This article is part of an ongoing collaboration between the Colorado School of Public Health, the Denver Museum of Nature & Science, and the Institute for Science & Policy. Watch the full recording of this session and find all of our previous COVID-19 webinars and recaps here.

Scientists, policymakers, and medical professionals have learned quite a bit about COVID-19 since the early days of the pandemic. Nevertheless, many of the biggest questions – How effective are tests? How do we really know if social distancing is working? -  remain salient to our public health response today and can now be updated with new data and new insights.

In our latest session, we welcomed back returning guests Michelle Barron, MD, Professor of Medicine-Infectious Disease at the University of Colorado School of Medicine, and Jude Bayham, Assistant Professor of Agricultural & Resource Economics at Colorado State University along with C. Neill Epperson, MD, Chair of Psychiatry at the University of Colorado School of Medicine, and Jonathan Samet, MD, MS, Professor of Epidemiology and Environmental and Occupational Health and Dean of the Colorado School of Public Health for a session dedicated entirely to viewer questions.

This transcript has been edited for length and clarity. Watch the full recording of the session here.

JONATHAN SAMET: I wanted to start by giving a fast overview of where things stand in Colorado and then sweep across the US and globally. The picture, of course, is a terrifying one in some senses. Globally, over a million deaths. In the United States. I saw yesterday in the New York Times that the rates are now highest in rural areas and particularly in some of the states to the north and west of us. We're now in sort of the third wave in the state of Colorado which is of concern. There are perhaps many explanations: return to schools and colleges and universities, going back inside, and perhaps all of us having some COVID fatigue and being less adherent to the infection control measures that we need to be taking. Our state has had 94,000 cases reported and that's only a fraction of those who have actually taken place. We estimate the about 8% of Coloradans have been affected. And we are at about 2,200 deaths in the state.

For the last three weeks, we've been on this rising curve that's consistent with having our reproductive number now running around 1.5. What that means is for each person who's infected, there are 1.5 new cases. Over time, this exponential rise in the epidemic curve will continue upwards so we use this curve to model what will happen.

When we look at hospitalizations, we see that there are many regions within the state where hospital numbers are trending up, including the Denver Metro area which, of course, counts for a large portion of the state's population. We don't want to get on a worse trajectory and that comes through more measures to reduce transmission. One of our worries is the coming holidays. We're basically a month out from the start of the Thanksgiving and Christmas holidays when people travel, people tend to mix. Too many of these scenarios [in the modeling] show us exceeding ICU bed capacity.

It takes some weeks for measures that reduce transmission to have an effect. Right now we're a month out from the holidays and these kinds of scenarios are a real imperative for action. That’s on all of us, and also of course our local public health agencies. So, just as a reminder, masks work when worn correctly. Maintain physical distancing and hand and face hygiene. Follow public health orders. Support contact tracing. Get your flu shots.

KRISTAN UHLENBROCK: Jon, can you explain the apparent causes of the waves we've seen in COVID-19, now that we’re into the third one?

JS: I think the easy answer is I wish I could. Many of us felt the July wave, which might have in part reflected the July 4 holiday weekend when people did mix. That was sort of well documented by anecdote. That wave peaked around July, 20 roughly and then dropped off and perhaps that was a good explanation. Now we face too many potential explanations, including our K-12, colleges, and universities reopening plus colder weather returning.

KU: I want to ask this to our entire panel: What are your current dining out habits? Outdoors only? Takeout only? A combination?

MICHELLE BARRON: I get takeout pretty frequently, so definitely take out. I've eaten out twice - outdoors only - early in the summer months when things were trending down and I felt like it was safe. I don't know that I would do it now. I feel more anxiety.

JUDE BAYHAM:  I'm pretty similar to Michelle. We do order takeout on occasion. I'm also in a multi-generational household, so we have my wife's parents living with us and so we really try to minimize any connections that we can.

NEILL EPPERSON: I'm pretty anxious. I’ve been outside a couple of times, but probably now that it's cold, I will not be doing that anymore. We do takeout quite a bit. We have two adult daughters with us and we work a lot of hours and they work a lot of hours, so takeout seems to be something that everybody's pretty comfortable with.

JS: And I'm right there with my colleagues. We've eaten out twice after a little bit of scouting about what it looked like and felt fine and safe. I think returning indoors is something different and goes back to how we're operating our buildings and are we ventilating enough.

