 All right. Well, hello everybody. Welcome to the second of what promises to be a more interminable than we want it to be series about COVID-19, the global pandemic, the national US scene, what we're learning and what we should be doing about it. Due to the weird dynamics of zoom people are still pouring into the holding pen area for the webinar. So we're going to get to a rolling start. My name is Jonathan Citrin. I teach on many things digital at Harvard University, and I am pleased with Dr. Margaret Bordeaux to, and our colleague Urs Gasser to co-chair a student at the Berkman Klein Center for Internet and Society on digital pandemic response. And as part of that, we're doing a series of zoom casts or whatever we're calling these things these days, where we talk with colleagues and people we'd like to be our colleagues about the dynamics of the pandemic and what's happening, what we know, what we don't know, and what you should know as a random person tuning in on zoom or watching this after the fact. So we should introduce the rest of our three person panel here. Dr. Bordeaux, Margaret, you are coming to us from probably from a COVID standpoint the safest possible place. You're in the middle of a national park. Is that right? That's right. I'm at Glacier National Park. I'm about 20 miles south of the Canadian border. Ready to make a quick escape. There is some ambient noise around from the train and from folks riding their motorbikes through the park, but it's beautiful here and yes, hopefully relatively COVID free. Wonderful. And Joe Allen, you teach at Harvard University as well in like, it's a weird way to put it, but this pandemic could basically be no more up your alley than any other event, right? This is basically the moment you were waiting for? Well, yeah, I wish it wasn't happening and unfortunately, yeah, this is something we do exposure risk assessment and and healthy buildings. So yeah, it's right in the alley of this pandemic unfortunately. Wonderful. And again, everything has an asterisk, but it's really great to have you here and to have the benefit of your expertise as so many of us are trying to sort out what's going on. And we're starting a slight affectation just curious, as we check in right now. For both you and for Margaret, what three words compound words are okay as a single word you would use to describe roughly the state of play of the pandemic in the United States of America on today, August 18 2020. Joe, what would your three words be? Thoroughly failed leadership. Oh, all right. Three words that work together. And capturing a certain level of disappointment. Margaret, what would you say. Right well I'll keep my word from last time which is reckoning on a bunch of different fronts tragic is the other thing I think we have to include now. The third is chaotic. I think we're entering a moment of particular chaos. As we go into the fall with some places having rising rising case loads other places trying to reopen schools and universities and businesses and it's, you know, a really very little direction as Joe said, in the way of leadership and then sometimes a malignant malignant leadership. And I imagine we'll have a chance to unpack all of those things over the course of our specifics and what we thought we would do is first get a quick update since our last zoom cast on the state of testing, which Margaret you and I talked about with Beth Cameron and KJ song. So it'd be great to kind of just get a quick snapshot of that situation. And then to talk about some of the evolving knowledge we have around the dynamics of COVID, particularly how it transmits indoor outdoor and admissions buildings pose particular challenges indoor spaces, and then get to school reopenings and talk about that, and then get to any questions. If we haven't hit them already from people who are tuned in. If you're on zoom, there's a Q&A button you can press to lodge a question if you're on YouTube I think you may be so well. So, with that said, why don't we turn to you Margaret and just fill us in since last time we basically talked it was a hair on fire moment around the state of testing in particular the delays in returning so called molecular PCR testing. So the time you get tested it gets hauled off to a lab, maybe one of just two corporate labs, a lot of the time quest and lab corp, and then can take so long that the point of having gotten tested especially if you're supposed to self isolate if you test positive is kind of lost when it takes so long to get the answer back. So, our great how are we doing since we last talked. Again, I'm never very cheery on the subject, you know, not a lot has changed in the states are scrambling. You know to try to make alternative arrangements so Georgia and Montana where I am right now actually actually had to get a COVID test here. You know, one of my kids spiked a fever and so I had to go and get a COVID test in Montana. They recently announced here that switch labs they were not going to use question lab core, Massachusetts is working very hard to, you know, be less dependent on question lab core. But still, it's, it's, it's not good I don't I don't think we're in a better place. And I think we're just seeing the results of that which is, you know, rising case loads we still don't have our arms around this. So I wish I could be positive but I'm just not. We do see a lot of, you know, announcements about new testing modalities that are coming out and a lot of enthusiasm for what might be able to be accomplished once once they do. But, you know, I'm all about implementation and I just don't see. You know, we need we need the cavalry right now, not in a few months so so I, you know, I still feel not great about it. I do think there is a lot of movement behind the scenes because of the testing issue to get governors to to work together to make a more coordinated plan. So I do think that that is starting to get some traction and there is some movement. So I think that's a silver lining. But, but yeah, no, I wish I had I wish I had better news. Got it. So there might be a rabbit out of a hat at some point but none we don't see tips of years yet, even with some of our colleagues attempting I think to help extract the rabbit. There's been a lot about serological testing, cheap testing that you could do at home as easily as testing your water hardness or something. Exactly. I'm also going to transfer back to plug in my phone so, but yes, I don't see any. I don't see any rabbits in any hats. I think this is all about hard work. It is about systematic planning. It is about leadership and not counting that there's going to be some miracle cure some miracle intervention that is going to save us we are going to have to actually do the work that is required to control this to control this outbreak, and we just have to grow up and do it. All right, well while you figure out a car charging scenario. Why don't we go to to you and I don't know if there's anything you want to add on testing feel free but otherwise I'm happy to get right rolling on one thing on testing really colleague might have been the Harvard School of Public Health Michael Mina and others have been being in charge for trying to pull this rabbit out, really around antigen testing this rapid saliva based but at home testing different from what the MBA and Yale announced of the weekend which is still a saliva based test but it's also a lab based test. So far there is the technology available for at home rapid test but to Margaret's point, you know we need it now. It can be ready but really it's been a hold up on the FDA's part so if you're interested in this topic. I would suggest following Michael Mina, who's been writing about it we put out a video over the weekend on a daily quick test, your hashtag daily quick test you'll find it's got over 100,000 user ready that explains the problem with current PCR testing. A quick test can do for us and really hope people start pushing on the FDA to approve it it takes a different mentality it's not a diagnostic test like we expected the doctor's office. It's a tool to control the pandemic or help control the pandemic so we need a mindset shift here and think about how we think about testing. So anyway that's a that's something that I see is on the uptick right now in terms of awareness and a new push for one of these rabbits out of the house. And you mentioned FDA does that mean that there are other countries where this is commonplace and we're just behind or is the world struggling to do these serological quick tests. Yeah they're not serological tests but yet others are starting to get on this to it's a paper based test and and thing is you can it's rapid right you can get an answer back in 15 minutes so this is the idea. If you mass produce them you can get them down to real cheap like on the order of a dollar per test. And the idea is well if you can drop these into a hotspot that's experiencing outbreak, you're no longer flying blind right even if the accuracy isn't perfect it doesn't matter if it's every day and rapid. Right now, as Margaret said you know we wait seven days that's a that's a useless test to get a result back after seven years. Sorry this is antigen testing and the antigen is trying to detect the virus itself. Exactly, exactly. Got it. Okay. Let's start talking about ventilation as a path towards talking about school reopenings and for that. It just be great to kind of in one place. There's lots of indoor versus outdoor so for example if you're outside and there's a lot of people around all those pictures of people on beaches whether or not using a fisheye camera, you're passing people on maybe a busy sidewalk but you're outdoors, that kind of thing. Are you, how much viral matter might you be receiving if you're passing people who are transmitting. I can jump in there I mean the reality is we don't know the dose response for this virus is one of the things we need to know but we do know that time spent outdoors is much