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May 21, 2020

LA County Antibody Testing Update


Neeraj Sood
Neeraj Sood | Professor and Vice Dean for Research, USC Price School of Public Policy

Neeraj Sood discusses early findings of his ongoing LA County antibody study. Sood points out that so far the study indicates that still more COVID-19 numbers are going unreported, even within this particular study. Dr. Sood also explores the various factors impacting policy moving forward, and emphasizes that it should be possible to have some middle ground between strict lockdown and an unregulated (and unsafe) return to normal. Richard Green fields questions about strategy options for the US in comparison to other countries and what can be done about asymptomatic carriers, while Dr. Sood iterates that the knowledge base of COVID-19 is improving, but still needs more growth.

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Please note this automated transcription may contain errors.

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Richard Green:  Good morning, everybody.

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Richard Green: Welcome to Lusk perspectives for May 21 2020, we are pleased to welcome back. Today,

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Richard Green: The first person we had unless perspectives roughly six weeks ago soon.

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Richard Green: As you will recall, Neeraj is a distinguished professor here at USC price school. He's the vice dean of faculty here is a senior fellow at the Shaffer center.

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Richard Green: Um, but what you may not know is since he first spoke to us about six weeks ago. He has turned into a rock star. And so I like to feel like I'm the Clive Davis of epidemiology because Clive Davis is the person who discovered Janis Joplin, among other people

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Richard Green: He is now. His, His work has been

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Richard Green: Featured in all the major newspapers. He's testifying before various legislative bodies. He is working closely with los Los Angeles County.

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Richard Green: As it has been and with its ongoing response to cove it and so he is really in the thick of things. And so we really appreciate that he's taking out some time for us this morning, Neeraj Sood should thank you for joining us again.

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Neeraj Sood: Richard. Thank you for that introduction.

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Richard Green: Um, I do have some slides.

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Richard Green: And just one bit of housekeeping is if you have questions, please post them in the Q AMP a box, you will see at the bottom of your screen. And I will afternoon, which gives his talk moderated conversation with him. So starting your H. With that, please take it away.

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Neeraj Sood: Okay, so can you see the slides.

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Richard Green: I can see them. Yes.

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Neeraj Sood: So I think last time I talked with you. We talked about the op ed that I published in The Wall Street Journal, so I'm not going to go over the points we made in the office. But since then, what we've done is we've conducted

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Neeraj Sood: A survey prevalence study in Santa Santa Clara County. On April 4 and then we conducted a thorough prevalence study in Los Angeles County. On April 10 and actually we just completed the second wave of the Los Angeles County study on

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Neeraj Sood: May 12

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Neeraj Sood: One of our nl be tested about 25 employees and 25 different cities and they've shared their data. So we are working on analyzing the data from the MV we are planning Sarah prevalent studies of first responders in LA.

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Neeraj Sood: Of children of people in nursing home populations. These are all special populations that LA County Public Health is interested in understanding

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Neeraj Sood: And numerous counties and cities have reached to us and we are basically sharing what we learned from these studies and sharing, not just what we learned, but sharing the challenges we faced and conducting these studies as they launch their own studies.

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Neeraj Sood: So what have we learned so far from the studies what we've learned is

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Neeraj Sood: That the number of confirmed cases of covert 19 are up to a proxy for the true extent of the infection in the community.

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Neeraj Sood: The early studies or in the earlier part of the epidemic. The true extent of the infection.

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Neeraj Sood: Based on confirmed cases could be or the you know the extent of inflection could be 50 times higher than the number of confirmed cases.

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Neeraj Sood: And the reason for this was early in the epidemic. We had a lot of cases, but we were not testing individuals we were only testing symptomatic individuals over time.

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Neeraj Sood: This gap between confirmed cases and the true extent of the infection is going to reduce or is going to narrow as we ramp up testing. So this number is, in some sense, not a fixed number and it's a function of how much underlying testing, there is happening in the community.

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Neeraj Sood: We've got a lot of comments about

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Neeraj Sood: You know, are these results valid, given the accuracy of the tests and given non response bias, which is that not everyone invited to participate in the study participates in a study

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Neeraj Sood: So the results of wave one were published in a in a leading medical journal called JAMA. So in that sense, they have

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Neeraj Sood: You know they have peer reviewed and the results are robust we discuss these issues with the peer reviewers, but we're still learning more, so

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Neeraj Sood: We're learning more about the accuracy of the tests and we are learning more about new statistical methods to adjust for non response bias. So the results might change over time as we, you know, use new tests or use new techniques to account for non response Baptists.

