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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. We've been hearing about all the new mandates and new guidance coming down because of the Delta variant and insufficient vaccination rates. All New York City municipal workers will need to show proof of vaccination or a negative COVID test once a week to return to their jobs in person. More and more private companies are doing similar things.

The Centers for Disease Control yesterday revoked its earlier guidance on masks for people who are vaccinated. They now say even vaccinated people should wear masks in public places indoors in areas where Delta virus transmission is high. Locally, that includes at least all of New York City and Long Island, probably Westchester and Rockland, they are considering their next moves. Ocean Atlantic and Monmouth counties in New Jersey have those high transmission rates too. That means it's advised to mask up indoors and public at most places on the Jersey Shore.

The CDC also cited increasing evidence that vaccinated people who don't even know they have asymptomatic cases of COVID, can spread it to unvaccinated people who are more at risk for serious illness. We'll talk about all this now, and big new study of all New Yorkers who have been tested for COVID and tested for antibodies for COVID during the whole pandemic. That study was done by CUNY and the Urgent Care Chain CityMD.

With us now are Dr. Denis Nash, Executive Director of CUNY's Institute for Implementation Science in Population Health, which means in plain English, he's a COVID pandemic expert, and Dr. Dan Frogel, Regional Chief Medical Officer for CityMD. Dr. Nash, welcome back. Dr. Frogel, welcome to WNYC.

Dr. Denis Nash: Hey, Brian, thanks for having us.

Dr. Dan Frogel: Thank you.

Brian: Dr. Nash, if we can start on the news, we've had the vaccines for six months now or so, all of a sudden there are all these mandates to get vaccinated or get tested from all kinds of employers. Why is this happening in this way?

Dr. Nash: Well, it may come across as a surprise to many people, and I think that partly has to do with the way that it was rolled out to begin with. When it happened, when the mask guidance initially came out from CDC, I was thinking, "Geez. They have to be also aware of the possibility that we could be seeing surges in cases like they're seeing in the UK as a result of more transmissible variants. They should be messaging along with that possibility to us about masking here in the US too," but they didn't. They said, "You don't need to worry about masks anymore if you're vaccinated, period."

We would be in a no better place now from a messaging standpoint had the CDC just said, "Look, this is what we're doing now, it's quite possible that things could

change for the worse, and we're going to need to walk and back." They didn't do that, and so now it feels like a big reversal.

Brian: I want to open up the phones on this right away and invite calls from New York City municipal workers, teachers, police officers, anyone else who works in city government, on the mayor's new mandate to get vaccinated or get tested to go back to work in person, 646-435-7280. Or, of course, even if you're working in person, this will be a requirement starting in September, earlier if you work in the public hospitals, 646-435-7280. Help us report this story.

What's the conversation like about that now, between you and your co-workers? What's your own opinion about maybe we should call it public safety versus individual choice, and your sense of how divisive or perhaps not divisive? This is among you and your colleagues, 646-435-7280, or any questions on the new masking guidance or anything relevant to our guests, Dr. Denis Nash, from CUNY, and Dr. Dan Frogel, Chief Regional Medical Officer for CityMD, 646-43 5-7280, or you can tweet your question or comment @BrianLehrer.

Dr. Frogel, one way to look at the mayor's mandate and the similar ones from private employers is that it's really a mandate to get tested once a week, and people can opt-out if they choose by getting vaccinated. Given the resistance to the vaccine so far by around 30% of the population in the city, I'm curious what increased demand you're expecting for your testing services at CityMD locations?

Dr. Frogel: Yes, I think it's a very valid point, a very valid question. Back earlier on the pandemic, some of these mandates came down as remember the nursing home employees who required sequential testing once or twice a week during that time, and we certainly saw an uptick in patients seeking evaluation from us. The wonderful thing about us at CityMD is not only do we have the best clinicians and certainly the best access, but we are very logistically prepared to really ramp up what we need to do to really provide access to clinical evaluation, diagnostic testing, and obviously, medical advice for anyone that would need it.

Brian: Has the city government or anyone else approached you to provide on-site testing services at municipal or private workplaces in light of these mandates?

Dr. Frogel: At this point, we're resource-restricted outside of what we're able to provide for our offices ourselves. It has been asked of us to do on-site testing, and do stand-ups, but we really have to concentrate for the accesses that we need, to the patients that we're seeing at our sites, and really being able to deliver the care that the patients are requiring and requesting.

