In connection with our March 4 Live from the Library Lounge webinar "Covid-19 and Public Libraries: One Year Later" PW caught up with Professor Jeffrey Shaman, one of the nation’s most prolific and visible researchers seeking to understand the novel coronavirus that has so upended our lives. Shaman is Director of the Climate and Health Program Mailman School of Public Health, Columbia University, where his team studies the transmission of infectious agents. In normal times, that means colds and flu. But in these extraordinary times, Shaman and his team have understandably focused on the Covid-19 pandemic. He also studies health in the built environment, a subject that will be of vital importance as we seek to come back from the pandemic.
The full 32-minute interview can be seen here.
A transcript, slightly edited for length and clarity is below.
Prior to the pandemic, you were already studying the way respiratory infections move with something called the Virome Project. Can you tell us briefly about that project and how it may have informed your work tracking COVID-19?
Yeah, this was an interesting thing. So part of the Virome Project is predicated on the idea of trying to figure out how abundant or prevalent common respiratory viruses are, things like influenza, respiratory syncytial virus, rhinovirus, and the endemic coronaviruses, which are these four wimpy viruses that go around and give us very mild symptoms and colds, typically, but circulate all the time. And the reason why we wanted to look at this and try to understand the prevalence is that it has to do with the way that we actually observe these viruses generally. And the way we observe respiratory viruses is, typically, through what I would call a passive surveillance system. In other words, we only get information from people who themselves seek clinical care. Everybody who avoids doctors or who has mild symptoms or maybe no symptoms at all, they're never going to be documented by that system.
So, what we set out to do in this Virome of Manhattan Project was to try to find out well, just how much flu and other respiratory viruses are there out there. We had a number of arms to the study, one of which was at a very prominent New York City tourist attraction, where we went into that and we would solicit visitors to that tourist attraction, and if they consented to the protocol, we'd take a medical history and we'd ask them questions. What we saw was that adults, because that's all we sampled, who were going around New York City at a very prominent attraction were clearly not slowing down their days, and that a lot of them were shedding common respiratory viruses. For instance, in the month of February, which was the worst month, we saw that one in nine persons was shedding a common respiratory virus. And this is supposedly a healthy population.
We also had another arm to the study, which was even more revealing. And this is what was called a cohort arm. We ultimately enrolled about 200 people and every day over their phone they told us about those nine common cold symptoms: sneezing, cough, sore throat, et cetera, which they rated as none, mild, moderate, and severe scale. It took them all of 30 seconds. What we could see from that is how many of those viral infections were actually going to be rated as symptomatic versus asymptomatic, how many were going to keep people home from school, how many were going to force people to take medicine, and how many were going to elicit people going to seek clinical care. And what we saw was that the vast majority of infections, even for something as severe as the flu, were undocumented. People never went to seek clinical care during their infection because of their symptoms.
So what are they doing? Well, they're going to work, they're going to school, they're going out shopping, they're getting on the subways, they're getting on buses. If they have a business trip, they'll get on a train or an airplane. If they have a vacation, they'll get on a plane. They do what you or I'd do during the winter typically if we had a little sniffle or a little sore throat or a little bit of chill. That is, nothing. We just go about our business. And in doing so, we're doing the virus a favor. We're taking it out and about and sharing it broadly in the community.
Now, to take this a step further, when in January of 2020 we saw how quickly this novel coronavirus was moving out from its epicenter in Wuhan, China, and spreading throughout China, we immediately said to ourselves, "this is behaving just like a common respiratory virus. The majority of infections may be undocumented. People are not even aware that they have this infection."
And that's indeed what turned out to be the case.
In a study released last month your team reported that the actual number of COVID-19 infections is likely ten times higher than the reported infection rate. Help me understand that. On one hand, that sounds like maybe that's a good thing because more people have antibodies to the coronavirus and we might get to some sort of herd immunity faster. But at the same time, that sounds alarming—because that's a lot of people out there shedding virus who may not be practicing social distancing or masking up.
