways, of course, the vaccines are crucial. Most of what I actually study and what my lab was focused on before COVID is vaccine immunology. I see the benefit is obviously there, the vaccines, it is the crux and the most important part of our public health program, but it was extraordinarily short-sighted to put all of our eggs in only the vaccine basket. I think there was so much confusion in particular about rapid tests. To this day, two years into this pandemic, we still do not formally recognize in our government that there is a public health use or utility of a test.

This is one of the biggest issues. It has led to so much confusion because, in our government, we only define tests as medical, clinical diagnostic tools, not for what people are using them for in this pandemic, which is public health. Not having that formal recognition has caused the CDC to conflate and confuse their own guidance around how to use these tests because they're trying to fit with what the FDA says, which the FDA calls these medical devices.

The CDC is a public health agency that's supposed to be pushing guidance around this public health emergency. Our government just simply, I think this is one of the biggest issues, they've never been able to come out and say, "Yes, these tests are good for public health testing to know if you need to isolate," because they've been put in a box by the FDA because the FDA doesn't formally recognize that these tests are being used for public health utility. Two years in, it's just completely silly and, frankly, a deadly oversight by our FDA.

Brian Lehrer: I see people are starting to call in already with questions for you. Let me invite everybody and make sure everybody has the phone number. Listeners, your rapid testing questions are welcome here for Dr. Michael Mina. 212-433-WNYC, 212-433-9692, or tweet @BrianLehrer. You can ask about the science of rapid tests, policy options regarding them as we were just starting to get into, or practical questions about how to use the rapid tests you have or what to use them for, or anything related for Dr. Mina at 212-433-WNYC, 212-433-9692 or, again, you can tweet your question @BrianLehrer.

About the scenario you were just laying out, the failure to see rapid tests as a public health tool, not just clinical health tool, I guess a more benign version that some others might put out would be that policymakers and manufacturing companies alike were surprised by the virus. We thought we were emerging from the pandemic before the Delta spike this summer, and then they couldn't assume a variant would emerge as transmissible as Omicron. Companies did not produce tests in this number and governments didn't mandate them in this number because neither thought there would be a market for this many. How much is that a way to look at what happened?

Dr. Michael Mina: That's certainly some of it, but I would argue that it really wasn't until just a couple of months ago that more than two test manufacturers were even really allowed on to the US market for home tests. It was Abbott and Quidel for most of the year, I think that that limited neither of those companies wanted to scale to an immense amount for the reasons you're saying, there wasn't a sure bet.

The government, if they really wanted these companies to-- If we're going to put our public health in the hands of private enterprise and industry, then certainly the government should have given pre-purchases or some sort of large contracts upfront to the manufacturers so they could actually feel comfortable about scaling. We didn't do that as a nation because we have had this unfortunately horribly optimistic view of what this pandemic would do. The companies weren't scaling, the government wasn't pushing for this. There's no reason that in a pandemic like this, we should not be hoping for the best, but absolutely expecting the worst.

We do this with defense. We're not at war. We don't have people bombing us as the United States every day, but yet we put trillions of dollars into our military for the day that that might occur. A pandemic, as we're seeing, is more deadly and more costly than any war we've ever fought. I think we should be putting that same type of forward-facing energy to say, "We're not positive, but the effects of being caught off guard or the impact of being caught off guard are so great that we should absolutely be putting much more into assuming the worst will happen and hoping and being delighted that it doesn't if it does not."

Brian Lehrer: We'll get into what you think we can do. At this point, you advocate free rapid testing for all. I'll ask you how that would work in this country if President Biden were to try to implement it, but to what you were just saying, did any country get this right? You retweeted part of a thread yesterday that included headlines from England, Australia, and Scotland all describing shortages of rapid tests compared to the demand.

Dr. Michael Mina: I would say that no country has gotten a perfect for sure. Some countries have done a lot more than the United States. Something I said all of 2020 was at the very least, we need to get people to understand these tests, to feel comfortable with them. We have to get the reporting systems going so that when we need them, it's not a hurdle just to explain them to people. The UK did a very good job at using them for much of this pandemic thus far.

