Without more coronavirus testing, the US is unprepared for a second wave of infections
Disease surveillance and some form of contact tracing are absolute necessities
I am an epidemiologist with some outbreak response experience, including for the West African Ebola epidemic in 2014–2015.
The current US COVID-19 trajectory could have been prevented by using proven public health measures early on. Instead, our only choice became the blunt and costly instrument of closing down public life. The shutdowns bought us time to address health system deficiencies, with attention focused on medical shortages. But the underlying problem is not ICU capacity.
We need to rapidly organize an overdue public health response to maximize effectiveness of these shutdowns and contain the virus in the upcoming months.
The points in this article are not new, and pandemics are not without precedent. We must apply the hard-learned lessons of rapid and large-scale mobilization from outbreaks like the West African Ebola epidemic, as well as the successes and failures of the varied responses to the current epidemic. Extensive use of a wide range of public health tools brought past outbreaks under control. Applying public health strategies flexibly, safely, and in evidence-based ways provides our best opportunity for ending this pandemic.
Urgent public health priorities are: isolation, disease surveillance, coordination and leadership, and filling the holes in our social safety net.
Hierarchy of isolation
Currently, COVID-19 patients not requiring hospitalization are being asked to stay home, leading to more household transmission. Transmission in household clusters has been cited as a key factor in the initial spread of the outbreak in Wuhan and Hubei, and public health measures to address this were a critical part of the Chinese government’s response.
Hotels that have lost their usual revenue have infrastructure for isolation; empty dorm rooms and large spaces like convention centers are alternatives.
Separate facilities should be options for: suspected patients awaiting test results (until rapid diagnostics are commonplace); confirmed patients unable to adequately isolate but not requiring hospitalization; still infectious recovering patients; and healthy, but high-risk, healthcare workers. The details will require careful planning and local authorities must choose evidence-based options that work best for them. But community spread will continue for longer without appropriate isolation options.
Disease surveillance encompasses several public health tools, some useful throughout the epidemic and others more useful during specific phases. Surveillance components include tools like testing, case detection and reporting, contact tracing, and screening. These are each large-scale efforts during a pandemic, and must work together in concert. State and local governments must prepare and staff robust systems now to carry out all of these, especially to be prepared for when the shutdowns end. This will require many trained workers, including volunteers, and harmonization.
Testing plays a crucial role within an effective public health response, and the delays and need for more testing have been well-documented. But lack of adequate testing should not cripple disease surveillance needed to monitor the size and progression of transmission.
For example, systems are needed for reporting suspected cases, including from doctors’ offices and health facilities based on reported symptoms (especially while lab test capacity is limited). Such reporting is not currently happening in most of the country. Many areas are still only testing severely ill patients, leaving us with little sense of how many cases may be in the community. This is wholly inadequate from a public health perspective where the goal is to understand the breadth of, and ultimately end, transmission. It is time to fix this now.
A robust surveillance system must be multi-faceted (e.g. reaching health facilities and the community; identifying official and unofficial case reporting) and nimble (e.g. prepared for a lack of or changes in testing). Where the public health response remains overwhelmed, partially sampling from some instead of all facilities and communities is a start.
Thorough contact tracing is not always viable in hard-hit places which already have large numbers of cases with exponential growth. But it is essential as transmission begins to drop, and is still one of the most powerful tools for transmission prevention in places with less spread currently.
Consistent and standardized screening procedures are needed at transit hubs where viruses can move long distances. Unlike what we have seen so far in the US, screening must be linked to testing, coordinated efforts along state lines, and strict isolation/quarantine strategies. There have been huge failures even in the last several days in this regard.
Technology may play a useful role in all of this. But it is important that privacy be respected from the beginning, both to ensure buy-in from a sometimes mistrustful public, and to avoid setting precedents for government overreach in the future.
Useful guidance from the WHO on pandemic influenza disease surveillance, relevant for the COVID-19 pandemic as well, is here.
Coordination and leadership
Responding to a pandemic requires extraordinary levels of coordination across all levels of government and civil society. The lack of a suitable, coordinated, and timely federal response has set us back, with state governments having to lead instead.
This is not the time to retain figureheads; those with the right experience (e.g. emergency preparedness, outbreak management) must be in key positions. Without reliable federal leadership, states must also coordinate between themselves, including on exchanging equipment and lessons learned.
Newly formed centralized COVID-19 task forces in several states are a good start. But too often, these task forces and their advisory boards focus on operations, logistics, and clinical needs while public health departments operate separately. This is to the detriment of a full and rapid response which needs public health at its core.
Protecting the vulnerable
The ongoing debate on the role of government in healthcare must be set aside right now both for humanitarian reasons and because our collective health depends on how we treat the least fortunate. The expanded sick leave and unemployment benefits from federal legislation are a good start, but the exemption of companies employing more than 500 is an enormous limitation.
State governments must ensure that every single person can seek care for COVID-19 without worrying about the bill.
Active outreach, including wellness checks, must be done for vulnerable groups including those experiencing homelessness, non-English speaking communities, some religious groups, and the unsupported elderly.
Infection control and humane policies must be enacted for closely-housed groups at high risk of rapid disease spread, including prisoners, detained migrants, and nursing home residents.
There will be plenty of twists and turns ahead in the fight against this virus. New tests, treatments, medical supplies, research findings, and vaccines will enable new ways to respond but also require careful system-wide thinking about integration and unintended consequences. Such changes will need to be accompanied by wide-reaching and trusted public outreach campaigns.
For example, new types of rapid tests available outside of conventional testing facilities will require modifying surveillance systems, educating the public, and offering guidance to healthcare providers. Emerging therapies must be equitably distributed. New challenges will emerge, such as a public growing weary of restrictions or the emergence of mutated forms of the virus. Society must devote resources to planning for these contingencies now.
Everyone wishes we had applied appropriate and extensive public health measures since January. A successful shutdown can effectively bring us back to that time point. Let us not waste another critical opportunity by not being prepared this time.
This article originally appeared on Medium and is reprinted here with permission from the author.