"More Testing!" Is Not Enough
Important insight on COVID-19 testing from Farzad Mostashari, M.D., and Ezekiel J. Emanuel, M.D.
In short, per their quote of Tom Frieden, former director of the Centers for Disease Control and Prevention, "Testing is not a panacea," but, they explain, "intelligent application of testing will provide vital public health information needed to effectively fight this pandemic."
Excerpt of their piece at StatNews, sent to me by an epi friend -- but the whole thing is worth reading:
If we are going to get a handle on this fearsome disease, we need to stop emphasizing the sheer number of tests and whether any citizen can walk up and get tested. Instead, we need to insist on four basic groups of information gathering as we expand testing.First, as a condition of receiving approval and test kits, laboratories should be required to submit basic information like age, county of residence, and testing site on every person tested -- not just the positives.
Second, we need a sero survey of multiple communities. Such studies test blood samples from randomly chosen individuals in a defined population. This is the way to assess the real percentage of people in a community who test positive for recent coronavirus infection. This gives a picture that is wider than just the individuals who are bringing themselves in for testing. Right now we simply have no idea how many Americans are infected with the coronavirus. This will be a key input to models trying to predict when herd immunity can begin to blunt the outbreak.
That means we need to do random testing of people in communities like New Rochelle or Seattle that have been hard-hit by the outbreak. When one of us (F.M.) worked in New York City leading the fight against West Nile virus, health workers went door to door, testing and surveying households in the epicenter of the outbreak to understand the true case-fatality rate and the true infection rate of the virus.
Third, the CDC needs to rapidly help state and local public health agencies set up what is known as sentinel testing for Covid-19. This means they need money and technical support to collect comprehensive clinical and exposure information on a systematic sample of patients. That could be through existing sentinel clinics set up for influenza surveillance, drive-through coronavirus testing sites, or having select hospitals volunteer to systematically collect key information and test results for a sample of patients with cough and fever or severe acute respiratory illness.
Fourth, we need to look deeply into the information we already have. We should investigate data being collected daily in nearly every state on what are known as syndromic surveillance clusters. One of us helped design and build such a system for monitoring emergency room visits in New York City, which are now showing unprecedented increases in respiratory and flu-like complaints since March 1. By last Thursday, there had been 4,663 emergency visits with these complaints in 2020, while last year there were only 1,603. We need to look at the data of these patients to understand how much of this increase in emergency room visits is actually related to Covid-19 and how much is due to worried people imagining they are infected. This could be a key way to understand just how much we have undercounted the severity of the spread of Covid-19, and a tool that other communities can use to detect when the outbreak is spreading rapidly.








The data should be shared internationally. Coordinated efforts need to be happening if they aren't already.
NicoleK at April 21, 2020 10:45 PM
Makes sense to me — but, unlike every other person on the Internet these days, I'm no expert in virology.
Kevin at April 21, 2020 10:47 PM
The randomized testing and sero surveys have already begun. It just takes time.
As for what has already been published it looks like the current number of 'cases' or 'positives' is undercounting by around a factor of 100. So the 819,321 cases for the US needs about two zeros added on the end, 81,932,100. Or about 24%.
For herd immunity for diseases like this one you typically need 90%-95%.
Ben at April 22, 2020 6:54 AM
I don’t think any of this will be particularly valuable in reopening the country. It will take too long to provide any useful information.
According to studies there are thirty (or more) strains of this virus out there now, and mutating rapidly. (There will probably never be a vaccine)
The politicians are looking for something, anything really to shove decisions off onto people and models who don’t have to stand for election.
We are in the middle of massive butt covering. And Montana is in a much different situation than Manhattan.
There has been a lot of shut down theater. I expect the panic to continue among those who don’t actually have to go to work, demanding that the rest of us stay home, so they can go out *safely* (safety is an illusion)
That equation should have been flipped. The elderly and vulnerable should have stayed home, while the rest of us toughed it out, and got past this.
