An interview with Dr. Brooke Nichols

By Dawna Stone

This spring, Running USA was able to spearhead the production of a research-based white paper that will help races get started again. Recognizing that every area of the country is different, and protocols and regulations are constantly changing, epidemiologist and medical modeler Dr. Brooke Nichols has outlined the safest way for running events to get back to the starting line.

Dr. Nichols brings a perfect mix of skills to this project. In addition to her epidemiology background, she has spent much of her career focused on mathematical modeling of HIV transmission. She’s also a dedicated runner who has completed the famous Comrades ultra. In 2020, those experiences came together when she was asked to help the Boston Athletic Association and other organizations with the science behind racing safely.

Dr. Nichols sat down with me for an interview on COVID-19, running, and her expectations for our industry and getting back to normal. If you missed our conversation, here is a condensed version. You can also watch the video if you’d like to hear the interview in its entirety.

If you haven’t had a chance to read the white paper, find it here by clicking through to a downloadable version. Many events have told us that they are taking this white paper with them as part of their permitting negotiations with city and county officials in advance of summer and fall events. Thanks to the Bank of America Chicago Marathon, Chicago Event Management, Brooks Sports and P3R for their sponsorship, which made this project possible.

Dawna: Tell us a bit about your background and how you decided to pursue quantitative implementation science?  I don’t think it’s something that most little kids dream of, becoming a mathematical modeler when they get older.

Dr. Nichols: No single scientific method is enough to answer some public health questions. I was trained as an epidemiologist and infectious disease epidemiologist, and in the mathematical modeling of infectious diseases. But the number of tools that you need to answer so many questions in public health is large. Modeling isn’t enough, epidemiology isn’t enough. Sometimes you need health economics, and you need to bring all these other disciplines together. And so that is what we’ve been calling quantitative implementation science. And as a little girl, obviously, quantitative implementation science wasn’t a thing because I was not grown up yet.

I’d always been interested in the fact that you can use math to explain the world around you. So that’s how I initially got started. My background is mostly in HIV modeling, and looking at different policy decisions around how can you prevent infections, as well as have you invested resources properly to ensure maximum impact?

Dawna: And then, along came coronavirus. How did that change your daily work?

Dr. Nichols: At least half of my time has been spent on coronavirus since March of last year. Because it turns out there’s not a lot of infectious disease modelers out there. Infectious disease epidemiologists were in high demand, and we pivoted all of our skill sets to work on coronavirus. Over the past year, my primary work has been working with country governments to look at testing policies and global resource allocationspecifically for coronavirus testing, and rapid antigen diagnostics. And I’ve been working with running events as well.

Dawna: How did you get started working with running events?

Dr. Nichols: I’ve been running distances from 5k to ultra-marathons and been an avid runner for as long as I can remember.

A former classmate of mine from my epidemiology studies was working with the Boston Marathon. He said, Brooke, you’re an actual infectious disease epidemiologist, and I know you run a lot. So why don’t you come talk to us, and we can see what we can figure out. And so that was my first connection between infectious disease epidemiology and my greatest passion, which is running. Since then, I’ve been serving on the Boston Marathon COVID-19 Medical & Event Operations Advisory Group.

Dawna: And I understand you’ve worked with some other major industry events as well?

Dr. Nichols: Yes, I have also done some work with Bank of America Chicago Marathon and Spartan event series over the last several months.

Dawna: With our race director audience in mind, what are the scientific and health factors that need to play into their planning for events this year and beyond?

Dr. Nichols: Coronavirus has evolved so rapidly, and our response has evolved rapidly. In a lot of ways, planning is about having a plan for  the worst case situation. For example, if vaccination isn’t scaled up to the extent we thought it was going to be, then what’s the plan? And trying to plan around that, instead of assuming that we’re going to hit certain targets. Because public health is notorious for not achieving the targets that they hoped that they would. But I do think we know enough now about the virus, how its transmitted, and almost all the key factors that come into running (and producing) a race.

Dawna: In the white paper you wrote that temperature checks are not useful or necessary for large events. Can you explain that?