While people point at the UK and say, "Look, they still have spread," what people are unable to see without good scientific backing for it, which does exist, is that despite the spread that the counterfactual, or what would have happened if they didn't have the tests would have been even worse. The UK government recently came out with a report that showed that the use of their rapid test reduced hospitalizations by 30%. In our terms, that would be potentially hundreds of thousands of lives saved in the United States.

Although there's still spread that's ongoing, the tests have actually had a massively influential impact in the UK. If nothing else, because this virus is of course going to become endemic, it's going to continue spreading, the tests have always been a means to keep outbreaks lower than they otherwise would be, and to buy time before while we were getting the vaccines rolled out, and now just to keep things from exploding as they have, and starting to shut down schools and businesses once again.

Brian Lehrer: Mark in Jersey City, you're on WNYC with Dr. Michael Mina. Hi, Mark?

Mark: Hey, Brian. First, I want to thank you both so much. Your guidance has been invaluable and made family visits and all kinds of things possible the past six months. Ever since the first episode in I think September or whatever, we test before seeing people and it's been great. I was just wondering though, we're also involved with a preschool here where obviously tests are in short supply, they're expensive. It's a lot to ask people to test every day.

If it's Monday, Thursday, like 48 hours, 72 hours, what efficacy do we have? Also, especially with Omicron, what is the situation with testing all the teachers and parents versus the kids, and should we favor maybe more tests for parents, or teachers and fewer for kids? What advice do you have there?

Dr. Michael Mina: It's a really good question and a complex one because we do have a shortage of tests, which means we can't use them in a fully optimal way. We have to decide where are these tests best utilized, and how are they best utilized? For a preschool or for any school, school administrators and decision-makers, and sometimes they'll be at the school, sometimes county or state level, have to decide what is the goal. Is the goal to stop every single case from entering into a school? Some private schools are doing that. If so, then you really want to essentially be testing every single day, but that's not reasonable for most.

The goal is oftentimes instead to have rapid identification of outbreaks so that then you can act on those in a time that's commensurate with the need. For that purpose, having some level of testing, whether it's once or twice a week of most individuals will be a good amount to know, do you have some outbreak that's ongoing now. If it's a small preschool, by the time you get to Friday, if an outbreak starts Monday, it might be too late. Then you might want to actually use your tests to help the families be able to deal with it.

If the kids are bringing COVID back home with them, for example, they might want to then say, "Hey, use them for the teachers, use them for more vulnerable individuals to prevent the children who are positive from necessarily bringing them towards at-risk people." It is an extremely complex situation because the tests don't exist in enough numbers that we really-- There's not a great answer.

Frankly, some of the better places for these tests given a shortage are to put them in places like nursing homes, so that no staff member walks into a nursing home on any given day without using a test that day because nursing homes are full of very vulnerable people. There's other places where maybe I would start prioritizing these tests over a place like a preschool. Unfortunately, it's not ideal, but we're in a resource-constrained environment that we're generally not used to being in the United States.

Brian Lehrer: As a follow up to that, we're hearing phrases now like test-to-stay, which is part of the system for keeping the New York City public schools and other systems open. If you're exposed but test negative and are vaccinated, you don't have to quarantine just from the exposure. I assume you support that use of rapid tests.

Dr. Michael Mina: I do. I'm not positive, I might have been one of the people who developed that term. Yes, certainly test-to-stay is one of the better uses of these tests, and that's where no child in America, and ideally anywhere, should have to quarantine because of this virus anymore. Quarantining is an information problem. It's when you don't know if you're actually infected, and so you're asked to stay home because you may have been exposed. That's an information problem. Rapid testing solves that information problem by giving you the information you need to know I am not infectious and, therefore, today I can go to school.

