COVID-19 Screening + Testing + Labs = Data for Better Decision-Making

We are on Day 22 of the COVID-19 pandemic since it hit the US (see trend line of cumulative cases/orange line and new cases/blue line). States are under-testing because labs are maxed out at capacity with 24/7 processing and have limited materials due to declining supply chains. Waiting for serious symptoms to present may not be effective for long now that community spread is here. The criteria for testing operates at a high threshold, and I understand it helps to assure that critically limited supplies are only used for the most likely who are infected among us. However, as we grow beyond contact tracing, it will become even more important to be able to rapidly identify cases. A confirmed case and subsequent death in James City County, VA had a reported (and known) 284 close contacts. The inherent capacity and support needed to communicate and track this number of contacts are immense. The canary in the mine was Italy, and now we are seeing significant impacts in Seattle, Northern California, and New York City.

In order to understand the magnitude that is happening, we need screening and testing; community spread is here! JAMA published on March 3, 2020, the imperative priorities for the US to enact in the evidence of what was to come. Health care workers, scientists, and local and state elected officials are imploring the need for testing data to do their jobs in a safe and effective way. We are at the mitigation phase where large provisions for screening and testing are critical, necessary, and needed now. This is not new information. If we, the United States of America, want to truly contain this pandemic spread and do it quickly, we must aggressively pursue a data-driven COVID-19 containment strategy. In order to do this, we must focus on fixing the evident gaps in screening, testing, and laboratory capacity and supply.

Locally to me in Virginia, near a cluster outbreak on the Peninsula, the first hospital started drive-through testing with very specific criteria today. Thresholds are in place because testing is extremely limited and only those who are symptomatic or have had close contact can be tested. This is a mistake; community spread is here! The local health care systems may not be ready for what is discovered either, but if we don't have data, we cannot fully know or understand how this disease is spreading and contain it for good. Many people who are infected have very mild symptoms and may not think to isolate themselves. Symptomology may not be the best indicator for testing; South Korea proved that COVID-19 can be controlled by pushing the pandemic down from a high of 909 new cases per day (on Feb 29) to just 74 cases yesterday (Mar 15). How did they do this? Testing. But what about screening?

Verily, a research company and a sister company of Google, announced today that they launched Project Baseline with a pilot online screening tool for Santa Clara County and San Mateo County in California. While this innovative concept to screen persons online and schedule follow-up testing sounds great on the surface, there are inherent red flags. Only those age 18 and older, located in the target counties, and willing to sign a COVID-19 Public Health Authorization Form (PHAF) can be screened. You sign the PHAF because you are giving your personal health information to a company and Google will be storing your information. The goal is to expand this platform after initial testing in these two areas, but that could ethically take weeks to complete. In addition, barriers to people who are chronically and systematically oppressed exist within this platform: you must have Internet access, have a Google account, whether you qualify for free testing or not (you have to pay), and is not available in any other language than English. This is not an equitable solution.

China and South Korea have demonstrated that rapid testing is completely possible (and not just for NBA basketball teams, celebrities, and others with privilege and influence). CDC released the requirement to send tests to them for confirmation, so that should help speed things up in getting results returned. However, commercial labs are clamoring for help from the federal government to secure swabs, pipettes, reagents, low-tech equipment, and personal protective equipment (PPE) because they are now performing the bulk of the country's tests. Even the concept of at-home testing is being proposed, but the inherent issues remain: the dire status of national supplies and lab capacity. Continued commitment from this administration is desperately needed to maintain the necessary volume of supplies. This is not a problem you ever want to have in the midst of a pandemic.

CDC moved too slowly. And it could have been avoided had pandemic preparedness plans been valued as well as public health system funding and capacity. We should not be trying to figure it out while we need it; it's way too late to plan in real-time. To be prepared means you have what you think you might need, and you've run tabletop drills frequently so you have an idea of what to expect. This is public health, and something that is evaluated after any national crisis or emergency from the World Trade Center attacks and the anthrax scare in 2001, to Hurricane Katrina in 2006, H1N1 in 2009, and Southern Border of the US in 2019.

Enhanced screening capabilities and improved testing capacity are still weeks out, which is unfortunate. So here's the deal: social distancing is the best we have to quell the spread. This was our map on Tuesday, March 10 via JHU Dashboard. And below is where we are a week later on March 16, 2020. Only one state has yet to have a confirmed case: West Virginia. If I were to project using the scale used for influenza spread, I would say we have moved from sporadic to local, and on the cusp of regional spread.

It's vital to understand why screening and testing are so very important right now. Because we need more data. Data drives decisions on needed ICU beds, ventilators, and other critical care capacity and equipment. Hospitals in key areas are already maxed out and can no longer support the need. Health care workers - the true heroes in pandemic times - put their lives on the line and risk exposure and are finding PPE supplies running dry already. Another essential point to data is the case fatality rate (which is not a biological constant nor fixed to a pathogen). It indicates the severity of disease in a particular context, at a particular time, and in particular populations, and further reflects the social and individual response to it. More specifically, the level, quality, and timing of treatment and care received, and the ability to recover from it. We know the fatality rate will increase and decrease depending on these factors, and we can still use it (along with testing data) as indicators of how we are containing, mitigating, and ultimately halting COVID-19.

I love data, especially population health data. I've been reading a lot on models being run on current data available for the US; here's one from China. Some indicate a peak in mid-April if nothing is done to a peak by late June if we practice enough restraint now with social distancing. The model below demonstrates peak exposure and disease spread at 40 days (dark blue line) will infect 10% of the population, given that incubation is 5 days (asymptomatic) and R0 is 3.5 (the number of persons that one infected person can expect to spread the virus). If we apply social distancing into the equation, we can see the effect to only 7.5% of the population at 45 days (light blue line) or even 3% of the population at 90 days (red line) at base peak. The longer we can stretch the base peak out, the more time we have to prepare, get our supply chains and lab capacity in better order for widespread testing, and reduces the demands on our health care systems. We need the testing data to tell us it's working.

To close, I want to see this pandemic end sooner than later, as I expect most of you do. We are in desperate need of testing, especially since we've put all our proverbial eggs in one basket with social distancing (I lament...all the Easter Egg Hunts!). Continue to socially distance yourself from others to stay healthy, as that is the goal: keep healthy people healthy first. Take this seriously and be well - community spread is here!