For a month or more, the press followed President Trump’s lead (as it generally does) by virtually ignoring the absolute importance of testing.
Fortunately, in the past couple of weeks, the press has rediscovered how important testing is if we are to reopen the economy safely.
Unfortunately, much of the discussion in the media is confusing, incomplete, and often somewhat misleading.
First, except for those who have recovered from COVID-19, no one has immunity to this virus. This is why it has become a pandemic. Until there is a safe and effective vaccine, every person on earth is susceptible to contracting the disease. Unless the virus is contained until there is a vaccine, most people eventually will contract it.
Vaccines are not easy to develop. It took five years for Dr. Jonas Salk to develop the polio vaccine. Others had been working to develop a polio vaccine before him. Despite decades of research, there is no vaccine for HIV, nor for hepatitis C. Estimates for a COVID-19 vaccine are 12 to 18 months. We cannot maintain closure of large portions of the economy for 12 months, much less 18.
Second, we do not know exactly how much immunity a person develops after having defeated the virus. There is evidence some people, particularly those who had very mild infections either can become reinfected, or the virus is dormant for a while before becoming active again, causing a person to relapse. Consequently, the only way to reopen the economy safely, without causing new spikes in infections is aggressive testing. We need to test both for the virus and for antibodies to the virus among those who have recovered from it.
Because President Trump refused to begin mobilizing the nation’s health care system in early January, we are at 8 to 10 weeks behind the curve on testing. He also refused the World Health Organization’s offer to provide the U.S. with tests, while declaring we develop our own tests. The first test developed by the Centers for Disease Control was unreliable. All of this pushed us farther and farther behind in effective, aggressive testing.
In the U.S., we have tested almost four million people. That is slightly over one percent of our population. This is grossly inadequate. With over 700,000 confirmed cases of the virus, we literally have no idea exactly how many people they subsequently infected who are either asymptomatic, or are sick but not diagnosed because enough tests are not available.
This is extremely important because some evidence indicates persons with the virus actually are more contagious while pre-symptomatic. This is unlike the Ebola virus where a person is not contagious until they have symptoms of the disease. Also, COVID-19 is much more contagious than Ebola. This is why COVID-19 is so dangerous and why very aggressive testing is an absolute necessity if we are to reopen the economy with any degree of safety.
For now, the virus’ spread is being somewhat contained by extensive “social distancing,” “sheltering at home” and constricting large segments of the economy. President Trump is absolutely correct in contending this constriction cannot be sustained indefinitely, or even for an extended time.
How do we reopen the economy without creating new spikes forcing us to shut down the economy again? Testing, testing, testing.
We are not getting ahead of the virus; we are not even in the ballpark. To reopen the economy safely, we absolutely need to know who has the virus, who does not have it, and who has recovered and has some degree immunity to it. Once we know those things, we will know who can and who cannot return to work; and also quickly identify and quarantine those who become infected.
Mayor Cuomo says, in New York, the curve appears to be flattening. Perhaps, but quite possibly not. The flattening of the curve may be more a function of inadequate testing than fewer people getting infected. (Robinson Meyer & Alexis Madrigal, “A New Statistic Reveals Why America’s COVID-19 Numbers are Flat” in The Atlantic, 16 April 2020)
Currently, we have nowhere near enough tests to test everyone who actually has symptoms, not even enough to test everyone who has severe symptoms, of the disease. Without aggressive testing, we are not getting ahead; we are falling behind. At least two doctors on one of the news networks have said we possibly need to be testing a million people a day. Since we have tested less than four million in over two months, that sounds like a lot. It is not a drop in the bucket compared to the testing we actually need. We probably need to be testing 25 million people a day; quite possibly more. I am not exaggerating.
How did I arrive at this number? Fair question. It is an extrapolation.
In areas designated as COVID-19 “hot spots”, every health care worker who has contact with patients needs to be tested every day. As soon as a health care worker tests positive, that worker needs to be quarantined until testing negative. This would include, for example, dentists and their staff. According to the Kaiser Family Foundation, there are almost 17 million health care workers in the U.S. Not all of them need to be tested every day, but millions do. Those working in areas where there are few to no confirmed cases probably should be tested every week. How many millions of tests per day is that? If a health care worker tests positive, every patient that worker has had contact with over the previous few days needs to be tested at least twice.