Any child who should be in quarantine, instead of doing that could take a test in the morning, and if they're negative, go to school that day and be very unlikely to be infectious and infecting anyone at their school. It's a very good use of these tests to keep kids in school. There's things like test-to-travel. The CDC has required testing to travel and from abroad, for example, another good use of a test. Test-to-treat is a really important one. That's going to become very important as we now have the Pfizer drug, for example, just got an EUA.

It needs to be started really early, so one of the best uses of these tests is for communities or governments to preposition the tests in vulnerable people's homes with a recommendation that if you feel any symptoms, use the test. If you are positive on a rapid test, then you can start getting your treatment very quick, which will make it very, very effective.

The Pfizer drug, for example, is 90% effective to keep people out of the hospital. It's an amazing drug, but it has to be started quickly, and that's another very, very good and important use of rapid tests. In particular, those in the case of what I do at eMed now is to authenticate them so that people can actually say, "I used a rapid test at home. Here's the authentication lab report." A doctor feels good about prescribing somebody a Pfizer drug based on that.

Brian Lehrer: One more follow-up about test-to-stay as used in New York City public schools and elsewhere in the school systems. Do you think the standard should be different for vaccinated and unvaccinated kids and teachers?

Dr. Michael Mina: No, I don't. Some other people might disagree, but the fact is, the hard truths of it is that vaccines are not doing enough to limit spread. They're doing an amazing job to stop disease, but what we're talking about when we're talking about testing for public health is stopping spread and vaccines don't do enough to stop spread, in my view, to warrant different policies based on vaccination status. The days of thinking that the vaccines were stopping spread of this virus, those are long gone. They're just not working in that way.

Brian Lehrer: Carolyn, Manhattan, you're on WNYC. Hi, Carol. Carol's not ready. Let's try Marian in Princeton, you're on WNYC with Dr. Michael Mina. Hi, Marian.

Marian: Hi. I'm wondering if you can settle a dispute I've been having with a couple of friends. I have a friend who had COVID recently, and he insists that a rapid test will continue to show positive for three months after he's completely recovered, which he has thank goodness. I keep telling him that's a PCR test that will continue to show positive for a long time after you've recovered. Can you settle this dispute for me, please?

Dr. Michael Mina: I sure can, I'm so glad you asked this because even our CDC director, unfortunately, got in front of the TV and created even more confusion around this. The whole benefit of a rapid antigen test is that they do not stay positive after you are infectious. A PCR, a lab PCR molecular test, they can stay positive for way too long, weeks after somebody has been infectious, sometimes even months, which is why really PCR was never the right test during this pandemic because millions of people have isolated because they got a PCR test that was positive after they were infectious.

To directly answer your question, a rapid antigen test does not stay positive when you are no longer infectious. It's very specific to the infectious period.

Brian Lehrer: Listener tweets this question. I bought two different tests from Duane Reade in Walgreens. One is by Flowflex, the other by Quidel. How do I know if they're accurate or what's the level of accuracy?

Dr. Michael Mina: Most of these tests are generally similarly accurate. FlowFlex is a test by a company called ACON. The Quidel test is called the Quidel QuickVue. They have slightly different form factors so using is slightly different, but they're both generally pretty darn good for identifying if you are infectious. The biggest difference between the two is that, unfortunately, the Quidel test, the QuickVue does have a fairly high number of false positives.

When somebody comes to me and says, "Hey, I'm using a Quidel test to screen people at my wedding," or whatever it might be, I oftentimes say, "Look, if you're positive on a Quidel test, and you don't know that you've been exposed or you've no reason to think you've been exposed, have another test right next to you just to be able to confirm quickly that-- [crosstalk]

Brian Lehrer: Have two brands of tests at home, you're saying?

Dr. Michael Mina: That's right. Not all tests need that. For example, the Abbott BinaxNOW or the Flowflex, those have very low false-positive rates. Abbott BinaxNOW has a false positive rate of 1 in 3000, which is better than a lot of PCR labs. Quidel test does maybe 1 in 150, which for public health use, that's actually high. I like to always have it. If I'm ever seeing somebody positive on Quidel and they're not symptomatic, I immediately say, "Look, use this other rapid antigen test to confirm," so you get your result and your confirmatory result all within just 20 minutes or so.