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Neeraj Sood: The other thing we found from these studies is that a lot of those who were infected did not experience symptoms consistent with go with 19 such as

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Neeraj Sood: Fever with cough fever with shortness of breath, loss of sense of smell or taste so it says there are a lot of people who don't work asymptomatic in terms of these symptoms.

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Neeraj Sood: The loss of sense of smell or taste seems to be the most important predictor of infection across these multiple studies.

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Neeraj Sood: And finally, the infection rates vary by geography income and race ethnicity. So in some sense, you know, an aggregate number for LA County masks, or for any community any large county Mike mask a lot of

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Neeraj Sood: Differences between the county, depending on what neighborhood you live in what your income level is and race ethnicity ism so on.

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Neeraj Sood: So now, what are the results from the studies mean for public policy. So I think the first implication is that the mortality rate and hospitalization rate.

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Neeraj Sood: Estimated based on number of confirmed cases is going to be higher than that mortality rate and hospitalization. Great.

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Neeraj Sood: Estimated based on number of confirmed or number of estimated infections are using the several prevalence settings.

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Neeraj Sood: So what we need to do is, is use these new estimates of ranges of mortality rates and ranges of hospitalization rates and update of our models and and disease forecasting models.

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Neeraj Sood: To see what would happen in the future as you change the underlying input into into those models in terms of the mortality and hospitalization rate.

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Neeraj Sood: And since the mortality and hospitalization estimates are going to be revised downwards what it would mean that the chances of the virus overwhelming their health care system are lower than what was initially assumed or forecasted

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Neeraj Sood: The second thing, this means is that contact racing is going to be more challenging for two reasons. One, there are many more infections.

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Neeraj Sood: Based on the several prevalence studies compared to the number of confirmed cases. And second, a lot of those infections might not have the classical symptoms of covert or might be asymptomatic.

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Neeraj Sood: So the traditional strategy of testing symptomatic individuals with fever and shortness of breath or fever and cough.

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Neeraj Sood: Might not be as effective as be pink and finally all like, not just this studies, but now there's been several efforts in across the nation. So other than

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Neeraj Sood: Kind of New York and the Northeast in a lot of these studies several prevalence has been in the three 4% 2% range. So what that means is, there is still 98% of the population that's acceptable.

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Neeraj Sood: And we think you know herd immunity might be achieved or the epidemic might end when like maybe 60% of the people get infected are 60% of the people are vaccinated

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Neeraj Sood: So this means that when we think about public policy decisions for covert we cannot have a two month time horizon.

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Neeraj Sood: This epidemic is not going to end in the next two months, we need to have a much longer time horizon.

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Neeraj Sood: In making these policy decisions. So I think the time horizon should be, you know, at least 18 months, two years till the time we have a vaccine or we achieve herd immunity in some other way.

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Neeraj Sood: So now the some

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Neeraj Sood: Additional parts on policy, the coal kind of beyond the results of the study.

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Neeraj Sood: So the first thing is, a lot of the disease epidemic modern show that social distancing or lockdowns they do not change the number of infections over the long run. What they do is change the timing of the infections. So if you don't have a lockdown. You have a high peak.

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Neeraj Sood: And

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Neeraj Sood: And then the infection stable over time. If so, the lockdown is just changing when that peak happens or how big that peak is. So in some sense, the

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Neeraj Sood: The benefit the primary benefit of a lockdown is having this is what flattening the curve is having a smaller peak so that the probability of overwhelming the healthcare system is reduced.

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Neeraj Sood: Which in turn would reduce covert related mortality, but there are several costs of stringent social distancing or lockdowns. One is that it increases the chances of a higher peak in the second way.

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Neeraj Sood: So just to kind of give you an example.

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Neeraj Sood: If we have a stringent lockdown for the next three months, and we are able to maintain Sarah prevalence at three 4% and then we let go because

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Neeraj Sood: We don't have political will to keep the lockdown or the economic and health consequences of the lockdown are too severe

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Neeraj Sood: Well, three months from now, we still have 97% of the population that's acceptable.

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Neeraj Sood: So now when we have a second wave of infection or a second seed of infection in this community. We're still going to get this much higher second P or higher peak in the second wave

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Neeraj Sood: But if he had already had 10% several prevalence. Then the second peak would be smaller because the virus would find it more difficult to spread in the community where more people have already had that section.