lower risk if you look at all the outbreaks of three more people. Nearly all of them are related to time spent indoors it makes sense we know how this virus is transmitted several modes are operating. And so there's been a lot of beat shaming out there others in our field have been talking about this a lot but the reality is you know people can still have a good time as they can during a pandemic as long as they're being safe and outdoors is a great time to do it. And in fact we should be taking advantage of this the periods where we have this nicer weather to get outside, stay distance because your risk is absolutely lower. One of the key reasons for one you have more space but to is that you essentially take this ventilation question off the table outdoors we have 100% dilution really. So your risk is much much much lower for any buildup or exposure to any airborne viral particles even at close distance. I don't think this is a question you're going to hate to answer but this is like classic sort of clueless consumer question I asked on my own behalf, not just a friend if you had to spend an hour in a public place. Where would you rather be indoors with a mask or outdoors without one. Margaret I know my answer what do you what it was yours. Well I would do outdoors for sure but don't wear a mask I get it but yes. No question I'm with Margaret there. And how bad is a typical modern indoor space compared to say badly ventilated ones and the outdoors. Well you know the reality is we've been under ventilating our indoor spaces for decades we're in the sick building era ushered in by our energy crisis in the 1970s where we started tightening up our building envelopes choking off the air supply to conserve energy. And so the standard setting body that sets ventilation standards for your home my home airplanes schools offices sets a minimum ventilation standard in fact by name it's the standard for acceptable indoor air quality ventilation for acceptable indoor air quality so I don't know about you I don't want to be in a place with acceptable indoor air quality you want good right or healthy. But that's the problem we're in this this era of this acceptable minimums and the end set for energy not human health, going back to the early 1900s we used to set ventilation based on infectious disease transmission. So that's our way we started tightening up the envelope driving down ventilation rates so then you have these conditions where people spending time indoors. There's not a lot of airflow indoor pollutants build up and that's everything from bio effluent chemical exposures and in this case, airborne viral particles. You know, we're, we're, we're, we're paying the consequences right now for our choices that we've stopped designing buildings for people I know we'll talk about schools I can tell you horror stories about the state of us schools and ventilation which is worse than what I just shared now. And can I ask how, how much is carbon dioxide co2 basically our breath coming out with oxygen going in a proxy for viral purposes how dangerous the spaces I have my co2 meter right here. Yeah, it looks like my space is at 712 is that right. Yeah, yep, 712 parts per million. Yeah, so, so for background right co2 majority of indoor co2 is from human exposure, some contribution from what's coming outside we use it all the time in my field to get a sense of the So at some point co2 will hit steady state in your room, a level where it's in balance. You can also look at the decay after you leave a room to get a sense of how well how much it's ventilating. So if you're meeting this minimum standard in most places you'll be at right about 1000 parts per million. In fact, my forensic investigator sick buildings for a long time a lot of people in my field will use 1000 is a quick cut off you go into a place is it 1000 gives you a quick sense. Lots of caveats around that but people use as a quick rule of thumb. You should be under 800 now even closer to 600 ideally and outdoors 400. Yeah, outdoors 400 and rising because of climate rising quickly, our next our other slow roll crisis that's been put on hold for a few months here. But yeah, so it's a useful proxy have to be careful about how you use it. But you know my team, for example, we wired up Harvard Business School just had a pilot day. A test day a mock run to get people back to classroom so we wired up an entire classroom with these sensors to get a set measuring co2 to get a sense of the spatial and temporal variability and as a real time check that the school was bringing enough outdoor air into that space. And is the relationship linear or geometric for instance if it jumps from 400 to 500 and 500 600 is each 100 units of additional parts per million co2 just sort of a linear progression or is it getting much worse for every jump you might detect. Yeah, it's a great question and in terms of what we know about, let's say ventilation, which first we know that ventilation is associated with higher ventilation associated with a lot of positive outcomes reduced infectious disease transmission I'll talk about in a second. Reduce our lower worker absenteeism fewer sick miss miss school days higher cognitive function performance for this virus like I said we don't know this dose response shape yet so it's we can't put a number on it that says hey at 800 your absolute risk is X. We are doing is putting these kind of relative terms on it to say well we know, for example, let's take a let's take a school and put a ventilation rate on this okay. We know at about the minimum standard, the target is 15 CFM per person cubic feet per minute per person that equates to about two air changes per hour. Now an air change means the entire volume of air in the space or in changes with fresh out there. So to air change per hour means every 30 minutes the full volume is cleared out. So if you target for a changes five air changes six air changing you're getting down to every 10 minutes that air is cleaned out. So you can kind of see the step function in risk with that relative risk reduction, but we don't quite know we just know it's better. You know, there's a lot of unknowns though we just you know you want to be an area that is meets that's above these minimum ventilation standards that we know are not set for infectious disease these higher rates have been associated with lower risk of things like influenza transmission. We just don't have the exact number for SARS-CoV-2. And how much could just for a space that you might be in but you don't own or control so you might be a student in a classroom or a patron in a restaurant. Just visiting and how much could opening a window make a difference for how safe that space is with respect to the breadth of other humans. So you make some massive difference and you mentioned the restaurant there's a high profile investigation that went around in Guangzhou. This restaurant was recirculating air only no fresh out there they had an air conditioner. Nothing wrong with air conditioning unless you're just running it on research mode. So they're constantly recirculating the air and they look they did computational fluid dynamic modeling to show the air was cycling over three tables. It's sick even people who are downwind of the infector the sick person, because you had this kind of confined space and build up of pollutants and to our including the virus. So, if you think about ventilation we can mechanically ventilate like a HPAC system on the roof right, but if you open windows it can lead to dramatic reductions and we've modeled this for example in cars showing that even cracking the window three inches, significantly reduces anything that's in the air the viral particles in the air. We've just wrapped up testing at a whole bunch of schools which I'm supposed to share with my town on Friday. But the takeaway here is that, you know, it shouldn't be surprising you open the windows the air exchange rate goes way up. It's going to depend on pressure differentials temperature gradients and things like this but you know you create you everybody knows that to their house right this is like you don't need a study to show you this. You open up the window create a cross breeze, you know, it cools off if it's you know if there's cooler air outside and you can kind of feel the air so you can get these dramatic reductions. So here may be just if only to preclude a patent by just stating it outright so now there's prior art in the public domain. Somebody could build a little device a gizmo that you put up in the room like a smoke alarm and it's basically a co2 detector. And if it taking into account other factors crests above a certain level says, it's time to open a window or get out and is that potentially a way to outfit indoor spaces so that it's not is this a safe space or an unsafe space but say that safety is going to be a function a lot of stuff including how many people are crammed into one particular place and how the wind is blowing that day that would let people adapt as they go is that a crazy idea or a good idea bad idea. It's a great idea and about you so your million dollar idea unfortunately is taken these exist throughout the world. My, you know, my lab of our we built these from scratch and the whole bunch of companies that sell lower cost real time monitors of air quality. Some of these can connect to the building information system so in real time to your point, hey, you know, CO2 hit a certain level let's open up the dampers in here in fact it's called demand control ventilation. A lot of sophisticated new buildings have that demand control means when CO occupancy a lot of people came into my room right now. If you had demand control ventilation the ventilation would kick on and bring it in. I like this is a strategy know my book on healthy buildings came out April co authored by Harvard Business School, Professor John McComber and we talk about the need to take the pulse of buildings like medical professionals do