Cole Hons: Greetings, fellow Homo sapiens and welcome to The Symbiotic Podcast.

For this episode, we collaborated for a second time with Matthew Ogden and Matt Paolizzi from Podward State to take a closer look at Penn State’s COVID-19 response.

Our guests were two infectious disease experts here at the university who have both spent countless hours since the start of this pandemic offering their best advice to Penn State administrators as they’ve navigated the ever-shifting challenges of these unprecedented times.

Dr. Catharine Paules is a practicing physician in the infectious disease department at the Penn State Hershey Medical Center. In addition to her service on Penn State’s coronavirus task force, Paules provides direct care to COVID patients, is actively engaged in research on COVID therapeutics, and has collaborated directly with Dr. Anthony Fauci.

Andrew Read is the director of the Huck Institutes of the Life Sciences here at Penn State, and is former director of Huck’s Center for Infectious Disease Dynamics. Read spearheaded a rapid-response seed-grant effort at Penn State in February 2020 that kick-started 48 coronavirus research projects across dozens of disciplines and is currently providing leadership for COVID testing of Centre County Pennsylvania’s population and the wastewater of State College, PA and Penn State’s University Park Campus.

I hope you’ll enjoy this inside look at what these tough times are like for experts trying to help keep everyone safe at a Big 10 research university.

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Intro (Nina Jablonski): Evolution involves more than the survival of the fittest. It's also about the survival of the most cooperative, and mutually beneficial relationships are critical to the survival of every species. Welcome to The Symbiotic Podcast, where we will explore the collaborative side of life and work to consciously evolve science itself.

Cole: Hello everybody, thanks so much for coming together today to be on these two podcasts, The Symbiotic Podcast and also Podward State. It's good to see you, Cat and Andrew and Matt and Matt. Thanks everybody for being here, we're doing this on a Monday morning. Well done, Penn State people! Well done! Maybe I'll just kick in with the first question, I really want to ask Andrew and Cat both, the two of you I know have been on, I think, multiple teams related to Penn State's COVID-19 response, testing teams and consulting with administration on how to really deal with this crisis in the best possible way and move forward. What's it like being on these teams and which teams have you been on so far?

Catharine (Cat) Paules: I started being asked to join teams probably as soon as this happened. As early as March we were already planning for the hospital: What kind of surg capabilities did we have? What kind of infection prevention policies did we need? We were frequently working within shortages such as testing shortages and personal protective equipment shortages. So, planning around those things can be very challenging as well. I've been on a lot of different planning groups and one of the things that I've learned is that you can never get too attached to your recommendations because with a brand new virus, those recommendations change every single day.

Cole: Wow. Andrew, what's your experience [crosstalk 00:01:29]?

Andrew Read: Yeah, I came into the university side of things a bit later than Cat. So, I was involved in the research response in March, that's for sure, generating seed grants and projects for the science side of things, many of which went on to support the university's operational plans and made possible various different types of testing that's happening on campus now. I can't remember when Cat and I ended up on the first meetings together. It feels like it might've been April or so. We've been part of the testing taskforce steering group. I'm also involved in a couple of the community studies in town here data for action and the wastewater sampling in University Park and in the main municipality as well.

I have to say, I'm definitely with Cat on the not getting too hung up on a particular recommendation, because the science is moving so fast. And the other thing that I've really come to appreciate, even though I did before, that the problem like this you need so much different types of expertise on, and it's really important to be listening to what everybody else is saying because they've got different angles and different perspectives. And that's been immensely stimulating, at the same time really shows how just being, I'm an infectious disease guy, so there's more to this problem than just understanding the infectious disease. And that's been really an interesting eye opener to me.

Matt Paolizzi: Yeah, obviously these teams were very quickly assembled as soon as a COVID response was needed. How has it been serving on these teams so far for you guys?

Cat: It's very interesting. I think what Andrew said is really true, that people come into these groups with different expertise and different things that they're really focusing on, so I try to remember that my job is to give them the infectious disease clinician's view of the problem and then be very willing and open to listen to others' opinion on the group.

Andrew: Yeah, I guess I found it different from managing and being involved in research project discussions in the sense that, well, the problem is very fast moving. And so something that you can be very caught up with is irrelevant two weeks later. So, that's been a bit of an eye opener. And then initially, I found it a bit frustrating because it wasn't clear who was assigned to do what. And at that early stage, it wasn't clear what the landscape looked like, so it wasn't clear what the issues really were. And so sometimes you're thinking about something, working on it for a week and it turns out somebody else has and you mightn't even have bothered.