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Neeraj Sood: We should also look at other costs of stringent social distancing. For example, it might have, you know, reduce our quality of life.

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Neeraj Sood: It might lead to other social problems related to that, such as drug abuse or domestic violence. It also has economic costs for household businesses nonprofits government

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Neeraj Sood: It has other costs on health care, for example, people delaying preventive care like CANCER SCREENINGS OR vaccinations, or people are not going to their health care provider, even when they have symptoms that could be treated.

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Neeraj Sood: And finally, last but not least, having children out of school can have long term consequences on their human capital formation and their, their prospects during their lifetime.

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Neeraj Sood: So I think we need to look at both the benefits of of social distancing, as well as the costs.

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Neeraj Sood: And choose a level of social distancing that maximizes the benefits net of these costs. So in some sense, you know, from an economic perspective, or from any whenever you look at an optimization problem.

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Neeraj Sood: One of the things you say is it's very difficult. Like, it's very rare where the corners are the optimal solution. So, which basically says,

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Neeraj Sood: Very stringent social distancing might not the optimal and business as usual also might not be optimal. The optimal path might be somewhere in the middle there. We are doing social distancing but at the same time we are cognizant of these costs and we are trying to

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Neeraj Sood: You know, minimize the cost at the same time, you know, trying to increase the benefits. The other thing is social distancing is is not the only policy option.

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Neeraj Sood: We should look at the costs and benefits of other policy options. So for example in Los Angeles County 50% of the deaths that are that are are in nursing homes.

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Neeraj Sood: So one strategy would be to focus a lot of effort on prevention in nursing homes or prevention in other high risk populations such as those who have a chronic conditions or intergenerational households.

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Neeraj Sood: Similarly, you know, there are two ways to reduce the chances of overwhelming the healthcare system. One is to reduce the demand and you can reduce the demand by making sure people are healthy and are doing social distancing

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Neeraj Sood: But on the other hand, you could also reduce the chances of overwhelming the system by increasing supply which is having more hospital beds having more ICU beds, making sure our healthcare workers are protected with the appropriate DP. So I think we need to

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Neeraj Sood: Consider all these different options when thinking about public policy and none of these decisions are going to be made that complete certainty.

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Neeraj Sood: So I cannot tell you right now, what I think, or, you know, what is for sure and optimal policy, policy makers are leaders will have to look at all these factors.

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Neeraj Sood: We would not, we would not know all the costs and benefits with complete certainty.

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Neeraj Sood: They will have to evaluate different policies and then and then go with a policy that they think makes sense and be adaptive so over time change policies as they learn more information about the benefits and costs and the effectiveness of different policies.

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Neeraj Sood: And probably stop there and take any questions.

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Richard Green: Your it's. Thank you very much, I guess, let me start with a question about your view that the mortality rate has been overstated by using confirmed cases as the denominator.

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Richard Green: Isn't there also a problem with the numerator, not being measured properly. And I'm thinking, in particular, you look at a place like New York

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Richard Green: And the excess death rate in New York at the peak was something like five, which is to say there was a week in which

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Richard Green: Five times as many people in New York City die than you would expect in a normal week and based on that week of the years average for the previous five years.

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Richard Green: And if you look at the number of confirmed deaths. It was a substantially lower number than that excess death number. And so, don't you need to adjust both the numerator and denominator. Yes.

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Neeraj Sood: Yes, so you need to adjust both the numerator and denominator and Richard, you're absolutely right that if you look at I think starting the last week of March. There is clear evidence that it's not just all cause mortality has has has been higher than expected.

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Neeraj Sood: And I think the the challenge here is is twofold that we need to figure out how much of that excess mortality is because of Kobe or because of Kobe associated lockdowns. So it could be that some of those access that are because

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Neeraj Sood: Like you gave me this anecdote that you're you know someone call your wife and said they had a crush on their chest but they didn't want to go to the ER.

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Neeraj Sood: Because they're afraid of corporate so I think some of an issue, look at data. I was in another meeting where they were presenting data from

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Neeraj Sood: The LA County, er, and you see a big drop in the number of people coming to er for a variety of reasons. So

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Neeraj Sood: I think that's the the challenge there. And would we ever know.

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Neeraj Sood: How much of those access that are because of lockdown or because just stop the fear. Like, not even the lockdown. Even if you open the lock down there might be still, the fear of going to a doctor and getting care. So we just don't know that, but I think

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Neeraj Sood: What we need to understand is how that number would change under alternate lockdown policies and it just, you know,

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Neeraj Sood: It's right now. You can make an educated guess. But this is the point I was saying that there is always going to be a lot of uncertainty about this and and you just have to make these decisions under that uncertainty.