We're not only doing testing at CityMD, we're seeing lots of patients with lots of different complaints that, frankly, actually, most of them have nothing to do with COVID. We certainly need our doctors and our clinicians to be there for that, but luckily, we have the resources to be able to do that. More importantly, we have such a vast geographic footprint, that it's really accessing us at CityMD, it's very easy, we're in all five boroughs, and in parts of Long Island, Westchester, Rockland, and even New Jersey.

Brian: Dr. Nash, multiple people have already contacted me to say they're not convinced that once-a-week testing is enough as an alternative to vaccination because of how frequently people have new exposures. Maybe it should be a PCR nasal swab test every other day or daily rapid test, which is less accurate, but much easier to administer. Do you have an opinion?

Dr. Nash: Yes. I have to say I've been really surprised by how little we've relied on the protection that routine testing can provide in this pandemic, given where we are with vaccination, the technology is there, it's possible to cheaply do more frequent rapid testing in many different situations. I think it depends on the frequency of exposure which in turn is related to what's going on in terms of the levels of community transmission in the background. I do think that the frequency of testing should be throttled according to that, in particular, and anything related to known exposures that happened, but there's the unknown exposures, which are related to high levels of transmission in the background.

Brian: Dr. Frogel, does CityMD offer rapid as well as PCR nasal swab testing?

Dr. Frogel: Yes, we offer rapid testing, antigen testing, those results take about 10 to 15 minutes to get. Then we send out to labs, to an external lab, for our PCR testing, takes about anywhere between one and three days to get those results.

Brian: There's a big difference in the amount of time it takes to get the results, that's why the one is called a rapid test, but how would you describe the differences between them in terms of accuracy and cost?

Dr. Frogel: From a sensitivity perspective, meaning the test being positive when you expect it to be positive, we're finding the rapid test from our internal understanding to be quite accurate. Positive tests are for the most part positive, there are a small number of patients that do test positive that when you do a PCR are negative, but we see that positivity rates are appropriate.

From a screening perspective, though, we do frequently find patients with a negative test, especially those that are symptomatic with a higher pretest probability. In those cases, we do send PCRs, and we do find a little bit more frequently, maybe a double-digit percentage of the time for those patients to have a false negative on those tests. There's definitely difference between the rapid test and the PCR. Right now, the PCR is our gold standard. Obviously, a lot of discussion about that, being valid, but that's the best test that we have and bunching up against that.

The rapid test is a very good test given the right clinical circumstance, assuming the patient's pretest probability, their risk, their symptoms, and what you think as far as what to expect from the results of the test.

Brian: Dr. Nash, some breaking news this morning. I don't know if you've even heard this one yet, but Mayor de Blasio just said this morning that starting on Friday, people who get vaccinated at city run sites will get $100. Are you in favor as a public health professional of in favor of that type of incentive, and do you think it will be effective at overcoming vaccine hesitancy?

Dr. Nash: That's really interesting, Brian. I had not heard that. I think that jurisdictions need to be trying all kinds of different strategies to see if they can increase vaccine uptake among those who are hesitant or otherwise having challenges getting vaccinated. I'm hopeful that-- I think health protection, public health protection is worth paying for and this is what we're trying to achieve here. I think it's worth exploring. I hope that we are able to learn, in fact, whether it is an effective approach so that we can decide if it should continue and other jurisdictions around the country can see if it's worth trying in their own backyards.

Brian: Do you have a comparative opinion between that type of incentive and the vaccine or testing requirements as more effective toward getting more people vaccinated, or is that the wrong question and they just have to work together?

Dr. Nash: I think there really needs to be a multitude of approaches, incentives, disincentives. It really is about now trying to-- No one strategy is going to work for everyone. I'm all in favor of trying multiple different strategies in the hopes of getting us where we need to be in the next few months.

Brian: We have a lot more to do with Dr. Dennis Nash and Dr. Dan Frogel. We haven't gotten to the CDCs new masking guidelines, which are a big change announced yesterday and also confusing to a lot of people, especially a lot of vaccinated people. We'll get to that. We have many calls coming in. We'll take some of your calls and questions via Twitter. Stay with us. Brian Lehrer on WNYC.

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Brian Lehrer on WNYC with Dr. Dennis Nash from CUNY Public Health, and Dr. Dan Frogel, Regional Chief Medical Officer for CityMD. Let's take a couple of calls from city workers with this new vaccination or testing mandate. Jason in Queens, you're on WNYC. Hi, Jason.