right it's a signal of some physiological indicator well here we want the pulse of the building. And to do that you take real time measurements of CO2 temperature relative humidity, even airborne particles VOC's as a way to sense you know buildings are changing every second when you're in the room it's changing over the order of years and decades we can see this, but they actually changed within a day. And so the only way to really know what's happening is to take the pulse of the building and take these real time measurements so that you can course correct fast. Right, if you say that Harvard Business School example I gave we had all those people in there. What happened if the ventilation system went down no one would know it. We might describe hey it's getting stuff in here it's a little uncomfortable the temperatures off right you can kind of sense it but you don't know it. And especially now that these levels we're talking about the 800 parts million you can't detect CO2. So the only way to know is to be taking these measurements, and it can be a real time indicator your points that hey we got to do something different, the room dynamics of changing. Got it. It does sound like that could either then be ideally the responsibility of whoever runs the building, possibly compelled to do it by some form of regulation, or failing that I guess those monitors can be cheap enough that you could have patrons of a restaurant students in a school designate one student to bring one or have the teacher have one at the desk. And if it goes off we've got to peel off a few kids or we're going outside I know it's cool today or something like that. Yeah, you know we talked about this with commercial building owners who know for years the paradigm is I'm a certified industrial hygienist these are the people that go out take measurements right. And in past years you go out take an air sample send it to a lab the data comes back and it's owned by the company right and protected usually, and everything's filtered through the company. Well now companies are saying well you know employees are coming in with this $100 sensor, and they don't need a fancy, you know, tests from industrial hygienists they just go hey, it's 12 I just told you the thousands this limit. Now you go into your work and they say it's 1200 in here and you send that to your facilities person right. So it's democratized, you know, this healthy buildings idea, and people are sharing that data they are sharing that to say, you know, buildings again, getting labeled sick buildings. You actually see this on websites like glass door right they don't just talk about their salary their title. You know how much money they're getting people say this place smells like garbage the ventilations poor I've been measuring it the air qualities off. And so these kind of labels are getting stuck on buildings now. And it's because of the democratization people can finally, you know, make the invisible visible with these cheap sensors. We have. Sorry, go ahead Margaret. I was going to say sort of to two other questions that's fascinating. But I'm sure that just to set the stage for our audience. I mean, one is it is covered transmitted through the ventilation system. I think that's one one thing, you know, given the data that you have right now is is covered able to travel through air ventilation systems and how far can it travel. And then two is I'm sure a lot of folks are thinking, well this all sounds good but you know we're in Boston and it's cold outside we have tough winters. You know, how, how do we deal with, you know, the elements in the winter, opening up windows seems nice all the pictures from New York City of all the kids sitting in their, you know, tubes and coats and having outdoor school in the winter during the flu pandemic of 1918. But those two things what's your I'm sure you get those questions a lot. That's a good question and interestingly enough, you know, Dr. Fauci was with us at the school public health, two weeks ago on the forum and I got to ask a question I asked about his position on airborne transmission. So there's some, I think a little bit. It's worth bringing it down for a second and that there isn't evidence yet, and I think it's unlikely that it gets transmitted through the duct into like an adjacent room, or someone can get sick. But there is plenty of evidence that the virus can be transmitted airborne within the room, and that's beyond this kind of magical six foot buffer. And so we're breaking that down a minute to understand where that came from and where it comes from is this you'll hear organizations like WHO still say this that that five micron particles so far as let's back up. And if I'm sick and a cop or sneeze or just talk, I admit a continuum of different particle sizes, right. Some will settle out quickly due to gravitational forces, some will float into the near field before talking and some will float beyond right. WHO says well five micron particles, settle out quickly before that six foot buffer, but that really ignores the laws of physics and many of my field are quite. I don't understand where that comes from because the reality is 100 micron particle is what settles out within three to six feet, a five micron particle will stay aloft for 30 minutes or more. And if you look at even basic airflow in a room, it can travel across the room we know this from aerosol physics right there's no question. The science there tells us this can happen and the reality is you admit a continuum particle sizes but very quickly within a second the large particles in respiratory droplets evaporate. So they might be large in the beginning but they become what we call droplet nuclei smaller airborne particles that can spread airborne. So let's break that that's one line of evidence in the airborne the physics of this. Second, if we have air sampling, we've now detected the viral RNA in places that can only be reached through airborne transport like in ducks right not saying it's infectious but showing that it travels certainly beyond where a patient would be in a hospital. The pushback has been well that's not viable that's just RNA. Well last week someone isolated viable virus. 16 feet from a patient again showing that not only is it spreading past that six foot magical barrier barrier, but can be viable. Third we go to case studies and this is right in my wheelhouse with the examples of the choir practice. The restaurant outbreak my team has modeled the cruise ship outbreak. And in each of those we've shown quantitatively through modeling that airborne transmission is occurring in fact in the cruise ship example we estimate that around 35 to 40% of the population where air assaults beyond that six foot buffer. And lastly have the epidemiology we have the super spreading events, which certainly suggests like other airborne viruses traditional airborne viruses that have a higher transmission through airborne. So I think if you look at the totality of evidence there right, the physics, the air sampling, the quantitative modeling and the epidemiology it certainly all supports the notion that transmissions happening beyond six foot. I said this going back to the first piece of road in early February. It's likely airborne transmission is happening. So we should be prudent and put in controls. The scientific community will argue this for decades, we still argue about influenza transmission modes right. So we're going to argue we won't be resolved forever right it'll be 1000 papers on this. But right now we're in the pandemic the virus points like I want practical I want implementation so bring in a little more fresh out our air and you know what if we're wrong about airborne transmission and it's like 2%. Maybe brought in more outdoor air. But if we're right and it's 40% and you're not putting in that control and adding that to mask wearing and hand washing and distancing well that's a major problem. And that's where we are right now I think all the evidence, every piece of evidence since February supports it there has been nothing to refute it. So I think it's really practical and prudent that people take these healthy building control strategies and put it in their arsenal of risk reduction strategies. It's kind of a nice way of illustrating that maybe the esoteric debate between are they respiratory droplets or aerosols is itself sort of esoteric. Not something it's both because of the 1% kind of doctrine you're mentioning which is like if there's even a small risk that this could be a significant vector we should be accounting for it now. Maybe because it sounds like there can be a shift back and forth even between those categories. So, maybe that's a way into talking about school openings because so far it's sounding like you can open a bunch of windows you're in better shape, but a lot of schools as at least two of our questioners have pointed out, tend to be built possibly because of oil and stock with windows that don't open and otherwise poor ventilation and get your kind of bullish on opening the schools you've written possibly about that and it'd be great to understand more about thinking about school reopening in that way. Yeah, I mean bullish, I don't think it's quite right but you know, look, there are two conditions precedent one you have to control spread and two, you have to make enhancements to your risk reduction strategies within the school. So it's the when and the what when to open, and what has to be done. And so that's where I've been bullish to say hey you know if you do those things sure school should open but if you look at what's happening same Georgia where they went back to schools and there were cases well look what they did right. And it's outrageously high and well beyond the metrics we propose with others at Harvard and what's acceptable for reopening so they felt that, and then on the what to do you see the pictures in there, it's overcrowding. No mask wearing and I've read their plan