S1E43: What Sports Can Teach Us About Mass Testing / Michael Mina, Rohan Nadkarni, Stephanie Apstein

“I think it’s a fascinating microcosm of the situation we’re in as a country. I do think the plan has also may be shown a way that the pandemic needs to be attacked on a larger scale, which is what can be done when testing is plentiful and accessible; what can be done when people are taking mask-wearing seriously; what can be done when people are social distancing, seriously, what can we do when people are quarantining seriously?” —Rohan Nadkarni

What would mass testing for COVID look like in America, and what can the world of sports teach us about it? Basketball and baseball teams have used frequent testing with and without strict quarantine to keep the players and coaches safe. On today’s episode of EPIDEMIC, our host Dr. Celine Gounder speaks with Dr. Michael Mina, an Assistant Professor of Epidemiology at the Harvard Chan School of Public Health, and Sports Illustrated writers Rohan Nadkarni and Stephanie Apstein. They discuss the potential and pitfalls of implementing mass testing in the world of sports and how these lessons may translate to the public at large.

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Steph Apstein: If you’re willing to accept a certain number of infections, you can do it without a bubble. And the question is just, “at what cost and how many infections are you willing to accept?” And I think baseball has, has given its answer, um, it, the number, that number is more than zero, and so they’re pressing up.

Celine Gounder: Welcome back to EPIDEMIC, a podcast about the social and public health impacts of the coronavirus. I’m Dr. Celine Gounder. Testing has been one of the biggest challenges of this pandemic. This spring, reagents, swabs, and other materials were in such short supply that people were discouraged from getting tested. And if people did get tested… backlogs left many waiting days… even weeks for results. President Trump has been one of the biggest critics of testing. He falsely claimed that testing was to blame for the soaring number of coronavirus cases across the country. At a rally this summer, he even called for less testing.

President Trump:“ When you test like that you’re going to find more cases! So I told my people, slow the testing down, please!” https://www.youtube.com/watch?v=vFwxvHEg2tM 

Celine Gounder: And at the end of August, the CDC bent to his will. The nation’s top public health authority said people who were exposed to someone with the coronavirus, and did not show symptoms, need not get tested.

But anyone can spread coronavirus — even if they don’t show symptoms. So the only way you’d know to stay home and protect others is through testing. That’s why infectious disease epidemiologists — like Dr. Michael Mina — are looking for ways for people to get tested… every… single… day.

Michael Mina: this should just become part of our daily routine.You would brush your teeth, you’d put in your contact lens and you’d take a coronavirus transmission indicating test.

Celine Gounder: Michael is an Assistant Professor of Epidemiology [00:06:30] at the Harvard Chan School of Public Health.

Michael Mina: The whole goal of this very daily testing in a hotspot is to try to detect the people who are potentially asymptomatically infected first and foremost or mildly symptomatic so they don’t know that they’re infected. Detect them before they go out of their house that morning or, or to class or whatever it might be and block transmission chains.

Celine Gounder: These tests aren’t available at the moment, but Michael says they could be. At the core of a lot of the expensive diagnostic tests… specifically the new lab-based antigen test, there’s a basic bit of technology.

Michael Mina : If you peel away all the plastic and get rid of the instrument, you actually have one of these very cheap to produce lateral flow assays. These paper strip tests that underlies the technology.

Celine Gounder: What you end up with looks a lot like a home pregnancy test.

Michael Mina: You’d end up with a test that works very well for the purposes of detecting somebody who’s transmissible.

Celine Gounder: So many hopes are pinned to the promise of a vaccine, but until an effective vaccine is ready and widely available, Michael says mass testing is one solution we can act on now.

Michael Mina: I view this as a low risk, doable solution at the very least to buy us time until we have vaccines to get epidemics that are raging under control.

Celine Gounder: Mass testing isn’t available currently for several reasons — and we’ll get to those — but there is one venue in American life where there is something very close to it.

Celine Gounder: Sports.

Celine Gounder: In late July, basketball and baseball resumed play. But to make that possible, players, coaches, and staff are getting the closest thing to mass testing we have in the United States right now.

