The following is an edited transcript of an MDAdvantage podcast with Steve Adubato and Brian L. Strom, MD, MPH, which was taped on May 6, 2020. Dr. Strom is the inaugural Chancellor of Rutgers Biomedical and Health Sciences. In this podcast, Dr. Strom discusses how a saliva-based test for COVID-19 was first developed at Rutgers–New Brunswick, which is a less invasive, more convenient and faster process than the swab. This test will greatly expand testing capacity in New Jersey, thus bolstering the economy.
ADUBATO: If it were not for the times we are living in, there would not be a Rutgers Center for COVID-19 Response and Pandemic Preparedness. What is this center, and what is its goal?
DR. STROM: You’re certainly right, Steve. It did not exist before. But we have enormous expertise at Rutgers, and since the COVID-19 epidemic began, we have been able to make huge contributions across the board, clinically and research-wise, and especially in the field of testing. One of the many things we have done is to develop the first point-of-care test for COVID-19. This means that at the test site, within 40 minutes you can get an answer, instead of sending the test to a lab and having it come back a day later, two days later or even a week or 10 days later, as originally happened.
We also have a lot of other research underway in the hope of maximizing the contribution Rutgers can make to understand and ameliorate this pandemic. Rutgers Biomedical and Health Sciences is very large, with eight schools and 10,000 people. We have now coordinated our COVID-19 efforts under one center with one leader, providing funding to launch pilot studies across the state.
This clearly is not the first pandemic the world has seen, and it’s not the last the world will see. That’s why we called it the Center for COVID-19 Response and Pandemic Preparedness. The idea is that once this is over, hopefully in two or three years, we can turn that same scientific talent toward better preparing for the next pandemic.
ADUBATO: Why is the saliva test for COVID-19 so important, and how available is the test going to be to make the difference it needs to make?
DR. STROM: The saliva test, which was developed by Jay Tischfield and Andy Brooks within Rutgers–New Brunswick, is an enormously important contribution. The standard method of collecting specimens for COVID-19 testing is slow, inconvenient and invasive. A healthcare worker puts what amounts to a type of Q-tip very far up the nose and takes a sample and then does the same thing very far into the throat. It’s very uncomfortable. You need a special Q-tip, which is in short supply, and a special viral medium to carry it, which is also in short supply. The person taking the specimen has to be in full protective gear, which has been in short supply. Then you bring the specimen to a lab, and it takes 24 to 48 hours to do the testing.
“We’re gearing up to be able to do 50,000 tests per day through high throughput screening as well as the saliva sampling, so, it’s a much better approach.”
The saliva test bypasses all of that. A person can drive up, spit in a cup and hand the cup back—a two-minute process that is much less invasive. We have a huge throughput with that. Previously, hospital labs could do 100 or 150 tests a day. We can do 10,000 tests a day. By next week, we’ll be able to do 20,000 tests a day. We’re gearing up to be able to do 50,000 tests per day through high throughput screening as well as the saliva sampling, so, it’s a much better approach. It allows much more rapid testing, and hopefully, we’ll be able to substantially help the state. Keep in mind, the state in totality is now doing between 7,000 and 10,000 tests per day, so this will markedly increase the amount of testing we can do to help the state return to a normal economy.
ADUBATO: How does the accessibility of testing connect to restarting the economy in our state?
DR. STROM: When you have an epidemic or pandemic like this, the usual first step is referred to as containment. When you identify somebody who is sick, you want to pull them into quarantine and keep them away from other people. Then you want to identify all of their contacts and pull them into quarantine as well. When containment fails, as it did here, you move to the next stage in controlling the pandemic, which is referred to as mitigation. Mitigation suppresses the economy by having everybody stay in their homes. This decreases the incidence of disease, because people aren’t interacting with each other. Once the numbers go back down, we want to move back into the containment stage, and testing is key to identifying cases. It’s particularly key with a disease like this, because you don’t even have to be symptomatic to have this disease and to be able to spread it to other people. Therefore, the only way to identify people who have the disease is to test them. For example, as we begin to think about reopening the economy, our hospital workers have to be tested. We have been taking care of enormous numbers, thousands, of patients with COVID-19. The RWJ Barnabas Health System had 1,600 patients. University Hospital in Newark had 250 patients. That’s down now below 100, so we are very successfully getting it down. But it’s not zero, and it’s not going to be zero for a long time, if ever. We need to be able to test our healthcare workers, because otherwise, patients aren’t going to want to come and get treated because they’re afraid of catching the disease. If a healthcare worker tests positive, you then keep them out of circulation for two weeks, and then they’ll be safe. So, testing is a really critically important part of the equation to get people interacting again to reopen the economy. Right now, when you go outside to a store, you don’t know who’s sick and who’s not. When you go to an emergency room, you don’t know if the doctor or nurse is carrying the COVID-19 virus. Once we test them, then that’s less likely. As we think about reopening the University, for example, we want to be able to test the students and the faculty before putting them in a classroom, because that way you know that they’re negative, whether they have symptoms or not. Testing is critical.
The other part that’s equally critical is contact tracing. When somebody tests positive for the virus, you need to pull them out of circulation, and you need to find everybody they interacted with and pull them out of circulation as well. The combination of testing and contact tracing is pivotal to be able to get the economy back [on track], and it can be done only once the number of cases drops way down, so that’s why we’re in mitigation mode now. The idea is to get the number of cases to decrease and then move back into containment mode. Testing is absolutely pivotal to containment.
ADUBATO: Obviously, everyone is asking the question about a vaccine. Is Rutgers working on a vaccine for COVID-19?