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Richard Green: So along those lines.

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Richard Green: One of the things I find compelling. I was listening to a pediatrician yesterday, very well known one who is very concerned about the decline in vaccinations.

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Richard Green: And she says they're down about 40% on trend. Remember that was her my wife told me that it's a, what is that what is the more implied mortality rate of people just not getting vaccinated for things they should be vaccinated. Our we have any sense.

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Neeraj Sood: I don't know that off the top of my mind ahead. But I think that, in general, we haven't spent as much time talking about all these other side effects.

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Neeraj Sood: That we are experiencing every day we know what's happening to covert mortality and covert cases.

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Neeraj Sood: But we know very little about all these other things and how big they are, and how relevant they are and how they change as we implement different policies. So I think that in general.

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Neeraj Sood: Those things are are less salient because we don't see them every day and we haven't done a good job quantifying them.

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Richard Green: So there is a question from the mind Gibson. How should anybody tests be compared in quality. Um, what is their sensitivity, specificity. So it's basically how good are they which ones are any good. It's

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Richard Green: Walk us through a little bit about how do you think that. Sure.

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Neeraj Sood: So the, the test. The two parameters you look at when looking at the validity of a test. One is called the specificity.

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Neeraj Sood: Which is one minus the so one minus specificity is the false positive rate of a test. So to just give you an example that test we used in

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Neeraj Sood: The Los Angeles County study had a specificity of 99.5% which means if I test 200 individuals.

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Neeraj Sood: I will get one false positive. So, there will be one individual who actually wasn't a positive, but the tests would say that was positive. So, the chance of a false positive is one and 200 or point 5%

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Neeraj Sood: The other measure of a test is the sensitivity of the test and one minus the sensitivity is the false negative rate of a test. So that says

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Neeraj Sood: If someone actually has

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Neeraj Sood: Covered and the test or has Kovar antibodies, but the test doesn't recognize that

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Neeraj Sood: And the test basically called to a negative. So our test had my dog wants to come in.

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Neeraj Sood: Meeting. So the other test had

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Neeraj Sood: Our test had a sensitivity of around 20% sorry of around 80% which means if the test hundred people who were

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Neeraj Sood: Positive the tests would only identify 80 of them as being positive. So what are these numbers mean in terms of trying to understand the value of a test.

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Neeraj Sood: So for the purposes of our study all we wanted to do was count the number of people.

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Neeraj Sood: Who were potentially infected. So as long as I know the false positive and the false negative rate of the test.

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Neeraj Sood: I can adjust my formula. So I can, I can look at the percent who tested positive and converted into a number which would be the percent who truly have Coburg anti bodies. So for that, all I need to do some math.

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Neeraj Sood: With the false positive rate and the false negative rate. So we did that math for the LA study. So you know if the percent who tested positive was 4%

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Neeraj Sood: After you adjust for the false positive and the false negative rate the percent who would have antibodies. We estimated that to be around 4.3%

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Neeraj Sood: But if you want to use these tests to make health care decisions, then it's a different issue because then you don't want to call someone a positive if they really don't have the antibodies. So, you know, they're

00:25:03.270 --> 00:25:16.740
Neeraj Sood: calling someone a false positive test is in some sense, more problematic than a false negative test because in some sense without testing. We are all presumed to be negative. Anyways, and we take precautions.

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Richard Green: Um, so, and by the way, I think I read in The Lancet some years ago that a dog entering a video meeting extends everybody's life expectancy by five minutes so

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Richard Green: Yeah, I'm going to skip the cute little bit because Elizabeth salvi has a follow up to your most recent answer, which is just how does the specificity and sensitivity of this test compare, for instance, to the flu test.

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Neeraj Sood: I, I don't know the sensitivity and specificity of the test.

00:25:51.720 --> 00:25:52.320
Neeraj Sood: So,

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Neeraj Sood: I you know I know the test. We looked at

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Richard Green: Yeah. Yeah. But I think the application is is is what you're doing this under counting, given the sensitivity and specificity. You're actually hundred counting the number of true cases.

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Neeraj Sood: So sensitive sensitivity. The low sensitivity implies, we are under accounting, but

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Neeraj Sood: The point 5% so the higher the specificity, like if the specificity was lower than you would be over counting

00:26:24.990 --> 00:26:28.800
Neeraj Sood: Right, because we wouldn't have more false positives. Right, right, right.