Dr. Nichols: Temperature checks are very likely to get the answer wrong. If you do not have coronavirus, it is likely to say incorrectly that this person needs to be screened out because of elevated temperature.  The other way around, I could have coronavirus and no temperature, and it would not screen me out.

The Cochrane Review, a systematic review of research in health care and health policy, has come to this specific question of the usefulness of temperature screens and they’ve also concluded that they are not very useful. And in many people with COVID, especially asymptomatic infection, the probability of having an elevated temperature is low. You’d actually miss your most important group of people, those who are infected but not exhibiting symptoms.

Dawna: Another conclusion that was interesting is that surface transmission of coronavirus is something that we don’t really have to worry about. Can you explain why that is?

Dr. Nichols: Early in the pandemic, we actually had no idea whether it was fomite transmission (surface contact transmission) or airborne aerosol droplets. I mean, the CDC didn’t officially agree on how it was transmitted until about a week ago. (Ed. note, conversation took place May 4.)

But now there’s been enough data and enough people infected with coronavirus that we now know that the vast majority of transmission events occur through the air, via people breathing, and not through surfaces. There are very few cases that can be linked directly or proven through just contact on surfaces.

Dawna: In the white paper you also talk about testing protocols and timeframes for doing testing. Can you talk a little bit more about that?

Dr. Nichols: There’s been a lot of discussion about rapid antigen diagnostics vs. PCR testing.  Most everyone considers PCR testing as the gold standard, which it is to some degree as it detects virus. So if you have virus alive and replicating that’s transmissible, or dead virus, where you can no longer infect someone, it will pick up the virus and say that you’re positive. For example, if I was infected three weeks ago, and I coughed on you today, I wouldn’t actually give you coronavirus. But the test would say that I’m positive still.

But the PCR test is good because it can pick up virus before you start transmitting, maybe a day or two in advance. Whereas an antigen test can only tell you sort of at that moment forward that you are no longer or that you are currently infectious. So antigen tests are actually really good testing tool to say whether or not you’re going to transmit the virus. Whereas PCR can give you a tiny bit of a signal ahead of time.

The other difference is that PCR testing typically needs to go to a lab, and there’s a turnaround time, so you don’t actually know the result of your test until a day or two later. With rapid antigen tests, you know straightaway.

Dawna: What are the implications here for events, differentiating between the small local events and large events with tens of thousands of participants?

Dr. Nichols: I tried to make the distinction in the white paper about large scale events. And when I talk about large scale events, I mean when people are traveling into a city or community from elsewhere. The reason that that matters is because not only are we trying to keep our races safe, but if you’re bringing in 50,000 people; not only the participants, their families, and others, all into an area that didn’t have those people before, there could be an impact. You could make the race safe, with no transmission events, or very few transmission events. The consideration would be the impact on the community. It’d be participants and their families and others who are part of the event, interacting with the local community at restaurants and social events around the race, that would be more of concern.

When we’re thinking local events, typically participants are just going to drive to the event the same day, they’re not staying in a hotel, they’re not going to different restaurants than they normally would, then you’re not going to impact the community differently.  When events are smaller and local, you wouldn’t necessarily need to use a testing strategy. But at a large event where you’re having people come from multiple locations, that testing strategy becomes more important. If you had access to rapid antigen tests, you could certainly consider that as part of your mitigation strategy at a small community event. But it matters to a lesser extent to global public health then it does at a large event.

Dawna: Is coronavirus eventually going to fall off our radar like SARS or Zika? Or do you think it’s something that we all have to worry about for years to come?

Dr. Nichols: We’re going to worry about it for forever. Eventually we will worry about it less, because it will kill people less frequently once people are vaccinated. But this is something that will become, by my estimation, endemic.­ We can’t get rid of it. If we could really vaccinate everyone in the world at the same time, maybe, but that is incredibly unlikely. This will more likely become more of a seasonal virus or a childhood virus potentially.

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At the conclusion of our conversation, Dr. Nichols answered webinar attendee questions about kids’ runs, vaccine frequency, stair climb events, and more. We invite you to view the recording to see those responses, and thank Dr. Nichols for her time and dedication to this project on behalf of Running USA and the running industry at large.