Brian Lehrer: Since you were willing to opine on brands there, do you have an opinion about Q, which Google and I think the defense department and some other big institutions are using?

Dr. Michael Mina: Yes. There's three molecular rapid tests. There's Q, Lucira, and Detect. Those are the three molecular tests. The issue with those is, on the one hand, they're slightly more sensitive. They're not hugely more sensitive than rapid antigen tests. They are a technology called LAMP. Unfortunately, because they are RNA tests, and like a PCR, they can stay positive even after you are infectious. They also tend to be more costly, but that said, if you really are mostly interested in getting the most sensitive rapid test, then Q, Lucira, and Detect are three very good, but also quite expensive tests because they are at home molecular RNA tests.

Brian Lehrer: One more how-to question from a listener and then we're going to get into your proposal for free rapid testing for all. Bodie in Brooklyn. You're on WNYC With Dr. Michael Mina. Hi, Bodie.

Bodie: Hi. I had a question about the application of the tests. I was tested yesterday both PCR and rapid at the same time. She barely swabbed the inside of my nose. I'm wondering what depth you have to go to or how long you really have to get in there.

Dr. Michael Mina: It's another great question. In general, you want to go around a centimeter into your nose. For these entry nose swabs, you don't have to feel like you're pushing the swab into the top of your head or the back of your head. It shouldn't be uncomfortable or make you tear. That said, you do want to swab what's called the nare of your nose, the front of your nose up about a centimeter, and you want to do that about five times per nostril.

If you're getting the swab done on you and you don't feel like somebody has actually gotten a good sample, a lot of people don't necessarily know how to do this so I recommend saying, "Hey, are you sure you actually got a good sample there?" In general, swabbing longer is not going to be detrimental, it's going to only be beneficial. I don't recommend people sit there and swab their nose for two minutes or something, that would be far too much. It is an important piece. [crosstalk]

Brian Lehrer: You were saying like five times around each nostril. Do you think that there's a lot of false negatives out there because people don't swab themselves long enough?

Dr. Michael Mina: Yes. If you were to just take your swab and stick it in your nose and swirl around for a second and take it out, it can. The good thing though is when you have a really high amount of viral load, and you have the greatest potential for spreading the virus, then actually even a pretty quick swab is going to probably detect it because you can sometimes have trillions of viral particles in your nose.

In general, swabbing is important and I do recommend that people really try to get the swab up there and swab, and spin it around five times there along the nares on each side before using it so that you get the most sensitive result.

Brian Lehrer: We'll come back with Dr. Michael Mina in a minute and talk about the policy piece. President Biden expected to speak more about this today. His first policy a few weeks ago for rapid at-home tests for free for anyone who asks for one up to a total of 500 million tests is being widely criticized as not good enough. Dr. Mina is advocating free rapid testing for all. We'll ask him how that would work when we come back after this.

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Brian Lehrer: Brian Lehrer on WNYC as we continue for another few minutes with Dr. Michael Mina, who has now left Harvard where he became the nation's chief advocate for a lot of rapid at-home testing. He's now chief science officer with a biotech software company based in Miami called eMed that calls itself the leading provider of at-home rapid COVID-19 tests with validated results. They do the validated results part. Dr. Mina, you have long advocated free rapid testing for all, how would that work in this country?

Dr. Michael Mina: The way that it would work is-- We're in a box now, we're painted into a corner because we don't have the test to really do it in a smart and useful way. How it could work in the future, or how it could have worked had we started planning for this a year ago or a year and a half ago is the US could have built the instrumentation in the factories to produce these tests. It's not very hard to build these. The government could have taken over that process and been pumping out lots and lots of these rapid tests with the goal of enabling Americans to be able to access free rapid tests on an ongoing basis, say twice a week.