KU: If a vaccine to prevent COVID-19 were available today ─ presuming that the vaccine has been deemed safe by health officials and is available to you ─ would you get one?

MB: I think the key point of the statement was that it's safe, and that everybody feels like it's safe. I think the efficacy question might be a little bit harder, but I think the safety issue has been out there.

KU: There are a batch of vaccines in development. What would be the impact of having several vaccines with different actions, and how would people know which one to choose if there was multiple available to them?

MB: So we're gonna make the presumption that they're all safe, and that there's obviously some data and how they work. And how we determine who they go to will depend on how they work. We know certainly with other vaccines that those over the age of 65 sometimes have less of a response. So maybe some of them will have better responses in those age groups and then we want to use it for them.

I think a lot of this will just be figuring it out. The first line is really going to be the health workers that are completely exposed and so I think that's going to be the first group. And then hopefully we’ll have it figured it out once we get to large public forums.

KU: Is the projected effectiveness of a COVID-19 vaccine expected to be like that of a flu vaccine?

MB: That's the million dollar question. I don't think anybody knows at this point. A lot of this will depend on how well it works and how the responses are

KU: Neill, this is a behavioral one. So you get a vaccine and you take it. When do you change your isolation habits?

NE: Well that’s a very good question and I don't really have an answer to that, because I think we still don't know that we’ll have a safe vaccine. Are you actually able to be around other people, to be exposed without getting the infection. So I think there's a lot that's unknown, unfortunately, and that's one of the reasons why, as much as possible, we have to stick to these public health prevention strategies until we know that we have a safe and effective vaccine.

KU: Jon, what do you think of the emergency use authorization mechanism for approving a vaccine, especially in light of the experience with other medications so far?

JS: It’s a complicated question. We have had emergency use authorization for therapeutics. I think the FDA has made a clear statement that they will look for a minimum efficacy of 20%, that they want sufficient follow up in the Phase III trials to assure that there's no unexpected adverse effects. I think the public is going to be looking for assurance of safety, regardless of the regulatory path that brings us to vaccines for people.

MB: The Governor has an advisory group is specific to the vaccine and we have all different voices on this committee. That's the key. We want to have the data in front of us, we want assurances that it's safe and efficacious, and then kind of go from there. The FDA will obviously be potentially necessary, but I think at the end of the day, and I think not unique to Colorado, everybody wants to have access to the data and the assurance that the safety and efficacy are met before we would ever recommend it.

KU: What is the process for determining a COVID-19 vaccine that would work on kids?

MB: Kids are not even in the trial group right now, so pediatric vaccines are on whole other level of regulatory things that have to go through. They're not considered to be at high risk from complications. I think that's why they were left off this initial round. But I know there are certainly studies that are going to be looking at that and really just haven't started yet.

KU: We're going to shift gears just a little bit and speak to mental health. Neill, what are we seeing?

NE: We are seeing a high level of stress, particularly with front line providers, our critical care units, people doing shift work. They're just mentally and physically exhausted and I think that the social isolation is getting to that point where, you know, not being able to be with friends and family regularly also ties into that fear of getting COVID or giving someone else COVID. It's hard to know how many people can be in my bubble, how many people can I socialize with in person safely? I think that really drives people to have a lot more anxiety.

One of the things that we've seen globally is that if there's not very clear cut messaging about what people can and can't do relatively safely, then that raises everybody's level of anxiety much more. I think we've seen that in our country around, you know, should you wear a mask or not wear a mask, who's doing this, who's doing that. I think what we're trying to say here is that wearing a mask and social distancing is something that is saving lives, it is keeping people from being infected, but at the same time social isolation is really not good for human mental health. It's one of the things that we crave as social human beings.

JS: We had an order on Friday advising no more than two households should gather and the total should not exceed 10 people. And I think we all have COVID fatigue, I think it's real, and we probably should get some reflections from Neill in particular on this phenomenon, but, you know, wearing masks and maintaining distancing remains so critical as we see the curve surge up again, particularly for those people who are in the susceptible groups.

NE: Absolutely. I think the answer to the question about COVID fatigue is picking the things that you feel like you can have control over and if you do feel that you can be with another family, just saying okay, these are the people that we're going to socialize with and we trust that these people are only socializing with us. Pick that group of people or that one or two families ─ however you feel comfortable.

