NATURE PODCAST

Coronapod: “Test, test, test!”

If testing and contact tracing are key to controlling the coronavirus outbreak, why aren’t they being done around the world?

In the first of our new podcast series, Benjamin Thompson, Noah Baker, and Amy Maxmen discuss the epidemiology needed to control the Covid-19 outbreak.

In this episode:

03:57 Testing times

Case numbers of Covid-19 have leapt around the world in recent days, but how many undetected cases are out there? We talk about the urgent need to deploy two of the cornerstones of effective epidemiology – testing and contact tracing – and discuss why these measures aren’t being rolled out worldwide.

News article: Scientists exposed to coronavirus wonder: why weren’t we notified?; News article: South Korea is reporting intimate details of COVID-19 cases: has it helped?; News explainer: What China’s coronavirus response can teach the rest of the world

14:23 Global governance in the wake of Covid-19

The International Health Regulations (IHR) were set up to help countries prepare for, and respond to, public-health emergencies. Rebecca Katz, a health security researcher specialising in emerging infectious diseases, tells us how the IHR are holding up during the Covid-19 outbreak.

Worldview: Pandemic policy can learn from arms control

Never miss an episode: Subscribe to the Nature Podcast on Apple Podcasts, Google Podcasts, Spotify or your favourite podcast app. Head here for the Nature Podcast RSS feed.

Nature Briefing

An essential round-up of science news, opinion and analysis, delivered to your inbox every weekday.

Transcript

In the first of our new podcast series, Benjamin Thompson, Noah Baker, and Amy Maxmen discuss the epidemiology needed to control the Covid-19 outbreak.

Benjamin Thompson

Welcome to Coronapod.

Noah Baker

In this show, we’re going to bring you Nature’s take on the latest COVID-19 developments.

Benjamin Thompson

And we’ll be speaking to experts around the world about research during the pandemic.

Amy Maxmen

I really don’t know how this plays out. We also don’t know a ton about this virus. There’s so many open questions. I just have a really hard time making predictions because I don’t know how the outbreak is going to change.

Benjamin Thompson

Hi, Benjamin from the Nature Podcast here, coming to you direct from my basement in South London, and I’m joined by Nature’s chief multimedia editor, Noah Baker. Noah, how are you doing and where are you right now?

Noah Baker

I am currently sitting in a crudely constructed pillow fort, which I’ve made out of an old dog crate and some duvets, to try to get a good-quality recording in rural Kent where my family live.

Benjamin Thompson

It’s not just me and Noah. We’re also joined by Amy Maxmen, senior reporter here at Nature, and you’re in San Francisco, right?

Amy Maxmen

I’m actually in Berkeley, California, right across the bay from San Francisco.

Noah Baker

So, Amy, our offices in London are closed, which is why Ben and I are held up at home. What’s life like in the Bay Area right now?

Amy Maxmen

It’s a state of emergency in California, and in this area, we’ve had orders to, they call it ‘shelter in place’, so only go out for essential duties.

Noah Baker

Does that mean that you aren’t able to leave the house to report?

Amy Maxmen

I don’t know about that one. I’m not going to ask.

Noah Baker

So, I assume that means that you’ve been calling up a lot of sources as you report on this outbreak?

Amy Maxmen

Yes, I have. I’ve been talking to lots of people around here. I know a lot of scientists between the University of California, San Francisco and Berkeley, Stanford, and I know that of course there’s this spirit of disruption here, so there’s all these biotech incubators, so you can imagine that there is kind of a lot sort of ramping up right now.

Noah Baker

It’s a really bizarre one to know how to report on something when you’re stuck in a room.

Amy Maxmen

It’s true. I mean I’m usually stuck in a room so it’s not really that different.

Benjamin Thompson

Well, it seems like this week has been a very significant one for us here. Offices and businesses are closed and it looks like schools are going to soon as well. Things are definitely happening apace.