And then big holes open up that nobody was working on and become obvious. The fluidity of it, early on, I personally found that a little bit difficult, because I'm used to better organized environments. Now, it's pretty organized, and now it's pretty clear who does what and what's going on. But back then, it was a pretty white-knuckle ride to start with.

Cole: Matt, you look like you got one for us.

Matthew Ogden: Yeah, I was just trying to put the words together in my head. But yeah, you guys keep mentioning how early on, because it was just a brand new disease, the science kept changing. And how did that necessarily affect the decisions you guys were trying to recommend and put together? This could be for either one of you.

Cat: I spent a ton of time reading anything that came out, basically, about COVID. And unfortunately, a lot of that early on was pre-print, so things that hadn't been peer reviewed, trying to learn in the setting of publishing data by these pre-prints or press releases, talking to colleagues that were in harder hit areas and really trying to learn from one another to get this up and going. And I don't think any of us like to be this far outside of our comfort zone with a brand new disease and trying to manage all of this in real time, so it made for some very long and challenging days. Still long and challenging, but at the beginning I think I was basically sleeping at the hospital for about a month.

Andrew: Yeah, I think too that as well as trying to keep up the information, it really dawned on me early on that universities are not set up to respond to pandemics, right? It's like a war setting, and in a war setting you have an army ready to go, and the army practices, and it knows what it's doing, and then when it goes into war, all the players and the pieces are in place already. Whereas the university is all about delivering education. So, obviously Cat, at the hospital end of things, is thinking the clinical side of things through all the time. And there's lots of people with that expertise. But the academic side and especially at University Park, there just wasn't a bunch of people who were used to fighting pandemics.

And it turns out you need an army of people and lots of things. For example, IT systems that we didn't have in place and testing systems that we didn't have in place and quarantine and isolation and all that – none of that existed at all. And to me, this idea that we had to suddenly step up and fight a fight without any of this going on, it's really quite something.

Cole: Andrew, what were the main driving factors that shaped Penn State's decision making when deciding whether or not to bring the students back for the fall semester? How did that all play out?

Andrew: Yeah, well, I'd say, neither Cat and I were involved in making those decisions. We were involved in putting in our scientific expertise into the areas which went into that decision making process. The way I think about it was that, and Cat's heard me say this before, basically, when you got a pandemic running, there are no good options. Not bringing people back has got problems, bringing them back has got problems. There's just – it totally sucks. There's no good options, and so it's all about trying to reason through what's the least bad option.

And so, in that sense, the university was taking into account the delivery of mission, education mission, the research mission, the fact that there was a lot of jobs on the line, there's a lot of COVID health-related issues and non-COVID related-health issues, as well. All of those things were in a pretty big mix. And very, very challenging decisions for leadership to make. I have to say, I was really glad I wasn't the one making the decisions. Really, really challenging. I found it challenging enough just to put in what I thought was going on in my area of it. Because you don't want to over-egg the risks, but you don't want to come in low on the risks, either. And I still find that challenging.

We're talking with leadership most days about the wastewater side of things, and I still have trouble with this... It feels very stressful trying to make a call on: is this a big deal right now or a small deal? And we'll know in a few weeks, but you've got to say something right now. And I think that was the same when we were in the run up to the opening, was lots of unknowns. And is that a big deal or a minor deal? We know a lot more now but, man, at the time it was stressful.

Cat: And I'll just say we ran into similar issues at the hospitals. And again, I wasn't involved in the actual decisions except to get some infectious disease expertise, but early on, we had seen what had happened in New York City and how their hospitals were just completely overwhelmed, so getting things shut down, delaying care, delaying certain surgeries, things like that went into our planning. But you can't do that indefinitely. People need to come in and see their doctors; people need to come in for their surgeries. So, trying to time all of that but still be prepared to handle what could be immense burdens of critically ill patients is something that we continue to struggle with.

Matt Paolizzi: And Cat, you mentioned all the expertise that you were giving on your side as well, trying to help out however you can. You've actually been involved at the very tippy top of the national response to COVID; you've actually been collaborating with doctor Anthony Fauci himself. Could you just tell us real quick how that collaboration with him started and what your experience working with him has been like?

Cat: I actually did my infectious disease fellowship at the National Institutes of Health. And after my fellowship I worked in an influenza lab with Kanta Subbarao, who's one of the world's experts in influenza and coronavirus, as she had worked in MERS. She actually took a job in Australia for the WHO Collaborating Center there. And at that point, I moved into Dr. Fauci's office to help primarily with influenza research coordination. But I was also there during the Zika responses, as well. And when I came here and things started to happen with COVID, I have a little bit of a background in influenza viruses and then had worked in this lab that worked on MERS. So, those were a natural fit for me, and I continued to work with Dr. Fauci and in any way he might need. And I'll just say, he's a hero. He's a public health hero for this country.