they don't talk about ventilation filtration. So they failed on both so it's not really a surprise that we've had cases in schools. When they failed to follow those two aspects of what has what metrics have to be have to be met. I am confident if we meet those metrics right if you have low community spread and the probability of entry into the school entering a cases lower that's obvious comes a numbers game. And then if you put these other strategy in place which we know work in hospitals and elsewhere, including and beyond airborne transmission right it's mass wearing is the densification is managing flows of people infuse of people. If you do those things we know we can really drive down risk so you know it's not quite that I'm saying hey everybody I'm not I'm not doing the Trump here everybody get back to school without giving a plan or strategy or resources it says, if you meet these conditions, sure, get back and if you meet these conditions well then you should expect cases like we've done Georgia. Margaret I know you've been thinking a ton about this too. Well, yeah, I mean my, my concern is, as Joe has already mentioned is, you know, really what is the context in which you're opening schools, and, you know, my, I go back to, you know, if basically you're you know your community transmission is is not really controlled and it's really two things it's not just how many infections you have in your community. That's certainly part of it but it's also really understanding how robust your public health measures to end community transmission are. You know, I still feel like people kind of treat this like a hurricane they're like, well the wind speed has gone down so it must be safe to go outside it's like actually you know it's not a hurricane it's stuff that we actually have to take action on to drive down the transmission rates and levels of the virus circulating in the community, and then, you know, take, take those actions, and then let's talk about, you know, reopening and taking on more risk, or at least have that context in mind. So that's where I think there's just a tremendous amount of magical thinking where we just think oh well okay yeah we we put some money in public health oh yeah we have we have a contact tracing program yeah and well we we've told people to wear those masks you know but like, really our testing is still very weak. We still are only detecting about 10 to 20 maybe at most 30% of our active cases that are infectious cases in our communities, in general, and that that's just, you know, so it's just, I think it's it leads people to believe that things are safe and that they're acting responsible when they're when they're not, I mean, and for people. So, so the other thing that really bothers me I mean I'll just to say is you do we do need a national plan. We need a strategy and and and that is to coordinate resources to set standards across states and communities, you know, to have a clear eye view of how we're even measuring community transmission that is in place, and so that's where my frustration is is in that that that we're not having a very intelligent conversation about really what we're dealing with to date. And so that that's not related to schools and whether schools could be made safe they absolutely can be made safe we've seen it we've seen buildings like hospitals as Dr. Allen has pointed out, you know, we can make places safe, but but I think that it's asking a lot to say okay let's reopen schools when we're not having a smart conversation about where we stand with community community transmission in general. I don't think that's that that controversial. But that that's my, you know, anyway, that that's my soapbox. Thank you and that absolutely seems to accord between the two of you with the need for a national plan. In the meantime, given that we don't have one it sounds like what you're each saying is there are conditions in time or somewhere within the US, where I guess transmission rates appear to be at their lowest, where it would be okay to hazard a reopening ready to spring the trap shot again. If we see community transmission going up is that the basic idea. Yeah, I mean I think that that's, that's right. I think the, the, you know, in some senses the K through 12 public school reopenings are, you know, I think I think we are in a better place to deliver that than we are universities because there's something called interstate transit, where people come to universities from other states with, you know, bringing with them the potentially the virus and so you know we are, I guess I feel a little bit on a hook where, you know, we are trying to cope with uncopable things and conditions, instead of trying to turn around and face them and fight them fight for them. We need to fight for a national plan. We need to fight for co or at least across state plan, where we get our governors to agree on standards and approaches and share resources intelligently. And so I think that my point is, is not. My point is, is that let's, let's, let's embrace that challenge. In addition to trying to make do, but I don't want to just continue to just say okay well we just have to make do we live in a democracy. We live in a country that we govern ourselves. So we can, you know, put pressure on our leadership to to do better and to and to work together so I just want to let people off the hook of that particular challenge as we pivot to talking about things like school reopening. And how much should part of the formula be whatever insights, the community is coming to the scientific community the medical community about the dynamics of this particular illness among kids, because we've heard a lot of different things about it. What else equal. And with your interstate travel piece out of the equation let's not let's just say K through 12 or pre K through 12. Is it a different thing with a daycare center versus a third grade versus a seventh grade, because of anything we know about how susceptible people at different ages are to the virus. This is interesting because Dr Alan and I might have way this a little differently you know I'm a pediatrician by training and it. I think this is really been a struggle for me personally. You know where I'm like, we're dealing with a virus where yes the evidence in general shows that you know children either do not certainly don't seem to be getting a sick from it. It doesn't seem to transmit it as readily, but I really have to say I there's some things that really give me pause. Really, this is a new virus you really don't understand the long term sequelae. I am worried about, you know, being overly reassuring. It's hard when I don't really understand the risk of that being said I think, you know the risk of keeping kids out of school is tremendous and that's a known a known risk. So, I've had I really struggled to balance known risk, which is significant against unknown risk that might be from, you know, very low risk to a very, very significant risk. I mean, how have you how have you felt about that. Yeah, it's really interesting right so you know you're you're right in your pediatrician deal with the kids. My background is exposure risk, but public health population statistics right so you know I think about this virus is not spared us in many ways, but a lot of ways with kids it has and they were to me really three additional important questions and think about you know this reopening questions run schools. And by the way I just want to say quickly that the plans we put in place my team put up also is intended to protect adults so not minimizing teacher and administrator risk but just talking about kids for now for a second. They're less likely to cash this in adults I think that's pretty robust at this point right becomes a joint probabilities question here, because then if they get it they're less likely to suffer the most severe consequences, a really large serial prevalence that they just just came out of Europe, 358,000 cases and kids 11 deaths so the infection fatality rate is only over 300,000 so of course it can happen. Fortunately, it's rare. But the infection fatality rate risk is quite low for kids really not not the long the unknown potential long term effects not withstanding of course the impacts of minor infection relatively minor infection but on the fatality question. They're largely relative to adults and their step functions at certain age groups in that risk. The third is the transmissibility question and it also my read of the full body of evidence looks like kids transmit less than adults certainly the zero to nine year olds do in that one big study out of South Korea, it's about two or three times less. A lot of people are jumping on that that South Korea study that showed there's a headline big headline New York Times unfortunately that said 10 to 19 year olds transmit the same or more than adults well, a lot of us flag that when it came out if you look the data, there wasn't something quite right in that age group they look, they didn't look like they're immediately younger age group and they immediately older age group they look like 70 year olds it didn't make sense. A lot of us were concerned about the methodology there about identifying who is the index patient and when, and it turns out just last week that study was largely corrected. It was an erroneous finding was an erroneous headline a couple weeks ago but that headline hit millions of people right you'll see everybody says well 10 to 90 year olds they spread the same as adults, and the correction, you know, you know maybe got like a dozen likes on Twitter or so, but anyway I know three big questions right they get it less, less likely to die from it really robust looks like they transmit it less. And against what Margaret said right these massive costs of keeping kids out of school it's a story that's not being told right now. We hear stories of cases, right, and importantly we do but you know there's a stamp recently 17 million kids don't have access to high speed internet. 