In this episode of EPIDEMIC, we’re going to look at this year’s very strange seasons of baseball and basketball. We’ll find out what their experience with testing can teach the rest of us about how to stop the spread of the virus.

Celine Gounder: Rohan Nadkarni writes about basketball for Sports Illustrated. Long-time listeners of the podcast will remember him from our first episode on sports back in May.

Rohan Nadkarni: Basically on March 11th, the NBA got its first positive corona test while play was still going on

Rohan Nadkarni: It was Rudy Gobert, a player on the Utah Jazz, tested positive and they shut down the entire league basically at that moment.

Rohan Nadkarni: So this plan was hatched to kind of play in Orlando, at Disney World, kind of taking advantage of the fact that they have a lot of hotel rooms there, a lot of space to create courts.

Celine Gounder: So in July, players started to arrive at Disney World to quarantine for weeks before they would be allowed to play. And the testing began.

Rohan Nadkarni: They had to have two negative tests before they were even allowed to leave their hotel rooms. Their food was being delivered to their hotel rooms. And they were able to get this situation underway with no one having any positive tests.

Celine Gounder: After that initial quarantine, players were expected to wear masks and socially distance. Players weren’t allowed to bring their families. No one was allowed to leave the bubble.

Rohan Nadkarni: What they’ve done really is create a situation where it’s easy to test people. It’s easy to trace people if you leave the bubble.

Celine Gounder: The rules were strict. The NBA even set up a hotline players could call to report others who weren’t following the rules. There was an early incident with Lou Williams–of the Los Angeles Clippers–that really shows how the NBA’s bubble system works.

Rohan Nadkarni: Lou Williams, who was a backup guard for the Clippers, had an excused absence for the team. He left the bubble briefly, but while he left the bubble, he was actually caught going to a gentleman’s club in Atlanta.

Rohan Nadkarni: But even that I don’t think he told the team he was going to do that. But even with with Lou Williams kind of breaking the protocol there and going to a crowded place while he was outside of the bubble, you know, the NBA’s protocols able to prevent him from spreading it once he got back inside. Uh, he had to quarantine immediately when he returned to the bubble. Uh, he was getting tested every day. He wasn’t allowed to be around his teammates. He wasn’t allowed to leave his hotel room. So, there have been a couple, uh, hiccups, but, but I think the systems in place have been able to respond to them pretty well.

Celine Gounder: NBA players in the bubble have been getting nasal swab tests. The league has also has been working with Yale’s School of Public Health to develop a saliva-based test. That test, called SalivaDirect, got emergency FDA authorization in August. Besides nasal swabs and saliva tests, the league has also been experimenting with other technology. Things like proximity sensors that start beeping at players when they spend too much time next to someone else. Some players are also wearing a ring that monitors changes in their vital signs that might indicate they’re getting sick. All of this costs money. A lot of money.

Rohan Nadkarni: This is certainly a very, very expensive process and set up for the league.It’s definitely costing them millions and millions of dollars, uh, to put on.

Celine Gounder: But so far, it’s working. At this recording, there hasn’t been a single case of COVID inside the bubble.

Celine Gounder: So if the NBA is the gold standard for coronavirus testing and prevention in the sports world, what does that make baseball? We’ll find out… after the break.

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Celine Gounder: This is Stephanie Apstein. She’s a colleague of Rohan’s, covering baseball for Sports Illustrated.

Stephanie Apstein: Well baseball is tough because in some ways it should be an easier sport to play. It’s outdoors, and it’s naturally fairly socially distanced, but it’s also… dirty. There are a lot of pitchers licking their hands. There’s a lot of spitting, a lot of behavior that would be sort of an epidemiologist’s worst nightmare, I think.

Celine Gounder: She says baseball’s experience this summer shows how important testing can be…and the limits of testing in the absence of other measures.

Stephanie Apstein: This has been one of the problems I think that baseball has faced. They’re testing every other day, which doesn’t sound that bad, but there are often delays of up to 48 hours when getting the tests back and because the sport is played every day, you end up with cases in which you could go almost four days between a testing positive and knowing about it. These doubleheaders, you could play like six games before you know that you’ve tested positive.