Cole: Absolutely, he's been through a lot and continues to go through a lot, and I think he's gained the respect of our nation – at least a huge majority of our nation – and the international community as well.

Andrew: I think within the scientific community and the public health community, he's a giant. And it's been amazing to me, no matter the political forces that are swirling around him, he stands strong on the science and the public health messaging. That's amazing.

Cat: And it's very few of us, I think, that ever get to meet and work with our hero, but I was fortunate enough to do that. And he's the kind of person that's better in person than he is on paper, if that's even possible.

Matthew Ogden: How did Penn State arrive at the testing regimen that was implemented for the fall? And how do you guys think it has worked so far?

Andrew: Well, the process was that, sometime in July, Cat and I and a number of others got formed into a testing taskforce where we were charged with coming up with a plan. And in fact, we came up with a number of different options amongst which leadership chose. We laid out the options and the pros and the cons. I think very early in the process, and particularly because we had the input from Cat and Melissa George, another clinician at Hershey, we got really focused on, at least from the University Park, the need to make sure that Mount Nittany, the healthcare hospital, the small community hospital, was not going to be overwhelmed.

In many ways, University Park is unique for the huge number of students and then the tiny size of the hospital. And if you think about other places in the country, I do believe we have the fewest intensive care beds for the population of students. And so the planning was all built around trying to make sure that did not get overwhelmed. And then from there it was, in my head at least, the logic was straightforward. You clearly got to test the symptomatic students, you got to provide symptomatic testing. You've got to provide testing for their close contacts. That was just, kind of, as taken.

And then it was, what else could we do? What other sorts of testing could we do on top of that, which might help minimize the chances that Mount Nittany would be overwhelmed? And that's where we added to that basis asymptomatic testing to try to get an eye on what was happening to any outbreaks that happened, what was happening to the overall growth of the case numbers before you see them in the growth of the case numbers. You don't want to be running the operation once you've got sick people, you want to see it happen beforehand. And that's where the asymptomatic testing came from. And then it was very clear that we couldn't test everybody, just because of the logistics and the cost and so forth. So, if you can't test to manage the size of the outbreak, you're just trying to get eyes on the outbreak, then we got to the one percent a day, because that gives you very good eyes on the problem. It doesn't solve it itself, it gives you indication of what's happening to the outbreak. And then that allows leadership to make decisions accordingly.

I believe that's really the way it developed. And we put various options to leadership. That one that we came to, plus what it would take to do more intensive sampling and what would happen if we did none. And then the pros and cons are worked through and laid out pretty clearly, I think. And then leadership chose. Cat is that your recollection of how things went?

Cat: Yes, I think that was a good summary of how things went. In an ideal world, we would test as many people as possible, as frequently as we could. And we laid out a variety of options and those things had to be worked with real world conditions of this outbreak.

Cole: And as far as the modeling that you did, looking at the various options, were there any big surprises on the numbers and how things played out, based on what you would've predicted and how things actually have gone?

Andrew: You mean in terms of how they've actually played out given what we were expecting?

Cole: Yeah.

Andrew: Yeah, I think we've had a couple of things that have been surprising that have been good, actually. One is that we were estimating that there'd be more sick students, so the proportion of students who got seriously sick has turned out to be less than in the models we were using. There's been less community transmission from students to the community than we were predicting – or not predicting, that we were putting into the models as parameters. Both of those things could change, I don't want to be in the slightest bit complacent, but so far in terms of how things have played out there's been a lot less community transmission than we were expecting, and the disease severity amongst the students has been a lot lower than the initial beta for that age group suggested from way back in March, April.

I think the other side of things was that the models were pretty strong on the need to make sure we didn't start the semester with lots of positive, infectious people on campus. The pre-arrival testing was an important part of trying to get those numbers down. And I think we still don't know the full extent to which that worked, but there was ... whatever it was, 140 cases or something which did not come onto campus which might've done otherwise. And at the very early stages, the small initial conditions make a big difference. If you have 10 versus 100 at the start makes a huge difference to how fast things roll. And I think that we probably could do better next time around, but it certainly made an impact on me that we're able to find those cases and keep some of them off campus at least.

Matt Paolizzi: Yeah, how has the testing sequence and how you go about testing students, how has that evolved since you first started? I know my own experience, when I got tested, I wasn't randomly selected, I applied for it myself. For me, at least, it was fairly smooth, which was going against a lot of feedback that I had heard from other students that said things were choppy at times, communication wasn't going well both ways. But at least in my experience, things seemed to go pretty well, and I haven't heard as much negative feedback, it seems like things have gotten better. So, how has that process evolved for you guys in figuring things out?