10,000 kids in Boston in May were virtual dropouts, only half the kids in Philadelphia in May checked in in elementary school checked in each day. I've had emails from teachers saying look in June, I haven't heard from my students since March I don't even know if they're okay, I'm worried if we don't go back what's going to happen with them. So the stories right now over the next couple weeks will be cases in schools right headline news, but next year's public health headlines are going to be horrific. We don't think there are consequences to keeping 10s of millions of kids outside of school. There are higher risk of abuse neglect exploitation, the loss of learning the loss of socialization, over 30 million kids rely on schools for meals. I mean these are massive massive massive costs. And just it's horrifying to recognize that our country hasn't prioritized this and getting kids back knowing that these these consequences are so severe and yet we're we're screwing around on the edges here honestly with reopening bars and restaurants and not doing the thing that is our first the number one priority we should be getting kids back to school and keeping community spread low so anyway that's a lot of a monologue there but really I think it's important to think about risk not just in the classroom but this bigger conversation of risk. And put it in context and you know we're not seeing those stories it's a missing story because these kids are missing. Maybe I can ask something to tie together. A lot of what we were just talking about with your mention of the study that then turned out to be retracted. It's no doubt, well known to people in public health, trying to communicate a message that people can easily grasp and hear while they're dealing with yapping kids and juggling their groceries and everything is very different from capturing every last subtlety and And I wonder if that translates to public policy as well that trying to have too many different factors about when you can reopen and then you have to shut again and what data you'd measure to know when you were in one zone or another. That how much should the policy guidelines be rather crude, even at the risk of missing some of the distinctions that you've both been so nicely talking about, particularly when if I'm just projecting out a little bit it sounds like if we were to be more discerning. It would probably mean that communities that have the budgets and the buildings to already be healthy or make them healthier. Then, thanks to the subtlety they start going back to school but communities that have worse physical infrastructure. Less of a prospect of ameliorating it and more community transmission because we know this is hitting poorer marginalized black and brown communities, significantly more than the baseline. So does that mean we would basically end up with a tiered system where thanks to the very subtlety that we're trying to capture and when it's okay to reopen. You end up with communities where everything feels fine and then you have communities left behind still stuck kind of online because we didn't have the rising tide try to to lift all of the boats. That's a really good point this equity question like we've seen already this virus is exposing these deep fishers within our society and the structural racism that's in our society that exists within the schools unfortunately I don't think it's as, you know, if we keep kids all home, that's going to exist the exact same reason right and if you bring back some will that inequality and equity is going to exist and be exacerbated as well. And so it's like it's it's there's no simple answer here other than honestly it's a systemic issue that needs to be fixed and fixed fast, and we haven't put forward the resources think about what we've done for stimulus right here right. Where has the real stimulus been for schools and I mean, I don't mean starting, you know, August 18. We should have been working on this in March when these schools close how are we going to get these kids back what resources do we need to fix our schools. 90% of schools don't even meet that minimum ventilation we were we were talking about the beginning 90% of us schools don't even meet the minimum. And so we failed we have failed as as Margaret said for this national response the resources aren't there the seriousness is not there. And that's the way honestly, right because different communities can have some people can lock it up and say oh my kids going to learn from home that's great well I bet you have resources I bet you have money maybe two parents in the house working you have high speed Internet maybe you have two computers and an iPad okay well that's not the reality for for the vast majority of the country. And so this has to be fixed the Margaret measures nice this has to be fixed at a national level this ad hoc approach, every community doing something different is not working in fact everyone's kind of, you know, fighting and pulling without some centralized messaging and the message is totally lost and confused because it shouldn't be a small Harvard program and healthy buildings putting out guidance for schools. It's been done by the CDC and where is that you know national guidance and leadership it's just been so absent since March. And it's exacerbating the structural issues in our society like everything else this this virus has exposed. It seems like a key message that should come in stereo so Margaret. Oh, you know I can barely talk about it. You know when you really step back and take the full measure of what's happening here it's just it's a horror movie. It's just a horror movie. It's it's watching everybody stampede for the exits and trample on each other. You know, I'm a big fan of zombie movies, because the theme of zombie movies is always, you know it's not the zombies that are scary it's what we're willing to do to each other that's the horror of the zombie movie and that's very much how I feel about this. So yeah, so so you know to your point I think you know basically it's a damned if you do damned if you don't kind of situation where schools of kids that are most in need of school who are most going to suffer tremendous consequences that they can't go to school are also being you know their option for school is the least healthy option and the one that's exposing them the most and of course they are likely to be children of parents who are, you know, not so much essential workers as they are disposable workers. People who cannot stay at home to work that don't have health insurance that don't have work protections that are being forced into job scenarios where they are having to interact with lots of people in a dangerous situation so it really is. I mean I don't even know the word, frankly, horrifying, but but let's you know that that's where we're at so let's get real here and start to think about the way that I would say it is when I got into public health I have to admit I'll just say this is my own bias. I kind of thought about like okay you know you're going to do the intervention that's going to help 80% of folks and okay then you'll work to try to address the 20% that you leave out that's sort of the and that's true of medicine to you're like okay let's think of the intervention that's going to help the most kind of a kind of a utilitarian approach but really what we have to do is the opposite we have to start on the margins we have to focus our throw our weight towards the margins because that's where towards the people who are the most vulnerable the most exposed that's where that's where resources should be going because as they become more protected, safer, healthier that's going to actually have the knock on results of helping the 80%. So anyway that's been my sort of own sort of realization or journey about how I've started to flip this because I think there's just a lot of like kind of struggling Oh of course you know poor people are going to suffer more. That's we shouldn't we shouldn't tolerate that as our starting position, we need to flip that. So, given the absence of national leadership here and the kind of chaotic scramble. That's happening right now that kind of the really scary part of the zombie movie as it were. Are there best practices that are emerging that would be able to leap from one school superintendent to another even across jurisdictional boundaries, one public health authority to another, or even one parent to another trying to make a decision in the interests of their child about whether to send them to daycare or to elementary school or even back off to university. Have there been ways in which we've seen islands in which this is being done right that we can try to light a taper from that and spread, given the absence of national leadership and understanding this is a distant second or third best. But are there, are there things we're learning that are simple and concrete enough that could be captured as best practices. Yeah, I think that answers definitely yes I have to say through all of this the one bright spot has been I think the scientific and medical communities. Every scientist and medical professionals focus on the same problem and breakthroughs are happening really, and they might be not on the headline news all the time, but, but I'll give you one example for schools right so we put out a guidance report and then we paired up with other scientists at Harvard and to be honest, you know, it's like this, this machine signed the machine that's percolating just under the radar and social channels people I've never collaborated with hey I like that report, this is my field. Can we take your report make a checklist I'm going to get it out to every superintendent. And that's what we do with their own a labs which is a tool go on days group or a software and runs it now. But that was that was like a collaboration they were really good at talking to superintendents I didn't have