“Well over 100 vaccine candidates are now being investigated throughout the world, and Rutgers is contributing to that effort.”
DR. STROM: Yes, we are. Well over 100 vaccine candidates are now being investigated throughout the world, and Rutgers is contributing to that effort. It’s not that hard to come up with a concept for the vaccine. The harder part and the slower part are in testing the vaccine—testing on large enough numbers of people to know that it will work. At this point, we are still assuming that antibodies will help. In 95 percent of viruses, if you get sick and you develop antibodies, you then can’t get the disease a second time. The epidemic can be halted when enough people in the population are immune, which stops the spread. This is called herd immunity. Let’s say I have COVID-19, and I go out to the grocery store. If everybody I interact with has not had it, this is a very infectious situation. I will spread it to multiple people who will get sick. But if most of them are immune, they won’t get it, and it won’t spread further. Typically, with most viruses, you need 50 percent to 70 percent of the population to have been sick to achieve herd immunity. That will take a while. A significant proportion of people who get this infection get very sick; some die.
Clearly, a better way of achieving herd immunity is to vaccinate, to get an injection and get the immunity from that. Rutgers, as well as a hundred other organizations, is working to develop and test a vaccine as quickly as we possibly can. Typically, that takes at least 18 to 24 months but usually much longer. With some diseases, you can never develop a vaccine. We still don’t have one for HIV. We still don’t have one for malaria. But we’re working on new methods of testing vaccines so that, hopefully, we can get it out sooner.
There is another alternative if herd immunity doesn’t work. The virus may die out over time. Most viruses, over time, become less pathogenic, because realistically, if a virus kills its host, a dead host can’t spread it to other people. So, by natural selection, the virus becomes less pathogenic, and then it becomes an endemic condition. That’s what happened with swine flu, and now, it comes back every year. It’s H1N1. Now, we vaccinate against it.
Clearly, our best hope of ending this pandemic lies in creating herd immunity through a vaccine.
ADUBATO: In addition to working on a vaccine for COVID-19, what are some of the treatment clinical trials underway at Rutgers?
DR. STROM: We have numerous studies underway, including clinical trials. For example, we have the largest healthcare worker study now underway. Early in the epidemic in New Jersey (which, of course, has become the epicenter of this epidemic for the world), we enrolled roughly 800 people. Roughly two-thirds (more than 500) were healthcare workers from either University Hospital in Newark or Robert Wood Johnson University Hospital in New Brunswick who were directly interacting with patients with COVID-19. We did antibody testing, and we did antigen viral testing on them. Those tests will be repeated every two weeks as the epidemic continues. What we’ve seen right away is very reassuring. Of the healthcare workers, fewer than 5 percent were positive for the virus initially. So, our personal protective equipment (PPE) was working. The infection rate was higher than the controls, but still not very high at all as we were successfully protecting our healthcare workers. We’re also watching to see if the people who have antibodies are protected from future conversion to become positive with the virus.
We are also conducting a whole series of other clinical trials. We have randomly assigned symptomatic people to treatment groups with hydroxychloroquine along with azithromycin, versus hydroxychloroquine by itself, to see whether azithromycin adds anything. We’re also randomly assigning people who are not symptomatic but are virus positive to treatment groups with hydroxychloroquine plus azithromycin versus hydroxychloroquine by itself versus a placebo. To people who are not symptomatic at all and not virus positive, we’re offering the opportunity to be randomly assigned to hydroxychloroquine versus placebo to see if hydroxychloroquine is helpful in preventing the disease. If we can find treatments that work or ideally, treatments that prevent the disease, we will change the course of the epidemic. If two months from now, we know that hydroxychloroquine is a successful treatment (which is looking less and less likely to be the case), we still won’t have a definitive answer. But if we can prevent the worst of the disease, and if we can treat people who have the worst disease, then it’s an important contribution. Then COVID-19 is no longer such a big deal as a disease—a terrible disease that causes people to end up in intensive care units (ICUs) on ventilators and too often die. If we can prevent that by treating people, then we can open the economy much more quickly without waiting for a vaccine. If people get sick, so be it; we can treat them. They won’t get very sick, and then we open the economy much sooner before there’s a vaccine. Ultimately, herd immunity works again when we get to 50 or 70 percent of the community being infected. Then, the disease will stop spreading on its own. So, trials of treatments are really important. If we can find good treatments, they certainly will save lives. In addition, it could change the course of the epidemic even before we have a preventive vaccine.
ADUBATO: There are so many lessons that I’m sure you have taken away from your experience thus far in this pandemic. What would you say is the most significant lesson that you have learned?
DR. STROM: I think the most significant lesson is the importance of preparedness. It was anticipated that we would have pandemics like this. We even had dry runs with swine flu and Ebola and other things, but the country wasn’t sufficiently prepared. We need to be prepared. This wasn’t the first pandemic, and it won’t be the last. There will be others. I think the importance of preparedness, and the importance of public health, is a critical lesson for the entire country. Hopefully, our work during this pandemic will make important contributions not only to this pandemic but also to preventing the next one.
ADUBATO: If there is this so-called second wave in the fall, will we be more prepared?
DR. STROM: Personally, I think there will be a second wave, but it probably won’t wait until the fall—particularly given that many states in the country are opening up too early. New Jersey is doing it right. Will we be more prepared? We will be more prepared, but hopefully, it won’t be so severe that it will overwhelm us.
ADUBATO: These are very important words from someone who understands this pandemic from a variety of perspectives. His voice is so important in this conversation. Dr. Brian Strom, I want to thank you on behalf of Patricia Costante, the CEO and Chairman of MDAdvantage, and on behalf of the entire team at MDAdvantage.