That's exactly right. And so this is the real issue. The idea of having this ascertainment, right, which is what fraction of infections are actually confirmed cases, people who've been swabbed and told you have SARS-CoV-2, the causative agent of COVID-19. What we found over time is that early on, because there wasn't a lot of testing capacity, that the ascertainment rate was pretty low. In the US, it was less than one in ten infections were a confirmed case by the time we got to the middle of March of last year. So we had a very, very low documentation rate last year at this time.
But over time, particularly as we moved into the summer and testing capacity increased, we've been able to meet demand better, and it's risen to almost about now it's about one in four infections we estimate is a confirmed case. It may be dropping down again. We'll have to see. But what that still means is that the majority of people who get this virus are never tested for it. Many of them may be asymptomatic or mildly symptomatic or maybe they just don't like doctors and they're toughing it out at home. But most of them are probably mild or asymptomatic. And these people are capable of sharing the virus and spreading it around. And that is of course a big problem.
So when you hear about that 10 number, it was actually a number more like 10 to 15. And what that refers to is the fact that, all right, if we have a certain number of people who are confirmed cases today, you should multiply that by four probably, maybe five, to find out how many new infections there are today. Okay? But then you also have to recognize that the average person is infectious for three to four days. They're shedding enough virus that they can pass it on to somebody else for three to four days, which means that you've got multiply it again. So if you multiply 4 by 3 1/2, that gives you 14. So that means that there's 14 times as many people who are currently actively infectious as there are confirmed cases in a given day.
Last April, it struck me when Dr. Anthony Fauci said that if we do everything right, we might hold deaths between 100,000 and 200,000. Well, this week we'll surpass 520,000 deaths in the US alone. At a minimum, that suggests to me we did not do everything right.
What’s your take on what we've done?
Well, you know, you're absolutely right. I'm sort of drifting back to your last question for a second, Andrew, which is, you know, isn't it a good thing that more people are infected and that they're mild? And the answer is yes, in a certain way. And people have debated it and said, "well, maybe the number's really high. Maybe only 1 in 50 people is a confirmed case," which would be really great, and we might have been done with it. But that hasn't proven to be the case.
In terms of this milestone that we've hit where we've passed, 500,000 deaths at this point, it is an enormous failure and it is a real tragedy on a personal level for people who've been touched by it obviously, and collectively as a nation. We didn't do a good job. We didn't take this seriously. We didn't use an evidence-based approach. There wasn't consistent communication that was evidence-based from our leaders. And there wasn't a collective will put together where we were encouraged to do things like masking and social distancing and not making it a petty political partisan issue, but doing it because we want to protect ourselves, our families, our neighbors and our country. We could have made it a patriotic duty to actually encourage people to wear masks and to do the things to protect each other so that we could be more like Vietnam.
Vietnam has been incredibly successful at controlling this virus. They're a country of 97 million people. They've had 2500 cases to date and 35 deaths. That's it—in a country of almost 100 million people. That was done by controlling the virus through non-pharmaceutical interventions, which they've done aggressively. And their economy has actually benefited from that and actually had growth last year, where many others have not.
Unfortunately, you know, when he said 100,000 to 200,000 deaths in the spring of last year, Dr. Fauci was doing that in a hopeful fashion. However, we've seen the numbers, and if you just look at how many people this virus should be able to infect, given a lack of preexisting immunity, the number who are dying from it based on it as a fraction of total infections, the number you would get if we just let this thing run wild is 800,000, maybe a million Americans would die from this if we didn't do anything. Now, we haven't done very well, and we're already at 520,000.
So let's talk a little bit about where we are now almost a year since the first lockdowns began. Talk to us about variants. My understanding is that variants are common for viruses, but how concerned should we be about the headlines that we're seeing about all these emerging new variants?
So, variants of concern are unfortunately of concern. We're not out of the woods with this yet, and it's because again it's a novel agent. We don't know what kind of pattern it's going to settle into.
For the endemic coronaviruses, there are four of these that infect humans and have for quite some time, causing very mild illness. They have funny alphanumeric names, like OC43 and HKU1. But these viruses have many, many variants. And they appear to be able to infect people over and over and over again throughout the course of their life span.