that connection they liked our report. They took it right and so these kind of things are happening. And that's one of like a million stories I have all these new collaborators I've never worked with over the past couple months because people are just saying, like problem solve. Hey, you have this I have this let's get together. Let's get a message out we did this last weekend, colleagues of new colleagues of mine out of Portland said we want to put together references for parents. It's a great we made a website 20 questions every parent should ask before sending their kids back to school. Questions you should ask little blurb on what you should expect for the answers things like this are really happening spreading through social media. The unfortunate thing is right it's maybe we're hitting some fraction population I'm sure there are other people doing the same thing it's just not cohesive so the messages and tied everywhere but it's certainly happening. But this is, you know, it's totally it's ad hoc, really, which has its own problems but, but messages getting out on to your point about what do we know about how it's spread, and then also about these control strategies and tips that people can use we built an online tool for people to help select portable air cleaners. So we built this little Excel tool another set of professors built another tool and how to assess risk indoors they're like Google sheets right, but people can plug and play and I mean they're I think they're really helpful to people so that's what's percolating it just hasn't bubbled up to some cohesive kind of any kind of national strategy really. It's all ad hoc. I would I mean you can take it as a positive thing or a negative thing but the but the fact is that you know if you look at basically any any state or even any community where the infection is was rising. You know you see people individually collectively trying to take actions and I very amused you know that through one of the funny things I feel like has been a commentary throughout this entire process. Is this nay saying about Americans they're like well Americans will never shut down Americans will never you know wear masks Americans will not blah blah blah and actually every single time you told Americans do it that this may help you. By and large they have I mean we have 75% of Americans saying that we want a national mask mandate I mean this idea that we can't. I totally agree I mean I think there's tremendous energy and people are working to try to figure out what to do and you know how to be helpful and how to open their schools how to support their communities. I that that cannot be denied and that that that is definitely happening I do want to say, you know, usually in these situations, however, whenever you have a DIY public health response. You know that there are, you know, the losers there are usually the most marginalized vulnerable and that that just is a tragedy and and is we shouldn't tolerate that. But, but I but I agree there is there is a lot of a lot of effort and people have with a lot of great ideas. So, so that's a good thing. Well I can't help but be trying to grasp for the practical even acknowledging the implausibility of a sudden transformation of a national leadership in the near term, and I just wonder is there a category of idea that's doable while still quite big and probably politically only doable if others are seen doing an example would be a kind of standard outfit for an outdoor heated tent in which, you know, put it in the baseball diamond of the school or the football field or the parking lot. And that becomes a year round place in which to do classes or a way of staggering groups of things that are not just let's punch a hole through the wall and ventilate our classroom and otherwise do it as we're normally doing it. But is there work being done on things like that that really would require a certain commitment, but that don't seem like having to plant a flag on the moon. Yeah, you know, I like that question and this motivated a piece. We wrote the Washington Post at the end of July with another professor which was, look, we're tight, we're short on time and resources to your point what can schools do, we're not going to put new mechanical systems on the roof I've heard some people saying every duck should have UV lights in it you know that's not going to happen in the next two weeks here. So we talked about the strategies that can really reduce risk and you use this school smart with smart as an acronym for assets. Stay home when sick right that eliminates some fraction that's obvious we have a symptomatics you have to do everything else and is mask up everyone should be masking by now. A is where I think it gets interesting an air cleaner in every classroom. So I talked to their cleaner manufacturers to figure out what their capacity would be. If we had a stimulus right a billion dollars we could put one of these in every classroom what can a portable air cleaner do with the have the filter, but we were talking about earlier in this podcast about air changes per hour. Well member schools might have to one air change per hour you want to get to five or six air changes you can have a portable air cleaner room you're in to give you four to five additional air changes per hour. So for a couple hundred bucks, you're essentially giving that that's a solution right plug and play plug it in. PEPA filter sits in the middle of the room. These are that's an important strategy that I think could be done to your point like what's now it's not that technologically savvy. It doesn't have to be. It can be equitable right ship these things all over the place the manufacturers on board where we're providing stimulus for vaccine makers and let's get the manufacturers these portable air cleaners put one in every classroom. That's doable I could be done in the next couple weeks for is our refresh indoor air ventilation and T to your point. It's temporary classrooms. Let's put some tents let's use the ball field let's get creative look at the medical community did the Jabot's convention center and and in Boston they were turned into hospitals. There were tents in Central Park. We should turn convention centers into schools. Let's put tents in every part I mean we can get real creative here instead of saying well we have this old crumbling infrastructure what are we going to do let's just jam a thousand kids back into it and do Hey, instead I think there are some creative solutions out there to your point we're running real short on time here, but there are things that can be done. And we know these reduced risk we know it right mass and ventilation air quality hand washing. That's really all they're doing not all they're doing in hospitals but really and they're doing it really well, but they don't physical distance high risk environment. We know these things can work. Gosh, instead of a chicken and every pot it's a HEPA cleaner in every classroom it doesn't have the same ring to it. To me. So we're cresting the top of the hour I think it would be great after we sort of formally adjourn any other participants who want to stick along feel free will just quickly kind of rifle through the remaining questions as kind of the deleted scenes, but to bring us in for a landing. It'd be great if each of you could give us what you figure the headlines are going to be six or nine months from now. And maybe to make it not too bleak if I'm anticipating where you would go feel free both to share the headlines that you plausibly would like to see if things could come together. But start with what's the likely headline, but what's going to be nine months from now, what would normally be maybe looking towards the end of a school year in May or June or something. What do you expect to be a top of mind front page kind of stuff with respect to the pandemic. I don't know. Margaret you want to go first. I'll try to be more more positive. Yeah, I, let's see. Well, my hope is that the headline would be something like Governor's rise to the challenge ensure struggling school districts have resources to keep their students safe. You know, the school year ends with, you know, despite fears that ends a lot better on a lot better note than we thought and we are now bridging into a national plan that is coming together with the, you know, next administration, whatever it may be. And filter media company producers all time high. He's not massive do that. Yes. Okay, and Joe but feel free also not just to give the desired headline but the plausible one I'd love a crystal ball gaze. Yeah, I'll be plausible and I actually am optimistic I'm not going to lie so I think the headline for next spring will be the Biden Harris administration starts to follow the science again. We elevate scientists and put in a cohesive national strategy, elevate CDC again start following recommendations. And we get our testing strategy in order we we should have been doing this in January and we failed. So I'm hopeful there and I think you know I had a piece in Washington post in July about six signs for optimism talking about things that I think are will come I think therapeutics are looking pretty good I think you know everyone's waiting for the vaccine at the end but other therapeutics. Hopefully, we have some already the most severely ill but other therapeutics for those even with minor, relatively minor infection. I think that looks good I hopefully we have, we have some new new set of tools for the doctors in the world to treat people with ahead of the vaccine so I'm hopeful there. I'm hopeful for these rapid antigen at home tests that say hey you're looking to get back to work well pop your, you know, 15 minute daily quick test and let us know that you're most likely clear. We're looking down, you know, explosive super spreader events. So I think those are all doable. I think they have been doable since January look we've known there was a plan to save lives and livelihoods right