Noah Baker

I was actually in Morocco at the beginning of this week. I left to go to Morocco on a holiday with all the government advice saying that’s just fine, and then we arrived and Morocco closed all of its land, sea and air borders in this very unprecedented move, and no one knew what to do about it. I’ve never followed an ambassador’s Twitter thread as closely as I did while I was in Morocco, and he was going, ‘Honestly, I don’t quite know what the situation is. This is unprecedented. We don’t know how to get you home,’ and this is the same for people all over the place, and these measures are coming in and it’s blindsiding people. Luckily, I did just about get on my last flight, but it’s scary times. People are scared.

Benjamin Thompson

Well, my story is much less exciting than that. I like to bake my own bread and the supermarkets here have been stripped bare of flour and, it has to be said, a great many other things as well.

Amy Maxmen

I wonder if it’ll restock because we had the same thing here and it was crazy, and that initial human response, like ‘Holy crap! Stock up on everything’ passed, and now they’ve restocked and they’re not allowing lots of people in the store, and it’s really calm and full of food. It’s weird.

Noah Baker

I’m kind of tempted to think that’s what’s going to happen here as well in general. Once the initial panic buying gets over, then people will settle in to what is essentially quite a dull time for a lot of people, which is staying at home and not being able to do very much.

Benjamin Thompson

I’ve got a stack of books this high to read, but I also have a child under one who is maybe not usually that up for just sitting quietly why I have an old read, so I think it’s going to be quite the time here I reckon.

Amy Maxmen

I like reporting so I’m busy.

Noah Baker

I can imagine, especially for you, you’re constantly busy right now.

Amy Maxmen

Yeah, I feel like I’m definitely not worried about being bored. I just mainly need to stay off Twitter for my sanity.

Benjamin Thompson

Noah and Amy, it seems like testing has been an important word this week. The WHO have been leaning quite heavily on countries to pick up the slack.

Amy Maxmen

So, that’s definitely true in the US. Testing is far, far, far below what it should be. I think a number of Asian countries have shown that you can test lots of people rapidly, and we had real problems, which I kind of covered a couple of weeks ago, with labs not being allowed to sort of use their tests with their being kind of a shortage of the tests from the CDC, and now that places are just finally allowed to ramp up, it’s taking them some time. There’s also a lot of regulatory hurdles to get through, so there’s not nearly enough testing. You have to have like a lot of kind of qualifications to get tested, such as be in a hospital with trouble breathing or have trouble breathing and have had known contact with somebody with COVID-19. Something else that the WHO is concerned about, as well as a number of epidemiologists I’ve talked with, is along with testing, kind of a part of the cornerstone response in all outbreaks is you test aggressively when you think somebody is suspected, and then rapidly figure out everybody they had close contact with for the past two weeks while they might have been infectious. Reach out to them, and then ask them to self-quarantine and to monitor them over time, and that can mean just a phone call to ask do they have any symptoms, and the second they show symptoms, to get them tested, so that’s kind of the cornerstone response that, say, Singapore truly excelled at. There’s reports of them doing this kind of investigation within two hours, figuring out all of the contacts and that’s sort of what’s lacking right now here.

Noah Baker

Yeah, it’s interesting because that has been very much in a lot of the response in East Asia. It was also true in South Korea. There was this very sort inclusive and holistic contact tracing that happened, and it’s interesting to me that in the UK this isn’t really happening to that extent either, and do you have any sort of idea as to why that approach hasn’t been taken in other countries?

Amy Maxmen

It’s really hard to say why. I can think one thing that’s definitely true is it’s not necessarily that there’s like a shortage of tests. Tests are kind of built with very basic molecular biology equipment, so it’s not so much a lack of tests as it is testing, as in all of the stuff that it takes to get a test done, which is getting the samples to the place where they’re being tested and having enough people at that place to run all of these samples. So, there’s a lack of testing, so that’s the first step. And then after that, you do have to have people who will talk to the person who tests positive, figure out their contacts and then reach out to those contacts and then even monitor them for 14 days, and like I said, it could just be even a phone call or you could think of tech solutions. So, why isn’t that happening? It all just takes a lot of work, quite frankly. It just takes a lot of person hours.