Celine Gounder: Compare that to the NBA’s bubble, where teams only play once a day and get tested everyday, regardless of if there’s a game or not.

Stephanie Apstein: You’ll have zero positive tests, zero positive tests zero, one, two, our, eight, and all of a sudden, it builds really fast in a way that they, I think were surprised by when, at first, when, when it first happened to the Marlins, I think they thought they had it under control…

Celine Gounder: Soon after, the St. Louis Cardinals had their own outbreak.

Stephanie Apstein: At one point 40% of the games scheduled that day had been postponed. So it’s been, it’s been pretty bad. At one point, most teams had played sixteen or seventeen games, and the Cardinals had played five.

Celine Gounder: MLB has postponed more than thirty games this year because of coronavirus concerns. At this recording, the New York Mets and Yankees were the latest teams to delay a series because of COVID.

Celine Gounder: So why did MLB opt for testing every other day? Stephanie says it has a lot to do with costs. There are a lot of people that need to get tested.

Stephanie Apstein: They are testing every player and they’re thirty teams, times twenty-eight players on rosters, three men taxi squad plus the, the minor leaguers they have at their alternate sites. And then they’re testing all of the coaches, stat guy, every PR guy, every trainer; its adds up a lot

Celine Gounder: The other major difference is, of course, that baseball is not being played in a bubble.

Stephanie Apstein: One thing that the NBA and NHL had going for them is that they were mostly only trying to stage the playoffs. Baseball was going to have  to try to do the entirety of the season. So the players were understandably not thrilled at leaving their families for that amount of time. And then also the owners were not very excited about it because the owners get a lot of money from stadium sponsorships. So the owners really wanted to have the games at home too. So there was no one really pushing for the bubble plan. So it died pretty quickly.

Celine Gounder: Comparing the experience of MLB and the NBA what are, you think, are some of the lessons that can be taken in terms of what works and what doesn’t work?

Stephanie Apstein: Uh, I mean, I think it would be impossible to do this without testing. It would be better if they were doing it daily but certainly if they had any less testing than they have right now, this would be a total disaster.

Celine Gounders: Take what happened to the Marlins.

Stephanie Apstein: The team has said, unequivocally, that they were not doing anything salacious. There were a few guys who went to get coffee, and there were players who got a little too comfortable and hung out around each other with their masks off. And that, it was kind of what most people are doing these days, so if behavior like that can lead to the outbreak on the scale that we saw with the Marlins, I don’t know how you avoid just decimating large groups without very regular testing.

Celine Gounder: The epidemiologist we heard from at the top of the show, Dr. Michael Mina, was asking himself the same question. How do you handle this pandemic if people don’t wear masks and socially distance perfectly? Is daily testing the answer?The highly sensitive nose-swab and saliva tests used by MLB and the NBA are known as PCR tests. They’re expensive… and they require laboratories to process the results. This level of testing is great if we want to know if one person has COVID. But if you’re trying to test the entire population of the United States, it’s not going to work. Major League Baseball was struggling with outbreaks when they were testing players every other day. If the average person has to wait up to a week or more for results, a coronavirus test is pretty much useless.So Michael is calling for a different kind of test. Something that can find the folks with the greatest risk of spreading the disease without bogging down the rest of the system.

Celine Gounder: Imagine if COVID cases were like fires in a city and PCR tests were like fire alarms.

Michael Mina: PCR doesn’t necessarily distinguish between the houses that are burning up in flames versus every time somebody lights a small match and puts a candle in their window. We don’t want to distract the fire brigade from going to the houses that are burning down by asking them to check out every single house where a match is lit. We want to have a test that is laser-focused on the greatest threats of the moment and those would be in this case, not the individual candles, but the houses that are, that are in a ball of flames.

Celine Gounder: He calls it public health testing.

Michael Mina: This is a pandemic. This is something where we want to focus less on the individual result and more on the power of that result to break transmission chains and affect change at the population level.