Andrew: Yeah, I don't know what it's been like in the hospital end, it'd be really interesting to hear that. Our end, on campus University Park ... what was incredible, we had nothing in place at all in the backend of July, when the decision was made about how to do this. And so within a few weeks, an awful lot of testing was stood up and not surprising ... I mean, to me it was amazing it came together as well as it did, as fast as it did. In the first few weeks there were a lot of glitches and a lot of choppiness, as you say

But if you think about the scale of things: thousands and thousands of people getting tested, samples going off, the IT systems to get the students to be of found, the operation – it was just massive. And I had nothing to with the actual implementation of the plans; the folk that had been working with Kelly Wolgast have just been amazing at making this happen. And you can see from the weekly calls, the twice weekly calls we're on at the moment, that they're getting better and better at it, so the IT systems are getting better, they are now managing turnaround test times much faster, they know where students are much better. Everything's getting better and better.

So we went from absolutely nothing to this vast enterprise involving hundreds and hundreds of people in a very short space of time. And yeah, a real testament to those folk that made things happen. To me, it's actually gone, that side of things, the logistics that's being pulled off, has been more amazing than I had conceived of possible at the beginning of August.

Cat: Yeah, I wasn't involved in the logistics up at University Park, but I was heavily involved in the discussions here at the hospital, throughout, since we first started testing people, and it's evolved in incredible ways. When we first started testing, we couldn't even run any tests here are the hospital. They were all going first to the CDC and then to the Department of Health, in a stepwise manner. Initially we were having to deal with a lot of paper forms to get people tested, which doesn't sound like a big deal except that it's a huge burden on whoever has to do those forms, send those forms, follow up the test results. And then we got more testing in steps here.

So, we may be able to do 10 tests in-house a day, send some to the Department of Health, and that's where we were for a time. And then gradually we've been able to test more and more people here, and then there's also been reference labs that we can send testing to. Right now at the hospital we do a mix. We send some tests to our in-house lab within our capabilities, and then we send some to our reference lab, which is Quest. And that usually has a two to three day turnaround. And then, in addition, when you actually do the testing, there's a lot that goes into it in terms of protecting the people that are actually doing the testing and other patients that might need to be tested or evaluated in the same locations.

Initially we did most of our testing through a drive-thru, where people would actually pull up and they would get their swab in their car, and the people that would be testing them would be in personal protective equipment, and then that would all be sent to the appropriate labs. And now we've moved some testing into clinic sites, as well. But that had to be done very carefully to make sure we were protecting anyone else that needed to be in the clinic. So it's a rapidly evolving process. We would love to have a test that we could do in 30 minutes without having to do an NP [nasopharyngeal] swab, just collect something like saliva. And we're looking at all of that as data evolves to see if we're happy with the sensitivity of that type of testing.

Cole: Got it, thank you.

Andrew: Yeah. And actually the testing needs in the hospital are often different from what's needed on campus, too. At the hospital, they've got to get extraordinarily accurate data on individual patients. Whereas in the University Park, from the point of view of managing the outbreak, often it's better. They have very many people tested with rapid turnaround times, even if it's not as accurate as you might want at a diagnostic clinical level, because then you can find people faster and get through more people. And that's definitely evolving.

I think the other thing that's been really an eye opener to me is that the walk-up testing, where students can go for whatever reason, they don't have to specify a reason, that's been hugely valuable. And that wasn't something we envisaged early on. I think that's been really, very good where people have had some exposure, they've got some concerns, and they can just walk up, no big deal. And that's been really good.

And then the other thing that's happened is we've been able to repurpose the animal diagnostics lab, which was set up for testing large numbers of animals for things like avian flu. That's been repurposed now and is testing a large number of humans, and that's made it possible to do testing at a scale locally that we weren't able to do prior to this, and that's, apart from the cost, also really helped with the turnaround time.

Cole: Adapt and overcome. Well, another difference between University Park and Hershey is that, Cat, you are there at the hospital, and I know that part of your job is actually dealing with COVID patients, can you speak about that a little bit? What's that been like for you to work on these teams and then be right there up against it.

Cat: Yeah, it's been really humbling because, I think, we do a lot of training in medicine and we feel very well-prepared to take care of patients. And I just remember when these patients first started coming into the hospital. We had one week at the beginning, where they were just rolling in, critically ill, all needing ventilators. Like nothing any of us had ever seen. I just remember standing up there in the ICU, with some of the ICU docs, looking around and just saying, "Wow, we've never seen anything like this." Over time, we've gotten a lot better at taking care of these patients. Early on, we had heard from reports in other countries that intubating the patients early, for example, was the best thing to do.