00:26:28.890 --> 00:26:31.710
Richard Green: So I'm from Rita lumbered

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Richard Green: She, she picked up on your statement, the chance of cases overwhelming the system are lower than thought. And she says, so how does that explain Italy, France in New York City. I'm surely the healthcare systems and those places were overwhelmed.

00:26:48.030 --> 00:26:52.890
Neeraj Sood: Yes, healthcare systems in those places were definitely overwhelmed and

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Neeraj Sood: All I'm saying is that these estimates imply that the chances of the i'm not saying the system might would not be overwhelmed. If he had 30% Sarah prevalence, very quickly, the system would be overwhelmed, even with the new estimate what, what I'm saying is

00:27:12.840 --> 00:27:18.870
Neeraj Sood: Early on we had estimates off from the who that mortality would be three to 4%

00:27:20.280 --> 00:27:23.580
Neeraj Sood: That would imply systems, getting over them very quickly.

00:27:25.170 --> 00:27:40.140
Neeraj Sood: These new studies imply mortality estimates that are much lower than that, ranging from point one to point 7% so that would imply the chances of the system being overwhelmed are lesser and the second is

00:27:41.430 --> 00:27:55.080
Neeraj Sood: We cannot extrapolate these findings. So I'm not saying take the findings from LA or Santa Clara or Indiana or wherever, all this testing has been done and extrapolate to other places, you do need to

00:27:56.100 --> 00:28:14.250
Neeraj Sood: The strain of the virus might be different in different places. So how contagious. It is might vary by geography population density varies the stage, the underlying health of the population varies. So there are a lot of different factors that might explain why.

00:28:15.360 --> 00:28:26.610
Neeraj Sood: A virus is more deadly or more infectious in certain areas, compared to others. And as I said, like right now. We still we still, there's a lot of uncertainty about this.

00:28:27.180 --> 00:28:35.070
Neeraj Sood: We still don't know a lot of things about the virus. So we cannot explain accurately. Why you know

00:28:36.030 --> 00:28:41.730
Neeraj Sood: What are the factors that led the virus too overwhelming the healthcare system.

00:28:42.120 --> 00:28:56.070
Neeraj Sood: In New York, and Italy, but not in so many other locations like why didn't it overwhelmed and Iran by them did overwhelm in India in Bangladesh in so many other places, so we we don't have a complete understanding of this

00:28:57.600 --> 00:29:13.110
Richard Green: So along the lines of a not complete understanding from Donovan Knowles the following question. There have been talks about the possibility of the virus mutating because of this RNA, allowing for there not to be an effective vaccine similar to that of HIV. Is there any truth to this.

00:29:15.030 --> 00:29:18.870
Neeraj Sood: Again, I'm not an immunologist, so I don't know.

00:29:20.640 --> 00:29:23.250
Neeraj Sood: What I've heard from immunologist is

00:29:24.810 --> 00:29:37.020
Neeraj Sood: That, you know, a vaccine will take time, but there is a good chance of having a vaccine. But again, you should take that with the caveat that I'm not an immunologist, this is just secondhand knowledge.

00:29:38.460 --> 00:29:45.300
Richard Green: So I'm from Horatio tracheotomy with many asymptomatic carriers out there.

00:29:46.470 --> 00:29:57.780
Richard Green: And the likes of Disney and other businesses, including airlines using temperature to allow access, can we not be allowing the surgeon cases. And I assume by that requiring people to have their temperature taken before they enter the part of the airplane.

00:30:00.510 --> 00:30:06.630
Richard Green: What percentage of the US population you expect will eventually be affected in the next three months if no vaccine is introduced.

00:30:07.830 --> 00:30:19.710
Neeraj Sood: So what fraction is infected will depend upon what we do over the next three months in terms of What practices do we follow in terms of opening up the economy.

00:30:21.060 --> 00:30:21.450
Neeraj Sood: And

00:30:23.970 --> 00:30:30.450
Neeraj Sood: And, you know, again, like, the question is, when you think about public policy, you got to think about the long run.

00:30:31.140 --> 00:30:45.900
Neeraj Sood: So you have to say, are we going to be in a stringent lockdown for 12 months or what is our plan of action. So one type of action would be to have a stringent lockdown for a certain amount of time.

00:30:46.740 --> 00:30:57.090
Neeraj Sood: Reduce the reproductive number of the defective reproductive number of the virus to below one and then gradually and safely start opening up the economy.