Benjamin Thompson

Amy, you’ve been talking to folk affected by this lack of testing.

Amy Maxmen

Very sadly, there’s one researcher, he’s a geneticist in Utah, who posted on Twitter, ‘I’m in the ICU with coronavirus,’ and it turned out that if you followed his thread, just about a week before, he attended a small meeting. It’s an NIH meeting to go over grant proposals where there was about 24 other geneticists. They sat in a small room for two days, and the way that all of these people who had sat in that meeting with him found out that one of their colleagues who had shared that small room had COVID was through Twitter, and that meant that for this whole past week, not only had they possibly been infected, but they’ve been mixing with their people at home. Very sadly, one of the researchers who I spoke with who had been at that meeting, she found out just after she had had dinner with her 88-year-old mother and 84-year-old father-in-law, and both of them have underlying conditions such as diabetes, and she’s just rightly terrified that she might have infected them and they could end up in the hospital or even worse.

Noah Baker

In the UK, initially there was this lack of testing – it was there but it wasn’t as prominent as it was in other countries – and now, the latest sort of advice that’s being given or the latest announcements that are coming from government advisors is that we are going to be ramping up testing. Is there any sense that the same is happening in the States now?

Amy Maxmen

I think a lot of researchers are getting frustrated with this idea of we’re ramping up testing, we’re ramping up testing. Well, it’s been three weeks and I spoke with somebody who’s an infectious disease specialist and a doctor who had also worked in Guinea during the Ebola outbreak in 2015, and he was saying right now, in kind of one of the wealthier parts of California, it’s taking up to three days to get results from a test.

Benjamin Thompson

What about other places in the US? I read reports that every state now has reported COVID-19.

Amy Maxmen

I think what’s happening in the Bay Area is probably happening elsewhere. I think there’s probably universities and also commercial labs that are ramping this up right now. It just sort of takes some time. I guess the big question looking back is why weren’t these steps taken back in February when it was clear that the outbreak was gigantic in China and that it was spreading?

Noah Baker

That’s something that we’ve certainly discussed as well in Nature’s pages, and there were calls from scientists to say no, follow the WHO guidelines sooner – test, test, test – and it seems odd that there is this disparity between the way that countries reacted, and one can only assume that perhaps there’s political drivers there, perhaps there’s conflicting scientific advice. It’s hard to really know what the reason for all these different decisions has been.

Amy Maxmen

Yeah, I agree, and it’s definitely something that I’m going to be looking into.

Benjamin Thompson

If we take a look at what else has been going on then, at time of recording, in China they have reported no new local cases of COVID-19, which suggests there are ways to get on top of this outbreak.

Amy Maxmen

You know, I actually just spoke with somebody from the World Health Organization, and I asked her kind of, ‘Listen, there’s even projections that maybe there’s more than 83,000 cases in the US right now and we’re just not seeing them because of a lack of testing.’ Mathematical modelling got that number. I was like, ‘Is it just too late for testing, contact tracing and quarantining if there are this many cases, which is sort of what some people are saying?’ And her immediate response was, ‘Definitely not,’ and she pointed to China where this is considered to be the number one reason why they were able to contain this outbreak, and there was one study that was covered in one of our recent stories at Nature that shows that without these measures, China’s outbreak might be five times worse than it was.

Noah Baker

And I think a similar study, so this might even be the same study from Southampton in the UK, suggested that if these measures were take one week earlier, it could have reduced the number of people infected by 66-67%, like a really, really high percentage.

Amy Maxmen

Yeah, exactly, so it was that same study, but that difference also comes from all of the measures – that’s including the contact tracing as well as social distancing and travel bans and everything like that.