But what we've actually found in the U.S. is that we can get these patients by and out of the hospital without intubating them, with keeping them on high flow oxygen and things like that to support their breathing. We've gotten used to seeing how quickly these patients can decline. For example, you might have somebody come into the hospital, and they're not requiring any oxygen. They just tell you, "Hey, I feel a little short of breath." Hours later, they might be requiring as much oxygen as we're able to give them in a medical setting. And that's what makes this incredibly different than things like influenza, where the decline is much, much slower.

And then we've also gotten better in terms of things that we can give these patients to help them. We've learned a lot about therapeutics, and we've definitely made strides. But we have a long way to go. I think we've really improved the group of patients that comes in and they're not critically ill yet, but we really need better interventions for the patients that do end up getting intubated. The mortality rates are still staggering in that group.

Cole: Is that still largely older individuals with underlying health conditions? Is that proving out in your experience as well?

Cat: Well, I really think that that is in a way a misnomer. We think in our head these are 90-year-olds that have cancer and all of these things. And while certainly that group does do poorly, some of the sickest patients we've seen are men in their 50s or 60s and their only real medical problem is obesity. Think how many people you know that fall into that group or how many of your family members might fall into that group. So, certainly mortality increases with age and having medical problems does lead to worse outcomes, but over 40% of the U.S. falls into medical comorbidity as defined by COVID risks.

Cole: Wow.

Cat: It's just a thing to really be aware of.

Andrew: Perhaps I could just add too that Cat skimmed over the personal impact, but I could see from when she'd come onto call straight off the wards and various of their colleagues, they often looked just exhausted. And to be then asked to do planning around the university, "Can you figure out whether this test matters?" or something. At times they just looked so completely exhausted and emotionally drained. To put on top of that these requests for "Can you help us think through whether we need to do the PCR test here or this test there or how many people do we need to do?" I just found it, the sacrifice they were making was amazing.

Cat: It is like nothing that I think most of us ever dream that we would face in the hospital setting. It takes an emotional toll watching these patients die. And it's really hard on the patients, because they're alone. So, we get really close to our patients and spend a lot of time talking with them and trying to talk to their families, because they're basically in isolation in our hospital without being able to see their loved ones. And that's a very challenging thing to watch. None of us want to see people suffer, and we're seeing a lot of it.

Matthew Ogden: Cat, can you tell us a little bit more about your research on the therapeutics for COVID and if any of them look particularly promising?

Cat: Yes, I've been so excited to be a part of these studies, because I feel like we are making big differences for patients by doing this research. Back in April, I started out as the site PI here for the ACTT [Adaptive COVID-19 Treatment Trial] clinical trial, which is an NIAID-sponsored therapeutics trial and was one of the first off the ground here in the United States. So, our trial, the very first part of the trial, compared Remdesivir to a placebo injection. And Remdesivir is an antiviral, meaning it stops viral replication. And it had looked really good in animal models so it was one of the first things we wanted to test. And then what we found in the first phase of the trial was that the time to clinical improvement was five days faster than people that got a placebo.

We were thrilled with that! It's not a knock out, right? Like, it didn't stop everybody in the trial from dying, but when we think of the antivirals we have from other diseases. Take influenza, for example, where we give people Tamiflu, and it might improve their symptoms by less than a day, and we're happy with that, we thought Remdesivir ... I mean, "This is good! We're getting people out of the hospital faster." That allows us to take care of patients, more of them, and it also gets them back to recovery quicker.

So that actually led to a full FDA approval of Remdesivir. And that happened last week, so now people can get that in the hospital. And then the second part of our trial wanted to improve upon that, specifically looking for interventions that are going to help people that are sicker. And so, we think that the second part of disease that lands people on a ventilator or a lot of oxygen is actually the immune system's overresponse to the virus. In the second part of the trial we added a medication called Baricitinib, which is something that actually decreases the immune response, to Remdesivir and compared it to Remdesivir alone. And in that part of the trial, we found that Baricitinib does improve time to recovery when added to Remdesivir, over Remdesivir alone. And there'll be more data on that coming and published, but that's been released as a press release, as of right now.

And then, right now we're looking at another medication called Interferon. And we're in phase three of this trial. And the trial will keep going and introducing new agents as long as we still have improvements to make on caring for these patients.

Cole: It's great to know that improvements are being made week by week and everybody coming together on this and doing better and better.

Cat: I think about it a little bit like HIV. We had a brand new disease with HIV and we found that one antiviral medication helped a little bit, but then we had to add additional things, and we made incremental progress. And I think that's what we're doing with COVID. We're learning, we're learning more about the disease, and we're testing therapeutics in real time as information becomes available. And we're also doing high quality research, and that's something that I'm very proud to be a part of.