Jason: Hello, thanks for having me, long-time listener. As a city worker, I just like to say I definitely support the mandate for vaccines and think it actually should have came sooner really. I'm still a little concerned about the once every seven days test, as you mentioned before, I'm not quite sure if that's even enough. I have some misgivings about what you just said about being paid for getting vaccinated now. I guess I understand the motivation, but do you feel like it's somewhat rewarding vaccine hesitancy in all of us that got vaccinated months ago and not getting that reward?

I'm a little bit mixed about that, but I definitely support the mandate. I also do hope the city reconsiders the work at home policy and is maybe willing to adjust that going forward too so that people that can work at home are not increasing the risk for those that do need to be in the office or on the train or they're in person.

Brian: Jason, thank you very much. There've been all kinds of incentives, lottery tickets, stone arts, Yankees tickets, now there's $100. Joe on Staten Island, your own WNYC. Hi, Joe.

Joe: Hey, a long-time listener. Like your show most of the time. Anyway, I just

wanted to say that if you work for the public, you serve the public's interest, then do it all the time. If you love pulling trash so much, but you don't want to go ahead and get vaccinated, then fine, go work for a company that pulls trash and doesn't require it. Then, you don't get all the good benefits that you get from being a city worker, but you got to take the good with the bad. Sometimes you just got to suck it up.

Brian: Joe, thank you very much. On liking the show most of the time, but not all of the time, I think it was Mayor Ed Koch, who said, "If you agree with me 80% of the time, you're a genius, if you agree with me 100% of the time, you're crazy." Thank you very much for that call. Dr. Nash, we have some breaking news along these lines. Governor Cuomo apparently just said that he will follow President Biden, he cited President Biden as the president who is reported to be mandating all federal employees to get vaccinated or tested. He says New York State will do the same effective Labor Day.

This is a side note, a side political note, in the ongoing war of one-upsmanship between Cuomo and de Blasio, he didn't say he's following Blasio, who did it before Biden. He said, he's following Biden, but nonetheless, Dr. Nash, it looks like all state employees in addition to city employees.

Dr. Nash: I do think it's a welcomed development. I agree with the earlier caller, this is public service and this is public health that the de Blasio administration, the Cuomo administration are trying to help us get to the other side of this pandemic, or at least through it as safely as possible. I do think as public employees and as the city and state government, example needs to be set.

Brian: Elizabeth in Queens, you're on WNYC. You have a question about the new masking guidance from the CDC, right?

Elizabeth: Hello.

Brian: Hi, Elizabeth. It's you do we have.

Elizabeth: Hi. Yes, this is Elizabeth from Queens. I have a question, not just about the masking guidance. I thought it was premature for the CDC to take away the masking requirements back in May, June when Delta variant was coming, but now a lot of my questions are more about how the Delta variant spreads. Most of the people that I know are vaccinated people, but my question is as a vaccinated person if I get an asymptomatic case of Delta, am I able to spread that to somebody who is also vaccinated? That's a huge question for me, especially when I see my senior citizen parents.

That's another unknown that I wish the CDC would talk more about is who are the 1% that are vaccinated that are dying from some COVID now because I would be curious to know what is the impact on the senior citizen segment because a lot of us do interact with elderly parents and elderly relatives and neighbors, and that would be really, really helpful to know. I don't know if the guests have an opinion or an answer about that.

Brian: It's a great question. Dr. Nash, can you help her?

Dr. Nash: Sure. I think the first thing to do is to step back and remember that the vaccines are effective against severe COVID and death from COVID. At baseline, before some of these more transmissible variants came about, they were in the range of 90% to 95% effective, and we know that, in other words, not perfect, but very, very effective. With the new Delta variant, the effectiveness is thought to be a bit lower, like in the high 80% range. The scenario the caller raised here about the possibility of a breakthrough infection with the Delta variant in a vaccinated person resulting in infection of another vaccinated person is certainly possible.

It's less likely that it would be with an unvaccinated person, but certainly possible for the reasons we just mentioned. Not perfect effectiveness, and also individuals, there are individuals for whom the vaccine just doesn't work as well, people with immune suppression, and very old people.

Brian: I guess we could look at stats by some of those particular groups which is very important to do because people who are past a certain age or people with immunosuppression for whatever reason would have different numbers than these, but I'm holding a calculator, Dr. Nash. I just did the math on the stats that I read yesterday of the number of people who've been vaccinated, who've died with COVID, and the number who've been vaccinated in America. It's about a thousand deaths, and about 161 million Americans vaccinated.