Noah Baker

And just to play devil’s advocate here, we’ve also had a story that our reporters have been working on in Nature this week, which is saying that actually, some of these contact tracing measures may actually now be crossing some other lines when it comes to things like privacy.

Amy Maxmen

So, yes, I think there was a story from South Korea that sort of pointed out health authorities were alerting contacts. You would get a text message on your phone saying that somebody you might have been in contact with has tested positive. You might even learn what that person had done within a couple of weeks before – I think that might have been part of it – so there’s questions about privacy that come up here. I think all of these measures are not fun or good. They’re all costly in some way. So, if you’re doing a lot of heavy contact tracing and quarantining, that’s going to infringe on our privacy. On the other side, if you’re weighing only the social distancing side, if you’re somebody like me who pretty much worked from home anyway, this sort of social distancing measure is almost cute. It means I’m going to like cook more and read more and that’s fine, but after a week or so, this is going to be hugely detrimental to the economy. Closing schools is really, really, very hard on parents. It takes out the workforce. So, just to be clear, I think both measures are good but just relying on one of them is a little bit dangerous.

Benjamin Thompson

But it seems that there’s also the issue that when these measures are alleviated, and of course hopefully that’s sooner rather than later, but when they are, everyone goes out at the same time to the cinema or to a bar and we get the whole thing all over again.

Amy Maxmen

Exactly, and one other thing that the WHO is saying about contact tracing is if you let up on that, you’re sure to get spikes. If you’re only pushing for social distancing, you’re sure to get a spike from a case like that, and if you’re not precisely trying to track those clusters and stop them from spreading further, this might go on for a very long time.

Noah Baker

So, do you have a sense of what the exit strategy might be when you’re talking about social distancing on a government level? Everyone can separate themselves from each other but how do you end that? What’s the end game? Is it a vaccine? Is it a treatment? How do you stop that?

Amy Maxmen

I feel like at this time, I am afraid to sort of make predictions because I really feel like we’re in unprecedented times, and the countries we look at having done well at this did things that we’re not doing. So, if we’re doing this different thing, where we’re going to mainly rely on social distancing measures, I really don’t know how this plays out. We also don’t know a ton about this virus. We don’t know if it changes with the weather. We don’t know if people can be re-infected more than once. We don’t know how much children are carrying it or how much asymptomatic people are spreading it, so there’s so many open questions. I just have a really hard time making predictions about how policies will change because I don’t know how the outbreak is going to change.

Benjamin Thompson

Well, Amy, as you say, loads of questions left to answer, and I reckon there’s loads left to ask as well. Now, I know you’ll be doing some of that over the next seven days, so let’s all meet up again then and find out what’s been going on. Noah and Amy, thank you so much for joining me today.

Noah Baker

Thanks, and I’ll see you next week.

Amy Maxmen

Take care.

Benjamin Thompson

As well as getting updates on the news, for this new podcast, we also wanted to hear from people whose work relates to the COVID-19 outbreak or who have been affected by it in some way. One of these people is Rebecca Katz, a health security researcher specialising in emerging infectious diseases. Last November, you may have read a World View that she wrote for Nature, discussing the potential shortcomings of the International Health Regulations. Now, these regulations were set up to guide the world in the event of a pandemic, and shortcomings may be problematic considering the current global situation. Nature reporter Nick Howe chatted to Rebecca earlier this week about how these regulations are holding up and what lessons we can take forward from this outbreak. He started by asking her how the WHO’s lack of recourse is bearing out in the wake of the coronavirus pandemic.

Rebecca Katz

The WHO struggles with the fact that it is a member-state organisation and that for any international agreement, there’s a balance between the agreement one strikes and national sovereignty. Where this is playing out right now are issues like travel restrictions and border closures. When the WHO declares a public health emergency of international concern as they did at the end of January for COVID, it comes with a set of evidence-based recommendations from the emergency committee on things like travel and trade. And those are just that, they’re recommendations, and the challenge is whether countries actually follow them. So, all of the travel bans that we saw initially in response, including the United States banning any travel from China, that was in violation of the International Health Regulations.