If every American or most Americans were participating and using a rapid test twice every week, what we showed in a lot of our research studies earlier in the pandemic was that if you could actually sever enough transmission chains by knowing that you are positive and having enough people do that every week, that we could have kept the outbreaks at bay. Where we are now is the President is probably going to come out with an announcement that they are bringing forward hundreds of millions of rapid tests.

Ideally, those will be for free, which I am a big advocate for because public health should not cost anyone money out of their pocket. Participating in public health should not cost you money. It'll be interesting to see how the President ends up disseminating these tests. My guess is they will go to individual states and each state will be on its own to figure out how to use these, and they'll probably be allocated on a population basis is my expectation.

Brian Lehrer: To use rapid testing to the full extent that you envision it in our country of 330 million people, how many tests would that require over the next year, say, and to make that free for everyone, what would that actually cost the government, cost the taxpayers?

Dr. Michael Mina: It wouldn't cost very much. These tests are very cheap to make, especially if the government's making it themselves and not having to purchase it from for-profit companies. We actually did some economic evaluations myself and Jim Stock, a professor of economics at Harvard, earlier last year. What we found was that you could provide rapid tests to the entirety of the country for a year to be used on once a week or twice-a-week basis for less than 1% of what this virus has cost Americans today.

We have to remember that this virus is now a $10 trillion virus for our country. It's hard to even fathom what $10 trillion is but it is a massive amount of money that this virus has cost. Actually when it comes down to the economics, paying for the test itself would not be expensive for the government because the economic gains we would get in return are massive. If we go back to when we shut the country down, every single day was costing around $15 to $20 billion of economic losses. That alone would have paid for a large-- One day of economic shutdown for the whole country would have paid for almost the entirety of the rapid testing program.

Brian Lehrer: Last question, which is also a policy question. NPR's Morning Edition had a segment today that included discussion of the CDC's reduction of the isolation period for essential workers with COVID from 10 days to 5 days. One of the rationales was that people are actually avoiding getting tested if they don't feel sick so they don't risk 10 days of isolation. They might be more willing to risk five days. What do you think is the best way to navigate the tension between prevention through widespread testing versus the disincentive to know?

Dr. Michael Mina: I think the best way is to give people the data of their own body. Most people don't stay infectious for 10 full days. A lot of people, if you're getting detected on a PCR test, you actually are getting told you're positive after your infectious stage has already passed. First, we have to get smarter about how we use these tests. We should never be isolating somebody who's no longer infectious, which is why PCR in the way we use them is inappropriate. The other thing is it's okay to try to limit the isolation period. Many people will potentially get out of isolation in two days.

If their rapid test is negative and they were told that they were positive on a PCR test, maybe they're not even infectious, and so you get two negative rapid tests in a row and you can leave isolation two days. Some people maybe they use a rapid test at five days before they leave isolation and they're negative, they can go back to work. Some people will still be very positive and so we want to ensure that when we do find people who are infectious that we-- They're hard enough to find the first place. When we do find people are infectious, we don't want to have them go back out and infect others.

The math is really pretty simple. If you allow somebody to go back to work just to get them back to work three days earlier, that individual might gain three days of their work back but if they go back while they're still infectious, they might infect three additional people in that workforce. That immediately then becomes a minimum of 15 person-days additional out of work. We really have to be taking this public health view and say the best thing we can do is when we know that somebody's infectious, not let them go and infect other people.

Using a rapid test is a very good way. We should not be saying just leave isolation at five days because we know that many people are still very infectious at that five-day mark from symptom onset. Use a rapid test to tell you. Again, it's this information problem and rapid tests solve it in real-time. They tell you are you very likely to still be infectious or are you very unlikely to be infectious, and you can go back to work.

Brian Lehrer: Dr. Michael Mina, formerly with Harvard, now with eMed. Thanks as always. We really appreciate it.

Dr. Michael Mina: Oh, absolutely. Thank you all.

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