00:30:58.110 --> 00:31:04.530
Neeraj Sood: Also to segment the risks which is take care of the nursing home population, which accounts for 50% of the deaths.

00:31:06.780 --> 00:31:23.130
Neeraj Sood: So I think there are just a variety of different strategies to do. But let's not look at, I can say, I'm pretty confident, if you open up the economy, the number of cases bill rights because this is a contagious disease and it goes back to more people. The question is,

00:31:24.840 --> 00:31:38.700
Neeraj Sood: What are our other options. How long can we, you know, sustain a stringent lock down, what would be the cost of those stringent drop down. So I think we have to do this balancing act. There we are trying to

00:31:40.170 --> 00:31:51.030
Neeraj Sood: Minimize all the costs of the lockdown. But at the same time, we don't want to overwhelm the system. So we are trying to open in a way that doesn't overwhelm the healthcare system.

00:31:52.290 --> 00:32:01.710
Richard Green: Yeah, so I i think i'd like to. We had a conversation yesterday about the following. Suppose you get the are of under one, which is to say that

00:32:02.190 --> 00:32:14.190
Richard Green: The average person infects fewer than one other people and what I ask you, is that what would that ultimately lead to the depth of the disease and you're applying know and so if you could explain that a little bit.

00:32:14.790 --> 00:32:22.410
Neeraj Sood: So like for example right now in LA County we think we are approaching and are less than one.

00:32:23.700 --> 00:32:32.970
Neeraj Sood: So if you have a are less than one. And right now we think our Sarah prevalence is around 3%. So if our is less than one.

00:32:34.470 --> 00:32:44.520
Neeraj Sood: And we continue with these measures the the disease might, you know, so the disease will start dying down and maybe it'll die down by the time we have a separate prevalence of 5%

00:32:45.240 --> 00:32:53.490
Neeraj Sood: So, so now what do we do after that, do we continue to stay in this stringent drop down and keep our below one

00:32:54.060 --> 00:33:02.490
Neeraj Sood: But if you've achieved that. And the disease has now stabilized that it's not increasing say beyond 345 percent of the population. And then you open up

00:33:03.000 --> 00:33:13.260
Neeraj Sood: When you open up, you still have 95% of the population that's acceptable and if you get someone who has coded re enter this population or see this population with covert

00:33:13.680 --> 00:33:22.410
Neeraj Sood: We will have a second wave of infection. So, and the second wave of infection is larger, the more susceptible people. You have

00:33:22.830 --> 00:33:30.810
Neeraj Sood: So if you have a population where only 50% of the people is are susceptible and you put a seed in the population. You've already in some sense.

00:33:31.080 --> 00:33:39.600
Neeraj Sood: Achieved herd immunity because 50% were already infected and that epidemic doesn't take off. But if you have a population where 95% are susceptible

00:33:40.200 --> 00:33:49.800
Neeraj Sood: You can stay in that block down for six months, but the moment you open it if 95% are susceptible. There are greater chances of having the second wave. So

00:33:50.700 --> 00:34:00.300
Neeraj Sood: The safest thing if you just scared about covert mortality and nothing else is to stay in a lockdown till the time you have a vaccine that is the safest thing.

00:34:01.080 --> 00:34:15.090
Neeraj Sood: If you just care about covert mortality. But if you care about all the other costs of a lockdown including health quality of life economic costs, then that doesn't seem like a sustainable strategy.

00:34:15.570 --> 00:34:22.650
Neeraj Sood: That we cannot be in a lockdown. For the next two years. So now the question is, how do you close that gap.

00:34:23.010 --> 00:34:33.090
Neeraj Sood: With and the same thing, we cannot do business as usual, because we've seen business as usual will lead to a big spike in infections and it will lead to a lot of unnecessary deaths.

00:34:33.540 --> 00:34:42.720
Neeraj Sood: So we need to find some strategy between lockdown. For the next two years versus business as usual. What is that strategy.

00:34:43.410 --> 00:34:53.520
Neeraj Sood: And what strategy would be optimal. No one really knows that for sure. We need to experiment a little monitor figure out

00:34:54.390 --> 00:35:00.780
Neeraj Sood: What what that optimal might look like. And that optimal will be different for different locations, because it might depend upon

00:35:01.020 --> 00:35:16.980
Neeraj Sood: How contagious. The viruses, it might depend upon how good your healthcare system. Is it might depend upon how good the underlying health of your population is what is happening in your economy, a lot of different factors. So V V need to make that decision under uncertainty.