Nick Howe

Right, we’re seeing more and more of these bans spreading. From your perspective, is this a good policy or I’m assuming there are reasons that these were part of the regulations the WHO put forward.

Rebecca Katz

I’m personally a little torn right now because I spent the last, what is it, 13 years studying the International Health Regulations and being a bit of a cheerleader for the treaty. While the WHO is still trying to provide that evidence base and guidelines, we’re very clearly seeing every country in the world kind of make their own call. And so, I’m torn because I’m personally struggling with how effective are the International Health Regulations at this point. Do we all acknowledge that nobody is paying attention to this agreement or does the organisation start to kind of adapt itself and think about what’s the best type of evidence they can and should be providing to countries around the world.

Nick Howe

These regulations are there in order to try and protect global health. What could be the potential downsides of countries going their own way and doing their own risk assessments?

Rebecca Katz

One of the reasons that we have an international agreement, it’s not only to protect public health but to do so under a certain set of conditions, so to take actions in ways that protect human rights to the extent possible, to take actions that limit travel and trade interruptions as much as possible. So, I think that is the challenge and as countries move on and do their own decisions, not to say that they’re necessarily wrong from a public health perspective, it means that there isn’t this overarching umbrella for the norms and standards that the treaty provide.

Nick Howe

And from your perspective then is there something that we can learn from this outbreak in order to try and improve these regulations or do we just need to get rid of them altogether?

Rebecca Katz

So, no, don’t get rid of them. Absolutely don’t get rid of them. I think they need to be updated, as in I’ve been arguing about this, about this need for them to be fit for purpose. I think they’re critical for outlining the types of core capacities that countries need to have in order to be able to provide an effective response. They’re critical for having this kind of shared government platform. But there is a tremendous amount that we can be learning from what is happening right now that hopefully will feed back eventually into updating and adapting the IHR in the modern world, and that’s everything from the discussions around how we make a declaration of a public health emergency of international concern. There’s been proposals from the secretary to say well, maybe we have different tiers, maybe we have regional before we have global. I think there’s also a lot of research that needs to be done. We’ve proposed some research to figure out what does it actually mean to countries, to organisations, to private industries, when the WHO makes one of these declarations. So, if saying the word ‘pandemic’ means something to an organisation or to an insurance clause then we need to know that, and we need to be able to capture it in a way that feeds directly back to decision makers so they know that if they do or don’t say certain words, what impact it will have on the rest of the world.

Nick Howe

Right, because I remember when the WHO announced that it was a pandemic. I think by that point people had been waiting for a while for such an announcement to be made, so when it finally came, it didn’t seem to make much difference.

Rebecca Katz

Exactly, which gets to why didn’t they say the word? They said everything but the word, and I think it was because they feared it would trigger certain actions.

Nick Howe

And with countries sort of closing borders and maybe not paying that much attention to these International Health Regulations, is there a worry that international cooperation is somewhat breaking down in the wake of this virus?

Rebecca Katz

I think we’re living in very challenging times and I worry about that. I worry about countries nationalising their stockpiles and their manufacturing capacity and I think when people get scared they start to take actions that may or may not be consistent with that they agreed upon during, I guess we’ll call it a peacetime. There are all issues that we’re going to have to revisit, but I do worry.

Benjamin Thompson

That was Rebecca Katz, director of the Center for Global Health, Science and Security at Georgetown University Medical School in the US. So, that’s it for this first edition of Coronapod. We’ll be back next Friday with another episode, and there’ll be a regular edition of the Nature Podcast on Wednesday as usual. Don’t forget to tell your friends about this show and until next time, I’ve been Benjamin Thompson. Thanks for listening.