Matt Paolizzi: Yeah, I mean, I feel like the attention, research especially, is just, "Vaccine? Where's the vaccine?" That's all anybody wants to talk about, and justifiably so. I feel everyone's waiting for that because we want to go back to normal, whatever that normal will look like. But really, like you mention with HIV, we still don't have a full cure for that. But we've, over the years, been able to develop these treatments to manage people who have the disease. If anything, that's possibly one of the most important things to do, especially with COVID. It's just to figure out how to treat people who have it currently and make sure that they can recover.

Cat: Yeah. And I've been pleased that we are making progress, but I think we have a long way to go. Vaccination is a good one. I certainly hope we have a vaccine, and I hope that it works well. But we still need to be able to treat these patients. So, it's an important part of the response.

Andrew: Yeah. Even with a fantastically effective inside vaccine, it's not going to go away in a hurry. And maybe never. We've only managed to eradicate one disease with a vaccine, one human disease with a vaccine. I think this is going to be around potentially for the rest of human history. And in those situations, treating the patients who can't get vaccinated, when the vaccine doesn't take those ... That's still going to be a key part of this response.

Cole: So, what is spring going to look like from your perspective, folks? When the students come back. I know the students are getting ready to go on November 20, right, is the last day of classes here on campus. And then everybody will go home ostensibly for Thanksgiving holiday and stay there until coming back in the spring with just remote classes until then. What is that shaping up to look like for a spring return?

Cat: I think it's really hard to predict anything in this pandemic, so right now I'm keeping my focus on the next couple of weeks. I've been very concerned with trends around the country, including in Pennsylvania, that show substantial increase in cases, hospitalizations are rising, and we know that, following that, will be deaths. And we are also experiencing increased cases here in Hershey, so I think our focus right now is getting through this and getting through the winter. And I hope that we reach a point in the spring where we've figured out how to keep things under control. Maybe with some additional tools in our belt, but right now I think we're really on the verge of very challenging times ahead.

Andrew: Yeah, I really agree with both the uncertainty about what spring will look like and also the need to maintain, be very concerned of the next few weeks. The national trends are not good, and everybody's coming back indoors now. It's a different ballpark from what it was in the summer. Just to correct you, Cole, it's true that there's going to be many people going back for Thanksgiving, but a lot of students live in town in their own apartments, and they'll come back after Thanksgiving, so the problem is not dispersing away. And I think coming into spring, we're going to have some very interesting issues with flu and colds. We don't know what that's going to look like. Some of the data from the southern hemisphere suggests that the social distancing is having a good impact on flus and colds, so maybe it won't be a big issue. Or maybe it'll be a big exacerbator, and we don't know at the moment.

Another issue that I do think is different from the start of fall is that students are going to go back to the same kind of residential situation they had before, the same dorms, the same apartments. We haven't got the mixing that we had at the start of the fall semester. So, if everybody who's had an apartment has had it, then that apartment is no longer the outbreak situation that it was in the fall.

If we were going back to square one and started steering everything around and all the students were going back to different apartments and different dorm rooms and so forth, it would stir the pot. That would be really not good. And that's what's going to happen the following fall – people are going to typically re-assort. Then there's the big unknown at the moment is how many of the students that have had it have mounted immune responses that are protective? At the moment the numbers are 3,600 or something students. That's about 10% of students. If you assume there's another 10% that got it and didn't know and we didn't catch it, that's 20%. Now, that's not herd immunity, but it's not nothing. And if it's focused in particular dorm rooms or particular apartment complexes, then that might be substantially higher, in which case, those areas might be less at risk than other situations.

That said, we're obviously a hugely long way from herd immunity in Centre County as a whole. So, the localized dynamics in apartment blocks and dorm rooms, could be different. What it's going to be like at a community level or a university wide level is just anybody's guess. And just to go back to Cat's earlier point, too, Mount Nittany's under more stress now than it has been all semester. We got local concerns right now, and we've got big unknowns going into the spring.

Cat: And I have to say I'm very worried about the holiday season. I think many of us are experiencing pandemic fatigue. We miss seeing our loved ones, this has been a very challenging couple of months, and I just really urge people to take precautions at the holidays. I can't even tell you how many people we've had critically ill here that come in, and their risk factor is they were clustering indoors with their family. And so, the 20-year-old with no health problems is probably going to do okay from COVID. We certainly see some that get critically ill, but for the most part they do okay.

