Infectious disease expert Dr. Mark Kortepeter discusses the importance of easy-to-use, readily available, and inexpensive Covid-19 diagnostic tests as case counts start to rise again.
You heard me right. When we think of countermeasures for a disease, we usually consider three things: diagnostic tests, treatments, and preventive measures, like vaccines. There is a lot of good news to celebrate, but some of the good news has been dampened by reality. Covid cases have fallen from their late August peak to the current plateau, but they appear to be rising again. Vaccines have demonstrated the ability to reduce hospital admissions, ICU stays, and death, but we are seeing breakthrough cases over time. We have multiple treatments that have demonstrated benefit, including two recent pills from Merck and Pfizer that will make it much easier to treat individuals early during illness, where it can have the biggest impact. Children five and older are now eligible for vaccination. Given that vaccine breakthrough cases can occur, and that those individuals can spread infection, vaccination alone is not the solution. In order to shut down an outbreak, you need to shut down viral spread. The way you do that is through easy-to-use, readily available, rapid diagnostics.
The Importance of Diagnostic Tests
Every newly minted “disease detective” in the Epidemic Intelligence Service at the CDC learns the basic steps of hunting down and stopping an outbreak. One critical step early on is to “confirm the diagnosis” via tests. Vaccines are generally considered a later step. Since we are fighting a “war” against the pathogen every new battlefield commander learns to minimize the enemy’s ability to “conceal and cover.” In a medical war that means unmasking the viral “enemy” by making a diagnosis.
Having a diagnostic test allows public health authorities to separate the infected from the uninfected. Why would you want to do this? It’s simple because then you can take measures to ensure that infected people stay out of circulation to prevent further spread.
The U.S. fumbled this key aspect of response early on. It took some time to recover, but we now have some pretty decent home and lab-based tests. Each type of test has its advantages and disadvantages. Sadly, nearly two years into the pandemic, we still have not figured out the operational plan to meet the demand for diagnostics. In early October, President Joe Biden announced a $1 billion priority investment to increase the availability of Covid tests. Unfortunately, it’s been a long time coming, and it has never received the appropriate attention.
A Patient’s Dilemma
Let me explain the challenge, using my own recent experience as a “patient.” A couple weeks ago, I received my annual flu shot. The next evening, I felt some muscle aches, followed by a stuffy nose and fatigue. No fever, no cough.
“Was it due to the vaccine?” I wondered. “Or maybe I caught the flu just before getting the flu vaccine. Could it be just a cold? Or, could it be Covid?” I was vaccinated against Covid (not yet boosted), so having a milder illness would not be surprising.
Here’s the dilemma: a lot of other respiratory illnesses can look like Covid early on (rhinovirus, other coronaviruses, adenovirus, influenza, parainfluenza, you name it). In medicine, we call this the “differential diagnosis.” In order to reduce spread of Covid, we need to be able to distinguish between these pathogens easily and quickly – and with Covid, we really need to enlist the patient’s help.
I had important meetings scheduled at work that I was expected to attend in person. Should I call in sick or attend the meetings remotely? I also needed to make flight reservations for an upcoming funeral – should I wait to make them, risking increased expense, until I knew for sure that I didn’t have Covid?
I didn’t feel sick enough not to go to work. In the past 30 years, I have taken about five sick days, so it is not in my nature to take a sick day. Should I just go to work then?
I decided that the responsible course was to get tested, but the testing site where I work had reduced its operating hours and closed 20 minutes before I arrived. I considered going to the emergency room, but they don’t need to be flooded by people with minor illnesses. Plus, if I didn’t have Covid, the last thing I wanted was to risk getting exposed in a hospital “hot zone” from Covid patients. All the $25 rapid test kits were sold out at the local drug stores. I could purchase a $125 PCR test if I wanted, but every time I have a minor ache or stuffy nose, there is no way I am going to pay $125 for a test that would take several days to obtain results. And if I had to test all my household members each time anyone has the sniffles, we’re talking about $500 – this is beyond reach for many people.
I looked up an online testing service – even with rapid transport, a PCR test would cost me $250 and still take three days, due to the shipping aspects. The online vendors and online drug stores were sold out of the less expensive rapid tests. Frustrated, I gave up. Fortunately, my wife was more persistent than I was, and after much searching, she found a county health department site about 5 miles from my house that was still open, so I drove there. Twenty-four hours later, my PCR test result came back negative. At least I could then feel comfortable I wouldn’t transmit Covid to my colleagues or anyone at the funeral.
I doubt my experience is unique. The rapid Covid tests fly off the local pharmacy shelves as soon as they are stocked. I know others who have had similar difficulty finding the rapid tests. My colleagues with school-aged children confessed that they notify their circle of friends when the Covid tests hit the shelves and dash to the store and buy them up. No wonder I couldn’t find any.
Fixing the Problem
The only way we are going to drive down spread is to enlist the patients across the United States to play their part in preventing spread. What we really need is for anyone who wants a test, even when they have minor respiratory complaints, to be able to get one quickly. It should be as easy to use and as accessible as a digital thermometer. Otherwise, the public out there just won’t do it, and spread will continue to occur. Ideally, once identifying themselves as positive, they can take the appropriate measures to minimize contact with others.
Having such readily available diagnostics can also improve the way we handle exposures. Quarantine is such a “blunt” instrument. We can refine the paradigm from quarantine of exposed individuals to “test and isolate” if positive with rapid diagnostics. It’s not perfect, but it’s better than closing schools or worksites and sending everyone back to remote learning and work. Investments in mobile test centers would also help.
In conclusion, in order to maximize the benefit of new treatments and to shut down spread, we need readily available, inexpensive (preferably free), accurate, rapid diagnostic tests. In a country that can take a vaccine from a concept to shots in arms in months and pass a $1.2 trillion infrastructure bill, it should be possible to make tests available to meet the demand. There is no time to waste with the rising cases and influenza season around the corner.
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