00:35:17.880 --> 00:35:30.060
Richard Green: So I cannot. So, so one of the most interesting facts out there about the disease right now is Singapore has as of yesterday or day before yesterday had 22 deaths out of 28,000

00:35:30.840 --> 00:35:41.760
Richard Green: Cases. So that's less than point 1%. And so what makes Singapore, different from the rest of the world so so beyond the fact that they have

00:35:43.830 --> 00:35:45.570
Richard Green: Their incidence is pretty low.

00:35:45.900 --> 00:35:51.360
Richard Green: Yeah, given their population tremendously low but that very low mortality rate is quite

00:35:51.390 --> 00:35:54.990
Neeraj Sood: Yet yeah i i don't know

00:35:56.040 --> 00:36:01.290
Neeraj Sood: Why they have expedience much lower mortality than

00:36:03.360 --> 00:36:16.680
Neeraj Sood: Other parts of the world. And I think the mortality rate is also going to change over time as we learn more about how to handle this disease, for example.

00:36:17.460 --> 00:36:28.500
Neeraj Sood: They were reports that individuals from hospitals were who had a call with infection were transferred to nursing homes where they spread the infection.

00:36:28.830 --> 00:36:34.830
Neeraj Sood: Now we know that is. And the reason they did that was they were trying to prevent infections in the hospital.

00:36:35.400 --> 00:36:41.520
Neeraj Sood: But transferring that person to a nursing home probably lead to many more deaths. Now everyone understands

00:36:42.060 --> 00:36:50.700
Neeraj Sood: We should not be doing that. And that was a bad strategy I think now everyone understands a lot of the infections are coming from nursing homes and Kongregate settings.

00:36:51.360 --> 00:37:00.870
Neeraj Sood: We have better technology for testing individuals and getting results more rapidly. So I think that's going to change the mortality rate over time.

00:37:01.440 --> 00:37:09.960
Neeraj Sood: A lot of physicians and healthcare providers are figuring out how to treat this disease like whether or not to use antique anticoagulants

00:37:10.350 --> 00:37:23.820
Neeraj Sood: Whether or not to use ventilators, and when to use ventilators, so I think over time, even if you don't have a vaccine. We're still going to reduce mortality by figuring out these other ways of better managing this disease.

00:37:24.750 --> 00:37:33.930
Richard Green: So, you know, and here's a good follow up again from Dr Lundberg did the Swedes perhaps have the right approach create herd immunity among children by keeping the schools open

00:37:34.410 --> 00:37:44.760
Richard Green: But unlike sweetened take much better care to protect the nursing home and other vulnerable populations. Yeah, thereby increasing herd immunity, but not achieving it at the cost of high mortality.

00:37:46.200 --> 00:37:50.790
Neeraj Sood: So I think there is this park there that one strategy is

00:37:51.810 --> 00:38:00.660
Neeraj Sood: To have the low risk population be infected so that we can develop code immunity and at the same time.

00:38:01.920 --> 00:38:06.240
Neeraj Sood: Invest heavy resources in protecting the high risk population.

00:38:07.620 --> 00:38:18.210
Neeraj Sood: So protecting the elderly, protecting intergenerational households protecting nursing homes and, you know, I think that's a strategy. Definitely worth considering.

00:38:19.650 --> 00:38:23.280
Richard Green: So from and I'm not following that. So I'm going to ask

00:38:24.750 --> 00:38:29.370
Richard Green: Lamont Gibson, if I can find them here on my list.

00:38:32.370 --> 00:38:37.530
Richard Green: I was going to give them permission to talk, but I'm not seeing them on my list anymore. I'm

00:38:39.120 --> 00:38:40.080
Richard Green: Here we go out

00:38:40.140 --> 00:38:42.300
USC Lusk Center for Real Estate: What I can do that sound.

00:38:42.390 --> 00:38:48.150
Richard Green: Okay, well yeah so so amount will you I'm not following the question you texted, could you can you try asking it.

00:38:48.300 --> 00:38:49.170
Richard Green: Live, please.

00:39:01.170 --> 00:39:02.070
Richard Green: So my

00:39:04.860 --> 00:39:06.120
USC Lusk Center for Real Estate: I think I just unmuted in

00:39:07.500 --> 00:39:08.940
Richard Green: Yeah, now he's unmuted.