But you bring them into an indoor setting, everyone eating, having Thanksgiving together or Christmas dinner, and they infect their 60-year-old father or 80-year-old grandmother. And then we have whole families that end up in our hospital with multiple people very ill and some of them dying. I think the holidays – it's very important to keep in mind some of these precautions that we've been taking.

Andrew: I do think it's really important that students take the advantage of the pre-departure testing that's available. And if in doubt, whatever the pause, go there. If you're going to be in contact with somebody who's high risk, go and make the most of that testing. And if you test positive, stay clear. I'd say if you test negative, be very careful still. But if you test positive, stay clear. I do think there's a really big perception difference that, amongst young people, this is no big deal. But it's a very significant deal for the young people who do get sick, and it's a very, very significant deal for the older folk.

We do need everybody to keep cool and that... missing a Thanksgiving or just keeping it to your local family – it's just a Thanksgiving; it's not the end of the world.

Matthew Ogden: I want to ask about, you guys mention the effect that the students have had on the local community, I believe, when they were making the decision whether or not to bring the students back or not, that was a big factor. Considering economically the local State College area, they need the students there. But at the same time, the student presence might endanger the at risk members of the local community. How is Penn State navigating this "town and gown" relationship with the local State College community in terms of the case numbers increasing so drastically since the students have returned?

Andrew: I think you're absolutely right, there's very complicated pros and cons about bringing the students back. And I remember in June, July very significant concerns about the economic issues of doing remote learning only and very large numbers of people very bothered about that. Then the students come back and we start to get cases and now a different group of people are concerned about the cases, obviously. So, very, very complicated issues. And again, I want to emphasize, I'm totally pleased that the provost and the president and so forth have to make the decisions of that magnitude and not me, because they are really, really challenging.

In terms of managing the situation now, I think there's a lot of work been going on too. Actually, look at what's happening to the community. So, in terms of the disease risk, what's going on? And there are ways that that's being looked at. For instance, one of the testing of the employees is a measure of how much movement there is between students and town folk. Then there's the question of what's going on at Mount Nittany and are the cases that are coming in there, student related, or are they likely to be independent of the students around? There's a lot of work going on looking at the problem and with the community study we've done looking at surveillance of the community folks, we took blood from 1,500 people, looking to see how many of them had seen the disease and converted. And we continued that in the early part of semester, looking to see whether it was changing when the students would back and it was not so. We didn't see significant spillover from students to the community. And now with the wastewater stuff we're doing, we're monitoring what's happening in the town waste supply so we can see the virus and the wastewater for the State College community and see what's going on at that level.

So, there's a lot of epidemiological analysis going on. But then I guess part of your message, too, is what's actually going on in terms of communicating that and reassuring or providing information for that? And there is a lot of messaging going on, a lot of messaging work on that. I would say it's pretty difficult to message when things are uncertain. So, messaging uncertainty is a tricky business at the best of the times, and there's a lot of uncertainty now. So, we're learning a lot about the messaging as well. And then, there really is an awful lot of communication going on between the university and the community leaders, the folk that are making decisions in town.

I, for example, am on an emergency group that is the fire people and the schools and the police and so forth. And I'm providing updates on what we're seeing in the wastewater to them so they can do planning and so forth and they ask any questions and things. There's a lot of communication going on on that sort. Going forward, I think everybody's keen to make sure that the messaging gets better and also that we provide information about what's going on. And when case numbers start to come down amongst the students, we've got to be making sure that we emphasize to everybody that this thing can turn very quickly, very, very quickly. And that epidemics can just rage again. Everybody's got to be careful, everybody's got to maintain best social distancing, hand washing, masking, and so forth.

But it's a tricky business, no question, that when you bring a large number of individuals into an area, it does change disease risks. But not doing so also changed economic risks and the health risks that go with the economics. So, very, very challenging.

Cat: And I think the other thing that makes it really challenging is, you're looking a couple of weeks in the future, so where our cases are now are the strain that's going to be on our health system in two or three weeks. And making sure that you are responding to data before things get completely out of control is an important part in responses, and it's why places in the country have gotten into trouble, and then it takes a couple of weeks before they really are able to unburden their healthcare systems, even with maximum interventions.

Andrew: That's one of the things I find most tricky about when we see the wastewater data every day. You've got to get ahead of it, you've got to see things early. And once it's really moving, you can be totally confident it's moving. But you need to be able to make the call before that. And that's very demanding, I think. Especially because we're still learning at the moment what it looks like when the thing turns. Yeah, as I keep saying to everybody, we're flying this airplane while we're building it and while we're designing it. And that is very unusual in any higher education context to have to do that.