The concern is that this new coronavirus will do the same thing, and if it does, then the question is: will the subsequent infections after your first infection or after receiving a vaccine, will they be milder? In other words, will this settle into a pattern where people are repeatedly infected by new variants that have arisen because of this virus, with milder infections so that we can get back to normal, where it's not the level of threat that it is right now because it has such a high infection fatality rate? And unfortunately, that's an open question, one that we really don't know the answer to as of yet.
These variants that we've been hearing about, things like the UK variant, the South African, the Brazilian, a couple new ones identified in New York State recently and California as well, these are of concern. We have to monitor them. We have to see how successfully they evade preexisting immunity for those who are naturally infected, or evade the vaccines that we're currently taking that were designed for other variants, or how they evade certain treatments, like monoclonal antibodies.
What we've seen so far is that in some cases, like the South African variant versus the AstraZeneca vaccine, which is not available in the U.S. but is used in other countries, it renders that vaccine almost completely ineffective, it appears. Similarly, there's a treatment from the monoclonal antibody by Lilly that's rendered ineffective because of that.
So what we really want to know and what we're going to have to monitor is how effectively and rapidly these variants evade the immunity that we already have. How often are people going to be re-infected and what is the likelihood that a person upon re-infection will wind up in the hospital.
Let's talk about vaccines. You know, my reading is that history shows us that vaccines can crush epidemics. I that going to be the case here? We hear about these different vaccines with different efficiency rates and people not wanting to take AstraZeneca because they want the Pfizer vaccine with a higher rate. But is it fair to say that we're in a race against a virus that is changing and that people should just get the shot that they can get?
Yeah, I think that's fair to say. I mean, you know, look, the Johnson & Johnson vaccine is coming out. It was just authorized in the United States and they're shipping the first doses as we speak. And you'll hear that, “Oh, it's 70% effictive against symptomatic illness.” But it's actually more effective against severe illness, as well, so it’s moving more towards the numbers that we see for the Pfizer and Moderna vaccines. And you should take it. If offered it, just take it. You know, don't worry about that. Get the vaccine in your arm. Get some protection.
The reality is there may be issues with some of these vaccines—it could be the Pfizer, it could be the Moderna, it could be the Johnson & Johnson—the same way we saw with AstraZeneca against the South African variant. We're just not going to know. It's impossible to know what will emerge.
Now, you know, the question we also ask is know, "you get the vaccine and then are you done with it?" That is the real question we all would love to know. And we'd love the answer to be that this is like the measles. You get a measles vaccination, maybe you get a booster, and you're set for life. You're not going to have to ever have the measles. The threat is completely quashed for the course of your lifetime, like the chicken pox vaccine as well.
Unfortunately, this novel coronavirus seems to be more like the flu, where we have a vaccine that is partially effective, and new variants will arise that manage to partially evade the immunity conferred by the vaccines that we develop. And if that's the case, we're going to be in this continued arms race where we're going to be wanting to produce new vaccines and new treatments that are targeted to the new variants that are out there, and we're going to have to try to stay a step ahead of it and provide those to people to give them boosts.
But the real thing that's going to be critical is whether or not upon re-infection or upon infection after seeing a vaccine, even if it's a variant that escapes and causes more symptomatic illness, are you still not going to wind up in the hospital? If we find that people are much less likely upon re-infection to wind up in the hospital, we're going to move into a zone where it's going to be more like the seasonal flu. If we're really lucky, it might be more like the endemic coronaviruses, which are even milder and don't put people in the hospital at very big rates. But if we're not so lucky, maybe it'll be like seasonal flu. If we're really unlucky, things won’t change much in terms of the rates of hospitalization upon reinfection. Those unfortunately are the open questions that we're going to only see over the course of time.
So our audience today is the library community, public librarians and administrators. So I wanted to get your take on a few things. One of the common complaints I hear from library directors is about the lack of actual concrete guidance—they can see the research and the facts and the science, but they still don't really know what to do. But they've been doing their best. So I wanted to run a few things by you and see if I could get your take. We'll do this in sort of a lightning round fashion. First opening, reopening public libraries. Good idea, bad idea?
I think it's premature. I would prefer to see case rates on a daily basis at much lower levels. I mean right now we're having 50,000-60,000 new cases a day on average. I would love to see it under 1,000. I'd like to see it like 500 cases in the entire United States on a given day, and a much higher rate of vaccination, and then we begin to start opening up with masking and do things in a cautious fashion and making sure we don't see surges in the communities in association with the reopening of libraries and other businesses.