00:39:11.760 --> 00:39:25.230
Richard Green: And I guess I'm not the question type just what assessment adjustment is made for similar but different IE less lethal Corona viruses. I guess I'm not quite sure what what's meant by assessment adjustment but I

00:39:27.090 --> 00:39:30.510
Neeraj Sood: So I think maybe the think he's referring to is

00:39:31.170 --> 00:39:31.920
The false

00:39:32.970 --> 00:39:34.590
Neeraj Sood: Positive rate of the test.

00:39:35.010 --> 00:39:35.580
Richard Green: And

00:39:35.970 --> 00:39:37.980
Neeraj Sood: If, if the test is

00:39:39.030 --> 00:39:42.720
Neeraj Sood: Picking up other Corona viruses that would be a false positive.

00:39:44.370 --> 00:39:45.840
Neeraj Sood: And as I said, like we

00:39:47.820 --> 00:40:03.630
Neeraj Sood: You know, we think the based on the data we have about the test the specificity of the test is pretty high at 99.5%. So just to kind of give you an example of V sent about hundred and 10 kicks to the FDA.

00:40:04.500 --> 00:40:18.390
Neeraj Sood: To ask them to test. The test kits. So they put at known covert negative samples into the test kit and the test kits at all 80 of them are negative. So the false positive rate. There was zero.

00:40:19.770 --> 00:40:34.620
Neeraj Sood: The FDA put 13 known Kobe positive samples and the test get picked up 28 out of the 30 so that would imply a sensitivity of 93% but the sensitivity does change.

00:40:36.270 --> 00:40:46.920
Neeraj Sood: Over time, so the sensitivity is lower early when you are infected because you're the number of antibodies are low, and the sensitivity increases.

00:40:47.490 --> 00:40:56.760
Neeraj Sood: At like the two week two, week mark where you there's a much greater chance that you have a more robust concentration of antibiotics.

00:40:57.570 --> 00:41:06.090
Neeraj Sood: In terms of cross reactivity to other Corona viruses. It also depends upon you know where you get your coven negative samples from and what

00:41:06.390 --> 00:41:24.540
Neeraj Sood: The underlying prevalence of these coronal viruses is in those populations. And we don't know a lot about that. So it could be that there are some false positives because of cross reactivity and some people think that's actually a good thing because that might show that

00:41:25.740 --> 00:41:35.760
Neeraj Sood: That you could have some potential immunity because you have antibodies that are reacting against multiple Corona viruses, including the new one.

00:41:37.650 --> 00:41:43.800
Richard Green: So here's, I think, a really good question and I don't know if you will know the answer. So I

00:41:44.490 --> 00:41:51.030
Richard Green: But I'm going to put it out there. Anyway, so we so we know in the US, African Americans are dying at a higher rate.

00:41:51.810 --> 00:42:04.380
Richard Green: Than other racial and ethnic groups. Is this a uniquely American phenomenon that there's one race, ethnicity, that's dying at a different rate from others, or do we see this in other parts of the world as well.

00:42:05.880 --> 00:42:09.750
Neeraj Sood: I, that's a great question. I don't know the answer to do it.

00:42:10.020 --> 00:42:19.140
Richard Green: Yeah, I thought it was fair to answer it. But, but it was such a great question on the off chance you the answer. I wanted to ask it anyway. Yeah.

00:42:19.260 --> 00:42:20.400
Richard Green: So, then maybe

00:42:20.460 --> 00:42:24.780
Richard Green: We should find at least a great question. But yeah, we, we don't know.

00:42:26.910 --> 00:42:42.210
Richard Green: Okay, well, um, that is, that's it for the questions we have before us today. So again you rich. Thank you very much for coming back and updating a son, what you've been up to since we first spoke

00:42:43.650 --> 00:43:00.030
Richard Green: roughly six weeks ago. Yeah. A OUR NEXT EVENT FOR LESS Perspectives is next Tuesday at 11am we will have a home builders panel featuring Adrian falling

00:43:01.350 --> 00:43:17.970
Richard Green: From Brookfield and Scott Laurie from Olson homes and then next Wednesday we will have a follow up on commercial tenant management with David Fincher Stanley iseman Lisa ready and Rachel wine. So

00:43:19.050 --> 00:43:27.180
Richard Green: That should be two excellent panel discussions we have about how things have changed in the world of real estate. The last month.

00:43:28.560 --> 00:43:34.770
Richard Green: Again, thank you all very much for joining us and we will look forward to seeing you next week. Have a good weekend.



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