But if you're an older person or you have a pre-existing condition, at this point, giving it another few months. As tired as we are, trying to say we need to get through the winter and I can control my situation through the winter and focusing on that. Everybody has to make those decisions for themselves and do the best they can. I have Zoom fatigue.

KU: Are there techniques for people to calm themselves if they’re feeling this way?

NE: I want to tell people to have some compassion for yourself, because you are not alone. This is a worldwide problem. When you look at all the data, insomnia seems to be one of the biggest symptoms that people consistently complain about, particularly frontline clinicians, but also in the general population. We actually have data showing that it's increased from what it was right before the stay at home orders or the lockdowns in some other countries.

So all I can say is that yes, it is awful. I mean, people think crazy things in the middle of the night. Our brains just go and if I lay awake in the middle of the night and I start seeing those thoughts I go, oh this catastrophizing. I tell myself, this is a crazy thing at night, that tomorrow morning, you won't be thinking this catastrophic thought or negative thought. I have to really message to myself to help calm down. I also do a lot of deep breathing and that belly breathing can be incredibly helpful.

I know people can say, well, I've tried that. Again, it takes time. It's not going to completely get rid of the thoughts that you have at night. But I think labeling the thoughts, that these are my nighttime thoughts, and knowing that in the morning they won't look as negative. That is one thing that I know personally helps calm myself and I know that it calms some of my patients.

If it is as bad in the morning and you still are having lots and lots of worries and having a difficult time calming yourself, that's when you should reach out to seek mental health care. And I think that that's something that more and more people are doing and the stigma about reaching out for mental health care is actually declining, because I think everyone knows that this is a bad situation.

When we're not in COVID, people can say, well I have such a great life, why am I distressed? Now you can say yes, I'm distressed, everybody is, and that people are, I think, feeling less stigmatized for reaching out. It never hurts to reach out to your primary care doctor or find a therapist or a lot of things online. It never hurts to reach out just to find somebody to talk to. Colorado Crisis Services are seeing lots more phone calls. They are a really excellent resource for everyone in Colorado.

KU: Jude, can you speak to some of the more unique methods of testing, such as wastewater testing?

JB: It's emerged as an incredibly useful tool. But it is part of a larger strategy, so it can give you a sense for what general trends are happening or in our case on a particular campus, within particular residence halls. But that needs to be paired with follow up and targeted testing and then isolation of those infected individuals for it to be an effective strategy in terms of broad level surveillance. There are folks at CSU that are doing that testing throughout the state of Colorado. Other universities are doing it. So I believe it's becoming more and more widespread.

KU: Michelle, could you speak to the differences between nasal swabs and the saliva tests that are available for home use? How reliable are those?

MB: All of the tests have a little bit of difference, just depending on which one you do. There is one where there's a nasal swab that just goes in part of your nose – the joke is that you’re doing a brain biopsy because of going all the way back.

Symptomatic patients tend to have better chances of testing positive than if you're asymptomatic. There's so much variability that you have to really look at the test and how it's collected and there's all sorts of nuances. I think it's important to know that if you are having symptoms and you think you have COVID, you’ve got to stay home. Even if you get a negative test, but you have symptoms or recent exposure, stay home. I think that's part of this, that people say, oh, well I got a negative test, I can do whatever I want, and then they don't wear a mask or they don't use social distancing, but they could still be infected and spread it unknowingly.

KU: We got a question to the effect of: if I’m exposed to a person who two days later tests positive for COVID-19, do I then quarantine for 14 days if I don't get sick? Am I great to go, or do I get a test and carry on? I really don't understand the timing of when I'm supposed to do.

MB: The challenge with this is that there’s an incubation period and that incubation period can follow a bell curve. The average incubation period in which somebody that's been exposed will then become symptomatic is about five to seven days. I've had individuals out to 10 to 14 days, so that's where the 14 day quarantine comes into play. Certainly I think getting testing if you're having symptoms is very valuable. The problem comes if you're part of what's called a critical workforce then it becomes challenging because you’re thinking, I'm sitting at home doing nothing when there's things I really need to be doing, so I'll just get a test at day seven and I'm good to go. I know it's challenging to be home 14 days but it's really based on science, and it's all about risk in terms of trying to mitigate other people getting the disease.

KU: Is the economic harm a greater and more immediate threat to many families than the virus itself?

