Over a week after I first became alarmed at how shockingly inept America’s covid-19 testing has been, today I’m finally seeing a lot of journalists investigating the problem. As Brian Resnick and Kylan Scott report:
Here’s a big, discomforting fact about the current coronavirus outbreak in the United States: We have no idea how large it is.
We don’t know because the US has been extremely slow to roll out diagnostic testing for the Covid-19 disease. It’s unclear if there’s a specific policy or decision to blame for the current situation. It arose from a combination of manufacturing problems, chronic underfunding, and an apparent lack of foresight. But no matter the specific reason, the testing challenges, scientists tell us, make us less prepared to deal with this unfolding public health crisis that will probably get worse before it gets better.
“I think that we could have probably controlled this, if we had effective testing,” Angela Rasmussen, a Columbia University virologist, says.
Accurate testing is critical to stopping an outbreak: When one person gets a confirmed diagnosis, they can be put in isolation where they won’t spread the disease further. Then their contacts can be identified and put into quarantine — so that they don’t spread the virus if they’ve become infected, too. That’s particularly important for a virus like this one, which seems able to spread before people show symptoms, or when their symptoms are mild.
Better testing, paired with aggressive public health actions — like social distancing, isolation of those who are sick, and tracing those who sick people made contact with — can still help save lives in the United States.
But it starts with testing…
Evidence is mounting that early in the outbreak, in January and February, China bought the world time with its aggressive action to contain the viral outbreak in its borders. The testing fiasco in the US indicates we didn’t use that time well.
“There was clear lack of foresight,” Nathan Grubaugh, an epidemiologist at the Yale School of Public Health, says. “We were very slow to roll out testing capacity to individual places — wherever that came from, it was a very bad strategy.”…
Making matters worse, some people who have sought tests in the past few weeks have been turned away. And these shortcomings make it harder for the public health community to react to a virus that spreads quickly and easily.
Many people don’t really show symptoms of Covid-19, or their symptoms are very mild, but you want them to be tested anyway if there is an opportunity… As cases of Covid-19 in China were increasing dramatically in January and February, a lot of the US response was focused on travel restrictions and travel-focused testing. In retrospect, there should have been more planning for a pandemic… We don’t need testing just to diagnose sick people coming into doctor’s offices and hospitals. We also need testing to do surveillance out in communities. “You actually have to go out like now in many places in the US and start taking samples from people,” Grubaugh says… Again, without testing, we’re in the dark. And while we’re in the dark, the virus can spread.
The public relations effort of the administration has tried to focus not on actual testing, but on how many “test kits” will be produced. Pence promised that 1.5 million tests would be going out this week, but that is misleading in two ways. First, they won’t have but a small fraction of that number ready and second, the number of “test kits” doesn’t matter at all unless they are actually used and very very few have been used. The actual testing is what we need and it is still a trickle. For example, The Atlantic reported that only 1,895 Americans had been tested as of this morning after surveying the health authorities of all 50 states, the District of Columbia, and the federal government. This is embarrassing compared with any reasonable standard:
In South Korea, more than 66,650 people were tested within a week of its first case of community transmission… The United Kingdom, which has only 115 positive cases [compared with 322 in the USA as of now], has so far tested 18,083 people for the virus…
Normally, the job of gathering these types of data in the U.S. would be left to epidemiologists at the CDC. The agency regularly collects and publishes positive and negative test results for several pathogens, including multiple types of the seasonal flu. But earlier this week, the agency announced that it would stop publishing negative results for the coronavirus, an extraordinary step that essentially keeps Americans from knowing how many people have been tested overall…
It has not always been so challenging to get estimates of the number of Americans tested. Throughout February, the CDC published a regular tally of Americans who had been tested for the pathogen. Last Saturday, several days after the country’s first case of community transmission was confirmed, that figure was 472.
Then the agency stopped updating the tally… Since the CDC’s pullback, it has become extremely difficult to track the nation’s growing capacity to test for the coronavirus.
Today the CDC resumed reporting how many tests that they have performed after a week of negligence. In the week since they last reported testing, the CDC has performed only 1,102 additional tests. And it isn’t like we couldn’t see the pandemic coming. The US was one of the first countries to get the disease way back in the beginning of January:
COVID-19 cases in the United States by date of illness onset, January 12, 2020, to March 5, 2020, at 4pm ET (n=67)**
Because the CDC is woefully unprepared to deal with all the testing America needs, a few days ago the FDA implemented a new Emergency Use Authorization which allows labs across the country to begin testing without submitting for prior approval. Better late than never. Now several state public health departments such as California, Washington, and New York have already developed their own testing capabilities and state universities and private medical labs are also rapidly ramping up testing capacity. The Atlantic again:
As more laboratories join in the effort, quality control will become more difficult… These types of measures are necessary because the United States’ response to the coronavirus is far behind the spread of the disease within its borders. Testing is the first and most important tool in understanding the epidemiology of a disease outbreak. In the United States, a series of failures has combined with the decentralized nature of our health-care system to handicap the nation’s ability to see the severity of the outbreak in hard numbers.
Today, more than a week after the country’s first case of community transmission, the most significant finding about the coronavirus’s spread in the United States has come from an independent genetic study, not from field data collected by the government. And no state or city has banned large gatherings or implemented the type of aggressive “social distancing” policies employed to battle the virus in Italy, Hong Kong, and other affluent places.
If the true extent of the outbreak were known through testing, the American situation would look worse. But health-care officials and providers would be better positioned to combat the virus. Hard decisions require data. For now, state and local governments don’t have the information they need.
Whereas the US did a great job testing for H1N1 and Zika using exactly the same technology, the covid-19 test has had numerous errors. Some people have argued that the quality is so bad that it isn’t worth doing until the quality is fixed. But China used some low-quality tests in its massive testing program which missed up to half of sick people and it helped them stop the growth of the epidemic anyhow despite a 50% false negative rate. That’s because they caught half of the sick people on the first test. Diagnosing half of the people with the virus is a whole lot better than none. And they retested people as symptoms got worse or when there were other signs of risk which meant that they could get 75% accurate on the second round (assuming independent probabilities) and some information is clearly better than none. Plus they also used chest CT imaging which was more accurate than the PCR test which is what most people mean when they talk about testing. The combination of chest CT and PCR test gives useful information even when both are imperfect by themselves.
Americans may already be dying unnecessarily because our lack of preparation to be able to do adequate testing.