from the beginning we knew since March other countries did it so it's not like this is rocket science at this point what needs to be done it's the Margaret said earlier it's about hard work. It's about doing the real work everyone doing their own responsibility. In terms of our own personal behavior change but also relying on hopefully your government to do their part and put in this this plan to get put us in the path towards a happier spring where kids are actually back in school wouldn't that be great I mean, I'll be thrilled if I'm back in the baseball field my kids next spring that will be that'll be a homerun that I'm taking all next summer off to by the way, exactly. Right. Well, that's the sequel to the horror movie. Well, okay. This episode of our zoom cast sponsored by princess cruise lines, but Joe, Margaret, I know I'm thanking you even as your co hosting our but thank you both so much for to use a perhaps fittingly airborne metaphor dissipating some of the fog around these topics. Really grateful for it looking forward to checking in again as we go and we can compare against our predictions. We'll try to see if there's other links we want to paste into the conference room that refer to some of the stuff I'll get Michael Minna's Twitter account posted there too, and we'll go from there so to our participants thank you for sticking along with us. I'll just like pause a moment for station identification and then I'd love to just run through some of these Q&As of people who put them in while we were talking if that's all right and that'll just kind of be a little extra bonus at the risk of losing some cohesion so. Okay, let's go right to it. It almost seems like a, you know, I know who wants to hit the buzzer for each one but Ryan Buddhist asks, looking ahead to a post COVID-19 world fingers crossed is any of this work on rapid testing vaccines etc going to be useful for any other diseases virus or other medical issues. We're going to cure the common cold out of this after all that's my own spin on his question. Oh, try Margaret. Oh, I know I'm not sure. I think that there are some actually. Well, I think there will certainly be real advances and how we understand this class of virus. And I also think I am optimistic that we are going to come out of this with a renewed with a new revised and rebuilt public health system in this country, and a. A new health care delivery way of delivering health care in general. So I think there's all sorts of great benefits that are going to come out. And yes, I do think we are going to have some advances in therapy, you know, therapies and countermeasures against Coronavirus is in general. A couple questions about transmission. Have there been any known transmissions outdoors. There have, yeah, really limited for the vast vast majority are confirmed to be indoors, especially when it's multiple. Yeah, but there have been a small small fraction short. And it's interesting to see, you know, in this also era of protests and such the number of people sort of mingling together like that sometimes with masks sometimes not quite something. And if it's 40% airborne transmission what's the other 60% surface contacts or does airborne transmission just being beyond six feet. Yeah, so really good question and so a caveat that's our modeling based off the cruise ship which is like an ideal experiment right you know the infector you know the time course who got sick when where they were in the ship so like, and what we're doing is taking that and using that model to build a tool that anybody can use in any indoor environment you plug and play your dimensions of your space and estimate risk. And that'll come out in the next week or two our teams finishing this web based model. But I want to be on a caveat there that's our estimate others have estimated different numbers that you know we don't know like I said we're going to talk about this for decades what that number is but we know that other modes of transmission or operate you know close contact large droplet transmission is happening. So some contributions from full might or contaminated surfaces looks like it's less playing a less big role. In terms of aerosol piece really interesting what's happening is that you know distance still matters you can imagine you know if Margaret and I are talking face to face. And even if the large droplets settle out quickly. So she's going to get a bigger dose of aerosols at three feet, then six feet, verse 12 feet so distance still matters right it's not like, you know there'll be fewer particles at the other end of this room then there will be close to the imagine like if I'm smoking a cigarette at three feet it's going to be really noxious six feet noxious but at the back of the room. You'll smell it, unless there's great ventilation maybe you won't even smell it so I think that's a useful way to think about you still want to distance and all modes of transmission operate I'm not saying you know open up the windows without hand washing or absolutely wear a mask to. And there's not just distance there's time I suppose if you had a perfectly sealed room with a big cloud of virus in it of all the various sizes and distributions. If you just wait for a while, does it sort of disintegrate on its own. There's a bad news there. The these particles stay loft indefinitely in fact they're going to be removed in one of four ways really eventually they'll impact on the walls. That's a small contribution. They'll be diluted through ventilation. They'll be cleaned out of the air through filtration, or they deposit in the lungs. And you know, and of course we're trying to avoid that last one but and I mentioned it but this isn't a minor thing when you do indoor equality modeling you have to account for loss in the lungs. There's a risk in a school classroom you have to say well certain number of these particles are being breathed in. And so those are removal I mean these these small particles they just they just stay loft right. These aren't like orphaned puppies that if they can't find a lung to adopt them within a certain period of time they waste away. Yeah I mean look I mean over a certain amount of time right the virus can be a little less active but really it's not good you know if you're staying in a room and I'm coughing in this room and I'm infectious and releasing this viral. It's going to increase, increase, increase until those one of those cleaning mechanisms happen removal mechanisms dilution, air cleaning through filtration or it's going to get absorbed in the lungs. And that's that's the reality you know over days yeah that's different right and of course you know buildings breathe even if you know nothing's a perfectly sealed box. You close your windows buildings are still breathing right even a home a typical home has happened or changed per hour you think well my windows are all closed yeah you're building still breathing through little cracks and crevices so there's always some dilution happening nobody's in a fortunately no one's in a perfectly sealed box and have other problems. And that raises question about filtration at least a couple people have asked about. You know they're trying to wade through should they get a little filtering unit for their room or their office and if so all of the constellation of words HEPA and MIRV 13 and all that. Anything that cuts through that or just get a subscription. Let's demystify that because it's not it's not that hard but I understand for a lot of people the first time they're thinking about these things so let's let's demystify entirely. Let's start with HEPA a lot of people have seen HEPA on a box right these are high efficiency, particularly air cleaners they can you maybe have seen 99.97% removal. They say well then it doesn't capture the small ones but the reality is filters are rated on their worst performance particle size. So point three microns for whatever for a lot of reasons I can tell you why is the hardest for filters to capture at bigger particle size it's near 100% that's smaller it's near 100. So remember that if you see 99.97 that's nearly 100% for the particle sizes we're interested in here. And actually we have that tool on our schools website if you want to say well it would work in my bedroom or office. You measure the size of your space height of the ceilings we have five step thing how do you select what we call a clean air delivery rate for your HEPA filter it's really straightforward. Anyway that's HEPA filtration. If you're in a building and you have mechanical systems up in the ceiling let's say you still want to use better filters to capture recirculated air and the rating systems not HEPA base it's called MIRV. Typical building has a MIRV 8 filter captures a small percent of airborne particles not designed for infection control. You want to upgrade to a MIRV 13 or better and that'll capture a greater percent. So really simple MIRV 13 in your mechanical system say in your office or if you're central air and if you think about a portable air cleaner for your school or home or even your dorm room. You have to be HEPA based and avoid the gimmicky stuff you know you don't need a air cleaner if you see something with like plasma or ion generation or UV. You know you don't need it just the HEPA filter works really well. Got it. Margaret anything we're missing from your point of view. No no I would definitely defer all questions to that effect. I'm learning. All right. Well let me just plow right ahead then on filtration. One thing is to have some central way of treating the air in the room. The other of course is to stick a filter over your mouth which I guess is a mask. Although not typically the way we're thinking about you know the build your own masks which are about preventing your output more than it is filtering your input. Closer we how possible is it to have sufficiently good masks I don't know if we're talking N95 P 100 or those the merbs of masks. That could make it so that you could wander into that stale room that has a miasma of virus in it and feel relatively secure. I'm not saying we should go into those spaces look if they're under ventilated. You should leave right but the master doing a really fine job here and you might be surprised that even these kind of homemade masks were using and even gators despite that headline that came out can actually be effective and here's why. Right normally, if you're in a health care setting or let's say a worker in industrial setting where N95 you're protecting yourself. You have to control on the other side. Take two people wearing masks in a room at 50% efficiency, not anywhere close to N95 right, but the particles that come out of my mouth, 50% removed my mask and then another 50% through your mass that's 75% reduction. That's pretty good for a mass that doesn't work that well and everyone can get a hold of anywhere and put on their face right at some of these baskets 60 or 70%. 