JB: I think casting it as an either/or is a false dichotomy, It's not like we can have the economy or health. Those things are inextricably linked. And so what I think some of the research is starting to show is people aren't going to engage in economic activity, i.e. going to restaurants, things that we talked about already, until they feel safe. And so it is critical that we suppress the virus, that we make places safe so that people can go out and engage in in economic activity. I think we've seen that now in other countries. That's kind of the crux of the whole issue. You know we are seeing different regions experience this differently. We're still trying to understand that data.

In terms of the policy response, one of the key questions that I've been focused on for months is this issue of how much of people's response is due to policy or just their own voluntary behavior in response to risk. It's a really hard question to answer. In this case, there's a lot of people working on it and I'll just say that, you know, it's a mix of the two. I wish we had clear cut answers for policymakers that would help decide some of these questions.

KU: A senior advisor to Dr. Fauci recently said, regarding the fear of transmission from surfaces, that that's like standing in the middle of a busy freeway with all the traffic around you and asking, what's the chance I'm going to get hit by a meteor? There's a chance, but it's pretty low and you have bigger things to worry about. How would you respond to that quote and talk about risk awareness generally?

JB: I think one thing that that we think a lot about is the salience of risk. So how salient, how obvious is his risk how on the front of people's minds is it? And I think we have some limited capacity to understand very complex risk.

NE: My understanding of what they were trying to say is that we have risk all around us and that the likelihood that they're going to get coronavirus is like the meteor. I wish it were like the meteor! But the risk is really so much greater. And I think it's about not just protecting yourself, it's about protecting other people.

I think had we all bought in a lot earlier and a lot sooner and basically been way more stringent, I think we could have been in much better shape. I think everybody at the beginning was much more like, okay we're all in this together and let's of do this. I wish we had been a lot more clear. Maybe some people might have thought it was draconian. Woulda, coulda, shoulda. We didn't shut down as dramatically across the country as I think would have been the preference of our public health officials.

And now we're in a situation where people are tired and exhausted. But I would just say, look, remember you're protecting other people in addition to yourself. And we've got to get through this winter and see where things are as we get through this period of time where we have to be indoors. So I think as much as we possibly can, we should take a deep breath and recognize that this was a little bit of a marathon.

KU: What is the latest thinking on transmission of the virus via surfaces?

JS: About six or eight weeks ago, we did the session with Shelly Miller on airborne transmission, and I had chaired the workshop at the National Academies where we took a deep look at modes of transmission, particularly air. And I think the evidence is pretty clear that airborne transmission by the smaller particles, the so called aerosols is probably what is most important, particularly as we move indoors. Fomite transmission exists, clearly, and it’s clearly important the viruses can stay viable for a while on surfaces. I'm not sure we've quite resolved how long that might be under different circumstances. Clearly, all the hand hygiene practices that are recommended should be followed. But I think that with us going indoors, airborne transmission by the smaller aerosols will be dominant.

KU: Are face shields effective?

JS: Face shields are not as effective as we might think looking at them. They funnel the air, but they don't block the particles.

KU: Jude, we had you on in May talking about mobility data. What have we learned since then about stay at home measures?

JB: I think we learned that they did at least add to people staying at home. One of the key questions is this is how much of that would have happened in the absence of policy versus how much of that was induced by policy. That's a critical question moving forward. One of the features we've been paying attention to is just the variation around the state. One of the interesting results is this sort of persistent additional time spent at home or less visitation to restaurants, and retail stores in the Denver metro area relative to some of the other outlying communities, so that's the high level takeaway.

KU: What's the best estimate of how long this pandemic will last?

NE: Our school is planning to teach remote in the spring. I think if we had an effective vaccine and it were delivered to enough of us to reach herd immunity, my optimistic scenario would be the fall. And, I think, to have enough of us vaccinated to get to that 70% level that we need for herd immunity, it's going to take a while. So there's much time and many steps from having a vaccine arrive to us getting back to normal.

KU: What has been one of your personal moments since the start of this pandemic that just changed the way you thought, or really just kind of struck you as interesting?

NE: In the first three months of COVID, we were sprinting, I mean it felt like we were going 24/7. My faculty and myself were really getting exhausted. We have to be able to see this as more of a marathon, and that you prepare differently for a marathon. So having compassion for myself and saying, I need a break, I can't do this today. Trying to find respite. It's something that I've been saying that we need to do with our frontline providers, to help them have respite because we can’t throw mental health services at people if they're too physically and psychologically exhausted. The mental health services are only been so good. Being kind to ourselves, doing what we need to do, taking breaks when we can. And recognizing that we're in it for the long haul. So, take a deep breath. Keep breathing deeply and love yourself and others that are in your circle.