According to my calculator, the death rate among vaccinated people who have died from or with COVID in their systems is six 10 thousandths of 1%, six 10 thousands of 1%, would be that death rate. That's worth people knowing when they hear about all these breakthrough infections, right?

Dr. Nash: Yes, I agree. I think the comparison number is the number of deaths among people who are not vaccinated and that rate is obviously much, much higher

Brian: With Delta spreading, however, Dr. Frogel, based on your experience at CityMD, what's been happening with COVID testing. Did it go way down in recent months when the virus seemed to be on the run in the city and is now coming back or how would you describe demand for COVID tests?

Dr. Frogel: Yes, during that time period, late May, early June, when the restrictions were lower, vaccination rates got up and disease prevalence came down, obviously, the demand for testing went down as the positivity rate. What we're noticing now over the last, probably, four to six weeks, a pretty dramatic uptick, and not only the volume of tests that we're doing, but also the positivity rate. At its lowest, we were a positivity rate on our tests that we were administering somewhere between 0.6% and 0.8% of the tests that were performing becoming positive.

As of even most recently as yesterday, we're a shade over 4.5% of the tests that we're administering, and the number of tests that were doing have probably tripled over that time. We're definitely seeing a larger demand for testing and a larger positivity rate. I can tell you more anecdotally, but with some data behind it, the vast

majority of our patients that we're seeing, that are testing positive are relatively mild symptoms.

Even the ones that are vaccinated are experiencing very mild symptoms, very different from what you've seen earlier in prior spikes especially in the early stages of the pandemic. That's very encouraging, that even though the patients that are vaccinated are getting this illness, the illness itself looks to be a lot less potent.

Brian: From there, Dr. Frogel, do you want to tell us about this big study that you and Dr. Nash and your colleagues did at CityMD and at CUNY Public Health on all the kinds of testing done during the pandemic?

Dr. Frogel: Sure. I'll, of course, ask Dennis to interject, certainly keep me honest. Dennis and his team and myself and our team, we have really tried to study the trends of the patients that we're seeing from a demographic perspective. Looking at the test that we were offering, we were doing PCR testing, rapid testing, and serologic testing, and trying to understand not only what types of patients were testing positives in their outcomes, but from a demographic perspective, a geographic perspective where they were coming from, but also trying to understand trends and what was going on with these patients. Patients that had tested positive, did they convert serologically to form antibodies and how long did those antibodies last?

Were we able to identify trends in that and what can we say? How can we shed light on what's happening to the body's response, to the immune response? We're also going to be looking very deeply into the longer COVID, what's been happening to these patients that have tested positive that are reporting persistent symptoms, both symptomatically, and also what's going on in their bodies. What lab parameters are interesting that we need to identify who's at risk for this? Certainly, how the body's behaving from a serologic perspective when it comes to antibodies, are they waxing, waning, and what can we predict for the future?

Brian: Dr. Nash, what are some of the big takeaways from this big study, from the data you already have?

Dr. Nash Well, just to first point out the scale of the work that's been happening at CityMD and around the city, but just that CityMD alone, there were 6.1 million COVID tests done to date since the start of the pandemic on about 2.8 million of new Yorkers, including those in long island and Westchester, with about 290,000 people diagnosed as positive. This is the data set that we're looking at from an epidemiological perspective. We've identified a number of important findings that relate to the epidemic.

One of the key findings was a very high zero positivity rate early on in the pandemic amongst school-aged children. Actually, the highest of any age group, upwards of 25% to 30% among kids age 5 to 14. This we think reflects the amount of exposure that was actually happening in schools before things were shut down and before masks were being used and things like that.

This age-specific zero prevalence information points to the importance of masking when it comes to schools returning fully in-person this fall. Other findings that are very significant in the CityMD data relate to race-ethnicity. We have seen a lot of the health inequities that have played out in this pandemic. The CityMD data has very rich information in their electronic health record on what people coming in for a test report as their race-ethnicity.

Typically, when we hear from the official statistics, they're broken down by a few racial-ethnic groups, non-Hispanic white, non-Hispanic Black, Asians, and other few groups. When you look at the richness of what's in the CityMD data, we're seeing, and just because it's New York City, hundreds of different race-ethnicity groups being reported and within a group, for example, Hispanic, there's many different spent Hispanic ethnicities with very wide variations in prevalence rates. What that says to us is that the way we monitor and report out and think about how this pandemic has affected people of different racial and ethnic backgrounds, it really is oversimplified when we break it down into four or five groups that we hear about.