90% effective to mass then starts to push 85% or greater, you can get up to 90%. So this is the universal this is the importance of universal masking right. You know if you're going to go into a really high risk environment no one's wearing mask people are sick well you better have something like an N95 on the doctor would wear. Once everybody has these source control mass on. You can drive down risk and I'll tell you all the risk calculators including the one my team is building from the cruise ship that are out there now even some that are based in Excel based on old equations that we use to estimate risk. You can drive down risk through engineering controls pretty good. The only way to really drive it down is universal mask wearing indoors really once you add the mass the equation that's when risk really drops before that. You're around the margins, you know, you're doing a good job 50% reduction 60% reduction great you hit you hit everyone wearing a mask you can drive it to 99%. At which point do you have the exponential curves in your favor you actually if you could do that long enough you just could kill it right because it then exhausts itself among the people where it lives. Yeah, so you have the engineering controls are happening and also you know we haven't really talked about this but dose matters right this is going back to Paracelsus dose makes the poison here. And it looks like that evidence is starting to show or to that you know it's it's that first to knock them that first hit you get well. The mass is limited you get one viral particle or some really small amount that's going to be a lot better if you want in terms of the likelihood of infection to maybe the depth of the infection. So that was control to and this is all all of that's playing a really important role. Yeah, got it. Back to testing so for Margaret. I, is anybody doing it right in America is there any jurisdiction you can point to where it's like all right at least within their law Florian they're doing it. Yeah, for sure. Lots of states have have you know transferred over to well so first of all testing for which purpose I mean there's kind of just a quick and dirty way to describe it there's kind of three venues where testing is happening and that's kind of Well, it's a little correlated to why you test. So testing is happening in hospitals when patients show up who are sick. And a lot of hospitals have their own, you know, internal labs that can do testing and they're turning those around, you know, quite readily and in general, you know, I think hospitals, by and large are doing a pretty good job of controlling the infection and taking care of patients when they come. The other place that testing is happening is in the is to the purpose of driving down community transmission. And that's where we struggled so that's where primary health care centers and community health centers have You know, are taking patients who've told they've been exposed they need to test or who have mild symptoms and want to get tested. And that was really tricky because all the a lot of those folks places primary care centers are locked into quest and lab core, but many have found alternatives to that and are now turning around testing more quickly. And then the third place is with the state pop up kind of ad hoc testing centers. You know, and these might be in the parking lots of CVS is or there might be a program where they go through and test everyone in a nursing home and states were also sending those tests to quest and lab core as well and we're getting, you know, we're having significant delays. So a lot of states are, you know, trying to figure out alternatives and some are successful in doing so. So there's definitely some progress in the in that regard to some degree. I mean, we're still having short, you know, as Dr Allen mentioned, you know, we we are really reliant on one type of test that has to got to be done a certain way and, you know, we're having some shortages with the reagents you need to run those tests and it's a complication. But, yeah, but by and large their their testing is happening and and and is starting to turn around in some in some places. So, so that's awesome. And just to say, you know, we're all really hoping that not only will we get some more efficiencies. Out of that approach to testing in the very short term, but we're also hoping that, you know, that we're going to have other ways of testing and other approaches to testing that hopefully can be harnessed and governed and allocated and ways that really give us much, much better control. So it's not all bad news. Right. And last question, any best practices similarly in school reopenings, whether school districts K through 12 or universities, any good models to point to or possibly models that are models of what not to do. Well, I think I'd point to the models of what not to first I think those are easy to find, even if you look at the outbreak in Israeli schools right people are saying well you know look what happened Israel Israeli schools but the reality is this report came out just two weeks ago to what happened was they had a heat wave and they closed the windows turn on the air conditioning only recirculated air and they took masks, they took their masks off during this so it really wasn't surprising then again and same thing with the Georgia schools the Georgia camps same thing read the CDC report there, but they have 15 kids in these camps so you know in the in these cabins. They say no ventilation windows close doors close the loud singing in the cabin and no mass, and then people say well it's shocking, you know that the kids got sick here is like well, you know it's kind of obvious especially when community spread is really high so a lot of lessons to be learned on on what's been gone wrong. The harder thing is what's gone right because there are a lot of those stories but they're hidden right they're not headline where even in our town right there's a, you know daycare has been open and no cases through and camps through the summer. YMCA is in New York City State Opens in March in New York City during the peak very few if any case is very very low, you know they were managed to control risk. So a lot of these learnings from what's gone right are harder to find really. And I think you know this is something we really need to improve as a country that my fears we're going to get to December will have, you know, sporadic outbreaks and some schools versus others some schools will be just fine and since we're not systematically collecting the data we're just not going to know why. So like we'll be in the same boat we are right now trying to guess well what strategy works but imagine we systematically collected that attractive we'd be able to say hey you know what's working and not working. When school doesn't mass it doesn't have this in place this is what we're seeing the outbreaks and we've learned that lack of data collection is a leadership thing or it's a just nobody's gotten around to being able to. There's no time to to navigate we're just trying to aviate here. I mean, this is all doable. I'd say, you know, it'll come down to enterprising scientists somewhere it's going to someone somewhere it's going to create the database right this is how it's been going this whole ad hoc thing. It should be centralized. You know, how do we manage this thing without using the data collection problems we've had through our society through the first couple months of this but it really concerns me with schools in particular because there's so much to learn and even the. The, what we've learned about what's gone wrong or right or totally anecdote. I know two stories from my town we have that from ymca we know the Georgia schools we know like a you know, that's like five things. We could know, you know, it's deeply frustrating and am I concerned is that we're just going to, you know, we're going to do the same thing for the next couple months and never really know what worked or didn't until way after the fact. Well, despite the just how troubled the times are and how dodgy a place we're in I come away from this conversation, feeling a little more comfortable that we've got really smart talented people on the case here and really thinking about the public interest and how we might be able, whether it's for mutual aid or otherwise to fill in the large gaps that exist in leadership and in coordination in trying to take on this problem. Joe, thank you so much for joining us. Margaret you're a total hero for coming in from a national park to do this and great reception. Yeah, thank you so much, Joe for being on the call it's fascinating and we just really appreciate your leaning in and and and really showing up here at this moment of need. And Jonathan, thank you also view for facilitating such a such awesome conversation. The pleasure. Thank you. I enjoyed it. Learned a lot too. So, very good. We'll catch you next week and thank you as well to our participants till soon. Take care. Bye bye.