Got it. You know, libraries are taking great care to quarantine materials that circulate. They wipe down computer stations in the library. They quarantine books for a few days before they recirculate them. What can you say about transmission via a book or a computer station? Is that something we should be concerned about? Is it high-risk, low-risk, moderate-risk?
You know, it's hard to say. I mean, there's sort of the CDC guidance now that thinks that surfaces, what's called fomites in the infectious disease epidemiology terms, are lower risk and not the dominant mode of transmission, that it's more dropletting or aerosol or some combination therein.
I think the reality is that you want to continue those practices. It doesn't hurt to do it. It is a bit of an inconvenience right now. But if it lowers the opportunities for transmission of the virus, which it will even if it's only a small increase associated with having surfaces that are not cleaned, you might as well clean the surfaces and store the books for a while to allow any viral particles that remain to decay.
Library buildings are old. Many of them are very old. How much of a priority should modern new air ventilation systems be? And is there a baseline for effectively filtering out airborne disease through these systems?
Yeah. You know, and I can't remember the terms for it, but there are certain filtration systems that, I forget what it's called, something with an M, and level 13 I think is the level you're supposed to go to, which is the level of efficacy that they have been recommending for the degree of filtration. [Editor’s note: the term is a MERV (Minimum Efficiency Reporting Values) rating. And, as Professor Shaman suggests, a MERV rating of 13 or above is considered hospital-level air quality.]
But this idea of the indoor environment and retrofitting buildings that we’ve heard so much about, particularly in the spring and early summer last year, as a means of trying to deal with this virus really poses a larger question, which is: How do we manage the indoor environment to keep people healthy? And we don't do a very good job of that.
The only thing we do is we try to manage temperature somewhat. We heat in the winter and we cool in the summer a bit, usually more the former than the latter necessarily. But we don't manage humidity levels. We don't filter the air. We don't manage particulate matter buildup of carbon dioxide. As a matter of fact, the indoor environment is an area that's very little studied and considering that we spend 90% of our time in it, it might be beneficial for us to consider what are the optimal conditions that would promote human health under different circumstances and how do we set up systems going forward that are going to help with that. And that includes the issue of ventilation and ventilation in response to a respiratory viral pandemic such as this.
You know, now we see things like spit guards and barriers. And these things I think make us feel a little bit safer. Are they effective? Should we get used to seeing front-line workers sort of like bank tellers behind some sort of barrier?
That's a great question. Humans are social creatures and we can't just try to thwart all the germs, you know, continually. We would like to be able to come together and we would like to have interaction. I don't think most of us want to live in a world of glass and plastic shields and whatnot.However, they are effective in cutting down the transmission of diseases. Right now we are particularly sensitive to that. The need for it is kind of acute.
I think that over time we will probably lapse, once we move into a post-pandemic phase and hopefully settle into some sort of equilibrium with this virus where it's not the threat that it is right now. Maybe then we'll be able to drop some of those things and have more of human interaction because I do think people crave it and we need it and it's very important Even with people who are not your immediate friends and family, the ability to interact without having some sort of barrier between people is not the ideal way of going forward.
I have to ask about masks. I mean, I don't know how it ever became a political position to wear a mask or not wear a mask. It seems like an easy thing to do. People are getting sick of them, I know, but we should be wearing masks, yes?
Absolutely. I mean, there's nothing to say other than you should wear a mask. I mean, we can certainly talk about the issues, of how it was made an issue of identity politics and a wedge issue, but I think we're all aware of who did that. Just wear a mask.
Children's services are a big part of what libraries do, but we don't really seem to understand the role that kids play with Covid-19. How should librarians approach reopening their kids' rooms?
There's a lot of conflicting information in the scientific literature about this still. There's evidence that's been more tilting towards the fact that children aren't as involved in the transmission of the virus. Early evidence seemed to suggest things such as, you know, they weren't involved, or they were involved, that they're just as capable of catching the virus, or they're only a third as capable of catching the virus, but there are three times as many contacts, therefore it all comes out in the wash. It's hard to say.