These are some of the findings that we've been reporting out. As Dan alludes to, there's a lot more sophisticated epidemiological analysis that we can do. One of the ones that we're doing now is to look at among people who are repeat testing. They were positive at one point in the pandemic. We look to see how many of them had a subsequent serologic test. We looked to see if their serologic test, their antibodies are positive or negative. We're beginning to see evidence that after about a hundred days or so after the infection, antibodies begin to wane. About half of people no longer seem to have them after about 270 days. This has implications for vaccination and the need to make sure that people are covered with protective vaccines.

Brian: We have time for one more caller. Here's a question about antibodies to the virus and vaccination from Elaine in Toms River. Hi, Elaine you are on WNYC.

Elaine: Hi. Thanks so much for taking my call. I'll try not to cry while I have this conversation. My husband's a transplant patient, kidney transplant. We know he's gotten two shots of Moderna. He's been tested. He has zero antibiotics. We know that the studies show that if he gets a third vaccine of Pfizer, it increases his rate. They're doing this in other countries. How can we get this done from him? I have called every place, every hospital where we had the transplant done, hospitals in New York, everyone's saying they cannot give him a third shot. When can I get this done?

Brian: Dr. Frogel, let me ask you first as a background question about the antibody test itself since you administer those at CityMD. She's talking about her husband who's a kidney transplant patient who's had both shots of the Moderna, but now tests as not having any antibodies. What does that test actually tell us?

Dr. Frogel: Well, we have to make sure we're understanding. There are two readily commercially available antibody tests. One test for the spike protein and one test for the nucleocapsid protein. It's important to understand the difference. The nucleocapsid protein, test-- Let me start back. When somebody has been infected with COVID, when we do an antibody test on them, we should be able to measure

both the spike protein and the nucleocapsid protein.

If someone hasn't been infected and there's only been vaccinated, we would for the most part expect them to have a spike protein response because that's what the body does. For the mRNA vaccines, it elicits the body to create spike protein antibodies. I think for your husband, it would be important to understand which tests we were actually doing. If it was the nucleocapsid antibody test, you may want to get the spike protein antibody test, especially if he wasn't infected to see if he's truly had an immune response to the vaccine.

Brian: Elaine, I hope that's helpful. I'm going to ask one closing question of Dr. Nash that may further inform how and if you can get that third shot for your husband that you want to get. It's actually based on more breaking news, a big morning for breaking COVID news. Dr. Nash, Pfizer just posted data, and CNN is reporting a third dose of the Pfizer COVID-19 vaccine can strongly boost protection against the Delta variant beyond the protection afforded by the standard two doses. Now, of course, this is from the company and we've talked before on the show about how the company would have a vested interest in selling more doses. This is not peer-reviewed yet or published, but it is released by Pfizer and being reported on this morning. What's your reaction?

Dr. Nash: My first reaction is that we have to keep our eyes on the prize and what we're looking for with vaccines is protection against severe disease and death at this point. I wonder when they're referring to these new data, it's talking about infection or if it's talking about severe disease. I think if it's infection, it's probably less important to pay attention to right now. We do need to be thinking about people like your caller's husband and all people who are immunocompromised as the first potential group to be worrying about for boosters.

I know that the Biden administration and others have been looking at the need for boosters, particularly for these groups; people with HIV, people who had transplants, people who are cancer patients, et cetera. Very important to be thinking about how we can get them protected. It may be that they need a different vaccine than the first one that they got if they're not having the kinds of neutralizing antibodies to the spike protein that Dan alluded to. I think we need to figure this out quickly for them.

Brian: Would you recommend anything for Eileen if she and her husband are convinced that he should get a third shot? Some people walk into pharmacies and say, "I haven't been vaccinated yet," and ask for a dose.

Dr. Nash: Well, I wouldn't recommend doing that without talking first with his provider. I think Dan's suggestion is really great. I would want to know what antibody test has been done. It would make sense that he's not showing any antibodies to the nucleocapsid protein, but the spike protein is the one they should be looking at. Try to work closely and really push with your healthcare provider to make this happen.

Brian: Eileen, good luck to you and your husband. We thank Dr. Dennis Nash, Executive Director of CUNY's Institute for Implementation Science in Population

Health, and Dr. Dan Frogel, Regional Chief Medical Officer for CityMD. Thank you both so much.

Dr. Frogel: Thank you.

Dr. Nash: Thanks, Brian, for having us.

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