Cole: Yeah, I think the whole world, to some degree, is in that state. Internationally, we're all dealing with this. Speaking of the whole world, I have one big wrap up question for the two of you. I know we only have you for a little while longer and I want to thank you again for giving us some of your time. But, how do you think Penn State's doing compared to other universities across the U.S.? Trying to keep tabs on – all these different universities have taken different approaches with testing and the response. Because, as you say, Andrew, everybody's in this. Build it as you're flying and trying to figure this out and change and adapt and evolve as we go. So, how do you think Penn State has been doing with this?

Andrew: Are you leaving that one for me, Cat?

Cole: Sure.

Andrew: First of all, I want to say it's too early to say. Okay? At the moment we've had three and a half thousand, 3,600 student cases. Vast majority of those have not been severe. But until we really got through more of this, we won't know what the final tally looks like, nor will well know what's happened with the community spillover issues. We've got a long way to go before we can actually say that University X did better than us or worse than us.

When I look around at the rest of the country, there are examples of places that, for example, do more testing than we have. Not obvious to me that that's actually led to terrifically better outcomes or worse outcomes. So I think the jury's still out. There are some places that did it a lot less than we have. But when you look at those ones, I feel proud about what Penn State's pulled off in such a short amount of time.

Could we have done more? Sure, I think we could've done more. Would that have made a big difference? Hard to say at this point. Things have actually gone relatively well so far, given where we thought we were going to be. Way better than the mathematical models. But again, I want to emphasize that we've got still some months to go, and I would say start counting spring as well, to see, before we can really draw the school card. It's not as easy as just comparing ... well, you say, "America's done much worse than Country X," or whatever. It's not as easy as that when it comes to university side of things, because the spillover rates matter a lot to the communities, the settings make a lot of variation, and the data are actually messier at the moment. So, I would say in general I'm amazed by what was pulled off, given the constraints and the logistics and the relatively late stage at which we got into things. So, it's been amazing.

Cat: And, I think just an important point is that testing is just one part of a comprehensive response. It's not the only part. It's not going to save you from an outbreak. It's helpful, but it's just one component. Other things that are critical are social distancing, masking, contact tracing, isolation, and quarantine. It's just one piece of the puzzle. And doing all of those things in conjunction is really how you manage an outbreak well.

Andrew: Yeah, I've heard, for example, that one of the reasons that the student cases may have started to decline is that the police in the borough were enforcing the masking regulations in the streets much more, and that that might've made a difference. Now, we don't know that, but that's an example of where something other than testing, testing, testing, could have a big impact. And at the end of the day, it really is about stopping transmission, and testing doesn't stop transmission unless it's merged with very fast turnaround times and excellent isolation. It's still a behavioral response by everybody involved that can slow this thing right down.

Cole: Right, so we all need to keep paying attention even though we're all tired, and it seems like it's been forever, and we can't believe this is still going on. And we do want to turn that corner, and we do want to see a vaccine, and we do want to see our loved ones again and all those things. It's taking a deep breath and say, "This is a marathon, this is not a sprint." And we need to just keep it up and try and stay as positive as we can. And thankfully we've got folks like yourselves, smart people who care a lot and are doing their best to put your heads together and build this plane as it flies and try and keep us in the air here.

Andrew: Yeah, I've been a bit surprised. You look in social media, and you see stuff that seems to assume that there's a bunch of idiots running things, and they have intent at heart, that they're looking to make money, yada, ya. And actually, that's not been my experience. Everybody involved has got very good intent, trying to do the best possible. Large number of experts working hard on things. Everybody disagrees at times, sure. But the intent is very positive, and people are really trying to make a difference and slow this thing right down.

And I do think there's a tendency to fall on the assumptions that things really are a result of some human failings. And at the end of the day, this pandemic, it came from nowhere. It's causing a huge amount of stress and disruption for which none of us have been set up for. And it's just bad, folks. It's just bad. And yeah, we can mitigate it by personal behavior. That's really, to me, the key issue. Really key.

Cat: And I just want to reiterate that we're on the same team here. None of us like that there's a pandemic. None of us like people dying or the economy taking a hit. We need to all take care of each other and do the things that we can, from a personal standpoint. Wear masks. Social distance. Those are things we can do to take care of each other. And we should all be caring about each other in these very challenging times.

Cole: Absolutely. Thanks for that, Cat. Thanks, Andrew, Matt, and Matt. Everybody here, thanks again for taking the time to have this important conversation. And for all those Penn State students out there, we feel you, and we're counting on you. We're all counting on each other to do the right thing for each other and continue to get through. Eventually we'll get on the other side of this thing. We are doing all we can. Thanks again to all the guests and Matt and Matt, thanks for doing your podcast as well and giving us this opportunity to share this with the community. Take care, everybody. Be well.