Celine Gounder: But there’s a problem. At the moment, there’s no regulatory pathway to bring these tests to market.

Michael Mina: I think to really get them out into the public will take either some change at the FDA to make a new regulatory pathway that evaluates these in the context of public health and does not compare them to the gold standard PCR.

Celine Gounder: The FDA could say these tests are public health surveillance tests a s opposed to clinical diagnostic tests that health care providers use in hospitals and doctor’s offices.

Michael Mina: And if that were to happen, then, I think the CDC or the NIH would have to step in very quickly and start certifying these tests because we don’t want bad tests to flood the market, like we saw with serology early on.

Celine Gounder: But not everyone agrees with Michael’s plan. Critics argue that even if a fast, cheap COVID test were available, it’s unlikely people would take it everyday. Michael says the point of mass-market rapid tests is not to replace masks and social distancing and other pandemic protocols. It’s just one more tool–layered on top of everything else–to help slow transmission.

Michael Mina: I always point to masks as a good example of what happened early in this pandemic when everyone said, “if you don’t have an N95, then don’t wear any masks you’ll, you know, you’ll,have a false sense of security.” Now nowadays we of course know that a lot of different types of masks can be used. The same thing is happening with these tests.These don’t have to be perfect. They just have to cut transmission in the same way that masks don’t have to be perfect. They just have to cut transmission, as long as we are still carrying forward with all of the public health efforts that we would otherwise be doing.

Rohan Nadkarni: I think it’s a fascinating microcosm of the situation we’re in as a country

Celine Gounder: Rohan Nadkarni, again.

Rohan Nadkarni: What the NBA is doing is feasible on a larger scale. But the problem is everyday people aren’t being given the resources like these players have to survive this pandemic. But if you’re, if you’re given those resources, if you’re given a reason not to leave your home and the messaging on masks wearing is consistent and, and in testing is plentiful. You’re seeing the results that can have. These people are, frankly, they’re able to go to work now because of the protocols in place.

Celine Gounder: But in the meantime, the NBA’s bubble at Disney World feels more like a fairy tale than reality. The vague protocols and outbreaks of the baseball season feel more familiar. Baseball players are definitely a privileged group, but they’re experiencing the same dilemma as many Americans: how to stay safe and still go to work? Here’s Stephanie Apstein again.

Stephanie Apstein: They’re kind of relying on the players’ desire to finish the season because the players only get paid if they finish the season. So their hope is that everybody is incentivized to take this seriously and behave.

Celine Gounder: We all have these same incentives, right? If we want society to fully re-open, we have an incentive to wear masks, social distance, and stay home if we’re sick. But the lack of leadership during this pandemic has shifted that responsibility to individuals.

Stephanie Apstein: This idea that the players need to be better has been hard for me to hear. And I hear it in…not just as it pertains to sports. You hear it I think a lot of the time from governors who lament all these young people who are at bars. Well, okay, but who opened the bars? You know, we have to ask them or leaders to make policies that people can follow. We can’t ask every citizen to be a public health expert.

Celine Gounder: Well, it’s also interesting that the financial incentives are not so strong that there’s not still some, some mixed adherence, you know? It doesn’t bode well for the reason of us.

Stephanie Apstein: It also seems like if you’re willing to accept a certain number of infections, you can do it without a bubble. And the question is just, at what cost and how many infections are you willing to accept? I think baseball has, has given its answer. Um, the number, that number is more than zero and so they’re pressing up.

Celine Gounder: “Epidemic” is brought to you by Just Human Productions. We’re funded in part by listeners like you. We’re powered and distributed by Simplecast.

Today’s episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Annabel Chen and Bryan Chen.

Additional audio in this episode from ESPN, CBS Sports HQ, MLB, and ABC News. Special thanks to Laurence Kotlikoff.

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And check out our sister podcast “American Diagnosis.” You can find it wherever you listen to podcasts or at americandiagnosis.fm. On “American Diagnosis,” we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health; in season 2, the opioid overdose crisis; and in season 3, gun violence in America.

I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”