I was a Senior Epidemiologist at the Centers for Disease Control and Prevention (CDC) and a Director of an epidemiology division up until my retirement. I spent 33 years at CDC and remember it as the premier public health agency in the world staffed with world-class scientists and respected public health professionals dedicated to their mission. I have followed the many and varied developments along the arc of COVID-19 since early January. I have a fairly unique perspective on this outbreak and intend to share some of my observations and opinions in a series of essays over the next few weeks. I hope some will find them enlightening and useful.

PUBLIC HEALTH THREAT

Make no mistake, COVID-19 is a legitimate threat to society, both nationally and globally. This is a pandemic of a highly infectious, sometimes serious, occasionally fatal virus for which the world has no vaccine. There is also no effective vaccine on the horizon for at least a year. We are going to have to weather the storm with old fashioned public health interventions for the foreseeable future. Pretty much the same interventions that were put in place during the 1918 flu pandemic. The more things change . . .

The United States will likely see their entire critical care medical care delivery system overwhelmed and we will witness a large number of very ill people not receiving the supportive care that might save their lives. I sincerely hope our country doesn’t have to experience these events,  but when you combine our delayed, bungled approach early in the crisis with our unsupportable paucity of testing capacity, the near future seems pretty clear.

TESTING

Where do I start?

Under normal circumstances, and particularly in a crisis, public health decisions are entirely based on the collection, analysis, and interpretation of surveillance data. (Political decisions are not, by the way, and they often Trump the public health decisions.) Not surprisingly, the better the surveillance data, the better the decision making. For an infectious disease outbreak like COVID-19, the most critical data are the reports of positive (and negative) tests in a given community or geographical area. Based on the data, public health authorities can effectively allocate resources, coordinate with the health care delivery system, and design effective interventions to reduce or stop the spread of the disease. The best tests for responding to an outbreak are rapid, sensitive, specific, and offer a quick turnaround. More than a month into the pandemic, the United States still does not have this required testing capacity. South Korea does. Japan does. Spain does. Almost all of the developed world does. The United States does not. This utter failure to obtain or develop adequate testing for a rapidly spreading, serious infectious virus is both inexcusable and tragic. Tragic because people will die unnecessarily in this country because of the lack of effective testing for COVID-19. Really is that simple.

Currently, in most states, to be tested for COVID-19 an individual must have signs and symptoms AND be over the age of 65 or have one of the chronic health conditions that place a person at higher risk. If you do not meet the age/chronic criteria, but you have signs and symptoms you must have a history of exposure to someone who has been diagnosed with COVID-19. So, you may look at these criteria and say, “Well, that makes a certain amount of sense.” No, it really does not.

From an epidemiological perspective, these testing restrictions only make sense if you have an extremely limited supply of tests and are only interested in identifying the people most at risk of hospitalization or death. This current testing regimen is diametrically opposed to finding and identifying all of the cases of COVID-19. The most important factor in controlling an infectious disease outbreak is to identify, isolate, and treat all cases as quickly as possible. The current criteria used for testing in this country almost ensures the continued community spread of the disease. In most states, if I’m young (under 65) and symptomatic, I’m not getting tested and I’m not getting counted. So, how many cases do you have Florida? Really?

Based on all of what is written above, let me ask a critical question in determining the impacts of COVID-19 on US society over the next 5 months: how many cases of COVID-19 are there in the United States? As of my writing this essay, CDC reports just over 7,000 cases and 97 death. I believe the death reporting is fairly accurate with perhaps a 2 day lag. However, my personal estimate, based on our bungled response to the outbreak so far and our extremely limited testing capacity, is that the US has had approximately 30,000-50,000 cases of COVID-19  since the inception of this pandemic. Certainly, I may be wrong and the number will fall out of that range, but I guarantee that my range is much closer to reality than 7,000.

One final thought for this session, how will the US make the decisions going forward about the effectiveness of their interventions (primarily: patient isolation and social distancing) without reliable case counts? As more testing becomes available and as CDC relaxes the stringent testing criteria, the number of cases will continue to rise, perhaps sharply, even if the interventions are effective. How will we know if social distancing is working? How will we know when the time is right to relax the restrictions? How long will a society like the US put up with being cooped up by a government that cannot provide answers?

There is no doubt that case numbers will continue to rise over the next 6-8 weeks if testing is available. With that in mind, social distancing, and all of the disruption in our daily lives that entails, will be the reality for the foreseeable future. Hunker down America.