JB: I think that resonates a lot with me and I felt very similar. Throughout the course of this pandemic, I think the “aha” moment for me being sort data focused were these mobility trends. And when I saw those start to increase in late April/May, I was really concerned that we would see widespread transmission. I think it really highlighted the importance of these other protective behaviors, so mask wearing, distancing, all of those things can matter. We can resume activities if we're adhering to those policies.

MB: It really has been about how we communicate and how we get messaging out within the healthcare system and with the public at large. Of course, it’s tough to have that messaging in a pandemic where we don't have all the information rapidly. We can also acknowledge their fear. We have to make some decisions with what we know and we have to move forward.

JS: I guess as an epidemiologist, I'd really prefer not to be living through the pandemic of our lifetimes. But I think one thing I realized is that those of us in public health can use science to inform us all about what are the best paths and what we are facing, and that we have a responsibility to do so and communicate about. Looking at the Colorado School of Public Health to step forward with colleagues at other schools and universities to try and do the science and through partnering for example with the Denver Museum of Nature and Science to reach out to you. I think that's also been really, really, really key and I think all of us are trying to engage. All of our panelists and many others are trying to do all we can to help the world understand what's going wrong. It's an important moment.

Lightning Round: Even More Viewer Questions Answered

Is there any chance that it will be safe to hold a large wedding gathering next summer?

JS: Well, there is a chance, but not a very high one, even under very optimistic assumptions.  You might wait until we know more about the results of the vaccine trials in progress, particularly with regard to their efficacy and safety.  We should know more at the start of 2021.

Do you have comparative data from other states, and even countries, to help tease out how much social distancing versus other factors (demographics, population health, access to care, etc.) are responsible for decreases in infections, hospitalizations, and/or deaths?

JB: All of these factors likely play a role in mitigating the severity of the pandemic.  We have data for some of these factors (e.g., mobile device data, demographics) and not others.  The challenge is that these factors interact with each other, the virus, and other human behaviors (hand washing, mask wearing).  Despite all of the data available, we only see part of the picture.  Evidence will continue to emerge as this pandemic will be studied for decades to come.

There have been cases of people getting COVID again after fully recovering from it. How concerning is this in relation to a vaccine? Does this suggest that immunity from COVID may not last very long? 

MB: Immunity to COVID-19 may indeed not be lifelong and that is actually expected given our knowledge of other coronaviruses and other similar respiratory viruses. In terms of how this impacts COVID-19 vaccines, it probably does not have a significant impact at this time, but if the COVID-19 virus mutates significantly, the vaccines that are currently in development may or may not be as effective as hoped. Additionally, if COVID-19 continues to circulate in the years to come, we may need to get a COVID-19 vaccine every year in a similar fashion to influenza vaccination.

How will the market system impact the manufacturing of a vaccine? Will companies who developed a successful one share with other companies so more can get distributed, or would government have tools to require that?

JB: This is a great question, and one I do not know the answer to.  Given the large economic costs to our current containment strategies, I suspect that market forces will facilitate the distribution of safe and effective vaccines.

I read that the Federal Government has shut down the Office of Vaccine Safety and that Federal agencies are failing to share all of the data related to the Covid-19 cases, hospitalizations, and deaths. What is the effect of these actions on your work in the state of Colorado?  Do you have strategies for dealing with these effects? 

MB: The state of Colorado continues to gather data through mandated reporting to CDPHE from all hospitals in the state. I believe that our data has not been impacted by these closures on the federal level.

How solid is reporting that small increments of time can add up to one-time 15 minutes of exposure? 

JS: The idea of thinking about cumulative time exposed is reasonable, as risk for infection depends in some way, still to be determined, on how much virus is inhaled.  The choice of 15 minutes is reasonable, but arbitrary, as is using 15 minutes for the cut-off for cumulative exposure.

If you are symptomatic and tested positive and isolate, do you need to be tested negative before you stop isolating?

MB: Repeat testing to end quarantine is no longer recommended. The current guidance is to use a time based strategy, specifically, 10 days of quarantine from time of symptom onset or time of positive test unless you are immunocompromised or require hospitalization and intensive care in which the time frame is 20 days of quarantine. This is based on several studies that show that infectivity of the virus declines to zero after 10 days in uncomplicated illness and 20 days in complicated illness.