Every police officer, firefighter, or public servant who daily has contact with the general public working in “hot spots” should be tested every day. Those workers in areas where there are no or few confirmed cases probably should be tested once a week. There are over two million police and fire fighters, and at least that many public servants with daily general public contact. In “hot spot” areas, every grocery store or pharmacy worker who has contact with the general public (cashiers, clerks, stockers) should be tested daily. Those working outside “hot spots” probably should be tested once a week. How many millions of tests per day is that?
It should be noted, people cannot tolerate daily nasal swab testing. Consequently, nasal swabs are not suited for daily testing. Fortunately, the FDA has given emergency approval for a saliva test, and two other saliva tests are in the final stages of development. (Matthew Mosk and Lucien Bruggerman “Scientist Behind Saliva Test Breakthrough Sees Bridge to Nationwide Coronavirus Screening”, ABC News, 16 April 2020) With saliva testing, we easily can test daily.
Ideally, schools reopens in the fall except in areas designated as “hot spots.” Children should remain at home where there are “hot spots.” We have over 56 million children in grades 1-12. How many millions of teachers and teachers’ aides, and clerical workers are there? All of those in schools outside “hot spots” probably should be tested once a week; and their temperatures probably should be checked every day. A student, teacher, or staff member in a school for one day with the virus can infect dozens of others throughout that day, causing a ripple effect of dozens and dozens of more infections day after day.
Also, when a person is diagnosed with COVID-19, there needs to be “contact tracing” and testing. That is, everyone with whom that person has been in contact with for the previous several days needs to be tested at least twice for the virus. The only way to get ahead of this virus is to track down every person who potentially has been infected by someone with the virus.
Those who have had the virus and are thought to have recovered need to be tested at least four times. Their first (or some subsequent) test confirmed the virus. Because this virus is tricky, once a person no longer has symptoms, the person should be tested twice about three days apart to have some (but not complete) confidence the person is virus-free. Sometime after the second negative test, the person should be tested for antibodies to the virus. Four tests.
There are multiple reasons to test for antibodies. In some Asian countries, there have been apparent relapses or reinfections. A person might have the virus, defeat it, but not develop a strong immunity, making the person susceptible to reinfection. Or the person’s body might not have eliminated the virus; it just went dormant and undetectable for a while. The antibody test should give us some confidence of a person’s subsequent immunity.
Equally importantly, there is evidence blood plasma from someone who has developed antibodies can help treat those who are seriously ill with the virus, thereby saving lives. Once there is enough blood plasma with antibodies available it possibly could be used to treat persons with milder symptoms to help reduce the severity of their infection and/or speed their recovery.
If you have “done the math” of all of those who need to be tested daily or weekly, who need multiple tests because they are infected or have been in contact with someone who is infected, or have developed strong antibodies, you can see why I said we need 25 million tests a day and quite possibly more. Once spread of the virus has been contained, testing can be reduced proportionately to the decline in new infections.
The temporary solution is testing, testing, testing. When we know who does not have the virus and who has recovered from the virus, we know who can stay at work, or go back to work, and who must stay home. Until then, we are rolling the dice. If we can spend over $2 trillion to keep the economy on life support, we certainly can spend (guesstimate) $50 billion a week to test aggressively and get people back to work. Actually, aggressive testing is less expensive than “economic life support” because more people working means less money needed to keep the economy afloat.
So, why aren’t we testing more aggressively? There are multiple inter-related reasons. We were at least two months late getting started developing and producing effective tests. Because that has been no leadership from the federal government and a lot of roadblocks, there has not been a coordinated effort to develop and distribute tests. This has slowed the process and delayed the manufacturing of tests.
Also, tests include multiple components, such as reagents that actually determine the presence of the virus and swabs to take mucus or saliva samples. It takes time to develop effective tests and ramp up production. But all of this can be done more quickly if there is coordinated direction by the federal government. Also, if the federal government is the sole purchasing agent and obviously buying in bulk, there are no “bidding wars” and costs of tests can be kept lower. As noted, that leadership, that coordinated direction has been sorely lacking.
Editor’s Note: The main image accompanying the above guest column shows a drive-thru coronavirus testing station in Wilmington, Delaware, on Mar 13, 2020.(Photo: Jennifer Corbett/Delaware News Journal via USA TODAY Network)