What is clear is that children do not suffer Covid-19 disease at the same rates that adults and the elderly and those with chronic conditions. In other words, this infection is really able to really infect lots and lots of people, including children. But it seems to really hit adults, and by adults, I mean 20 to 50 years old. But it's a disease of the elderly. The older you get, the likelihood that you'll wind up in the hospital because of a SARS-CoV-2 infection increases quite dramatically. And, you know, elderly people who have chronic conditions, somebody who's 85, 75 years old, they're a thousand times more likely to wind up in the hospital than somebody who's 8 years old who gets this.
But we do know that children can get it. We know they're capable of passing it on. So the risk is non-zero. There is some risk associated with it. And we have to remember that children aren't always the most hygienic, particularly young kids. And so, you know, having policies in place that try to keep the masks, limit their interactions with each other, keep them distanced, that is going to be beneficial for people until we have everyone vaccinated and the viral infection rates are dropped down so that we have a sense that a lot of people are protected and the amount of virus that's circulating in our communities is very low.
Okay, last question. I'm hearing a lot of optimism in the press, right? We're seeing the numbers sort of go down. And this may be the most 2020 thing I've said so far in 2021, but optimism scares me a little bit. Because we've seen how, normally with outbreaks you see like a bell-like curve, right? Infections go up and then come down. But with this virus we're seeing curves. It's going up to a new plateau, then it's going up to another plateau. I'm worried that we're going to find ourselves hitting another plateau and going up again. Where do you fall on this? How optimistic are you? Could we see another third spike here? And what would you suggest?
Well, we certainly could. We don't know what's going to happen, and I think we have to keep that in mind that this is a novel respiratory agent. We do not know specifically what it will do.
However, I will say that the pattern it has followed is very consistent with what we observed in 2009 and 1968 and 1918 with other pandemics. Those were influenza pandemics, but influenza is also a respiratory virus. With those, they had a spring wave, they had a fall wave, they had a winter wave, and then they had another wave the following winter. So, if we were on track to follow that we're not going to have another big wave of this maybe until next winter. But those pandemics happened, particularly in 1918 and 1968, in the absence of an effective vaccine against it. Now we have a vaccine and that's going to hopefully disrupt this pandemic.
So, I am cautiously optimistic. I do not however think the numbers of cases that we are seeing, the way they plummeted during the month of February, will continue as precipitously however. We've already seen a plateauing at around 50-60-70,000 cases a day over the last two weeks. We need to remember that 50,000 cases a day is a lot. That's more than it ever was in the spring wave. It’s near the peak of what we saw in the summer wave. That is a lot of people who are coming down with this, and it's a lot of people who are potentially going to die from the infection. So it's really critical that we look at this in a kind of a clear-eyed fashion. Right now, as the vaccine is being rolled out, we need to maintain our non-pharmaceutical interventions. We need to continue with the mask usage, the social distancing, limiting of gatherings, all those other policies that we have in place that are trying to prevent or limit the opportunities for person-to-person transmission. Because right now we're in a race, and the race is to get the vaccine in as many people's arms as possible before those individuals are infected with the virus.
You know, maybe 55% or 60% of our country has yet to be infected by this virus, and we would like to get the vaccine in as many of those people's arms as possible. However, if we let our guard down, the virus will accelerate and more people will be infected before they get the vaccine. But if we were to ramp up our non-pharmaceutical interventions then fewer people would be infected and more people could get the vaccine before ever encountering the virus.
Again, I'm going to use this example of Vietnam. Vietnam has had 2500 cases to date in a country of 97 million people. If they get the vaccine and are able to limit the numbers over the next year to another 5,000 people as confirmed cases, and they get the vaccine into 80% or 90% percent of their population's arms, then the vast majority of the people of Vietnam will have been vaccinated before they ever encountered the virus. That would be a real success story if that were to hold.
So the idea is to hold onto these non-pharmaceutical interventions and even increase them for the time being while we're spilling out and distributing and administering these vaccines so that we can get people protected. That way, if they do get infected, the results will be milder. They're not going to wind up in hospital, and they're not going to wind up dying from it, or less likely to at least.