Indications are, everyone will be exposed to it eventually anyway.
Isab at April 22, 2020 7:03 AM
The serology testing will show those who have had an immune response to covid, not those who (necessarily) actively HAVE covid.
It is worth knowing, particularly with the young, how many may already be immune. If 90percent of kids are immune in an area, schools could reopen, for instance.
Obviously, we would want to make sure they aren't contagious (end of infection type scenario where they haven't cleared it but have antibodies)
Anon at April 22, 2020 7:21 AM
The article is a month old, so it would be interesting to know how much of the information it recommends we gather is actually being found and reported. This pandemic is challenging every single system in the world to adapt at blinding speed. I'm sure that everyone is in favor of finding out everything we can as fast as we can and apply the information in the smartest possible ways. On a personal level, I need to know some very particular statistics in order to plan my life from here on out. We've all heard that obesity and age and heart problems and lung problems and diabetes are big risk factors. However, like an enormous number of people, I am technically in a lot of those categories but in a minor way. My BMI is in the overweight zone, but not obese (and I REALLY need to get back to low carb eating because I am gaining weight during this lock-down). I'm just over 60. I have asthma but it's mild and controlled; most days I don't even use a preventative inhaler and I've never had to use a nebulizer. I have Type II diabetes but it's well-controlled and I have no known complications...well, it was very well-controlled before the lock-down when I started to eat every carb in sight. I don't have high blood pressure but there is serious heart disease in my family so G-d alone knows how much my arteries may be sludged. It's probably going to be a LONG time before we have the data and studies to let me and my doctor know just how likely it would be for me to have serious complications or to die from the WuFlu. I try not to think about the implications right now, because it raises the possibility that in order to be "safe" I would be in semi-quarantine for years. Maybe I would rather take a non-miniscule chance of death than not see my kids again for years, or not be able to go about some semblance of a normal life.
RigelDog at April 22, 2020 7:55 AM
RigelDog, this might give you some peace of mind, emphasis mine:
https://www.usatoday.com/story/opinion/2020/04/21/oral-polio-vaccine-has-potential-treat-coronavirus-column/5162859002/
That's the Sabin oral polio vaccine. It is quite likely you've had this. Unless you got Salk's.
I R A Darth Aggie at April 22, 2020 9:01 AM
Thanks for the info, Darth! I may have had both the Salk and the Sabin vaccine, because I was born in 1957. I imagine I would have had the Salk given to me as a toddler, and then I have a vague recollection of being given an oral vaccine in grade school because people were talking about how it was such a great development in preventing polio.
RigelDog at April 22, 2020 9:21 AM
If you're interested, this book gives a pretty good history of both vaccines and the struggle to create and test them.
Salk favored a live virus and Sabin favored using a dead one. Unfortunately for Sabin, Salk got to the finish line first and vaccinated a great deal fo the world's population. As a result, Sabin's vaccine had to be tested in the Soviet Union, which still had a large unvaccinated population.
The book also gives a pretty good, and harrowing, description of what living with random polio outbreaks was like; the fear and panic it could incite.
Few people are left alive who had childhood polio - Alan Alda (7) and Mitch McConnell (2) to name a two. Alda was treated with Sister Elizabeth Kenny's controversial physical therapy regimen and credits it for curing him (and for making him a feminist). McConnell was treated at Warm Springs and credits the treatment for preventing him from being disabled for life, although he still has trouble getting around due to the lingering effects in his legs.
Conan the Grammarian at April 22, 2020 11:27 AM
"The data should be shared internationally. Coordinated efforts need to be happening if they aren't already."
Heh. Do comprehenive analysis, and you have a wonderful idea of how to attack anywhere or everywhere on Earth.
Do you think HIPAA applies? Hope not. It won't.
Radwaste at April 22, 2020 1:42 PM
> Alda was treated
Mark Donahue received the Kenny treatment, and had an otherwise(!) short life of considerable athleticism.
Crid at April 22, 2020 7:42 PM
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