Frequent cheap tests will allow us to reopen

An abridged and updated version of this post appeared in the Eugene-Springfield Register-Guard on September 26, 2020.

If we as a society implement frequent, low-sensitivity, inexpensive, rapid-turn-around tests for COVID-19, we will quickly be able to reopen schools, workplaces, and society in general. With multiple tests a week – even daily tests at first – that deliver results in 15 minutes or less at just a dollar or two each, we can allow everyone who isn’t infectious to participate safely while identifying infectious individuals quickly and cost-effectively.

This idea – that lower-quality tests are the key – is counterintuitive, so let me explain. And you’ll see how I, as a parent and a university instructor, came to believe in this path.

The current pandemic has sparked massive mobilization of virtually all sectors of society. The federal government has thrown trillions of dollars at the problem; states are working around the clock to channel resources and set new rules, often adjusting to fluctuations in cases, hospitalizations, and deaths. Office-based businesses have abandoned their buildings to meet by Zoom. Restaurants live or die by take-out traffic. And we’re all spending money to cover ourselves in masks and hand sanitizer.

Despite this push, there is widespread agreement that we are still struggling in one essential area: testing.

We surely lag on volume for starters. Some observers, such as the public health experts at the Rockefeller Foundation, suggest that the United States should have reached three million tests per day by July and ultimately 30 million tests per day by October, far beyond our current pace that is well under a million per day.

Yet our more serious challenge is our mindset about what testing is supposed to do. We are currently overly focused on an understandable but misplaced desire for quality: high-sensitivity tests that detect the presence of virus, even at low levels. Indeed, the Food and Drug Administration, the agency that regulates such tests, has until recently sought primarily to avoid false negatives – that is, test results that incorrectly diagnose someone as not carrying the virus at all. 

This caution is understandable, as our instinct is to find the enemy wherever it is. Polymerase Chain Reaction (PCR) tests are, and will likely remain, the standard for highest-quality diagnostic tests. When we need to know with the highest certainty if someone has or has had COVID-19, a PCR test will be the choice.

Unfortunately, at a broader scale, that focus on sensitivity has led us down an awkward path. Standard PCR tests have high sensitivity, but they are also expensive, generally require skilled personnel and specialized equipment to administer and analyze, and take time to get results. Even without bottlenecks, you have to wait hours or an entire day for results. When things get busy, we’ve seen backlogs of a week or more, rendering the results nearly useless for stopping the spread of the virus. In short, there is no chance of doing the millions of necessary PCR tests if we want rapid results. By contrast, low-sensitivity tests can be made to be quick and easy, and they are likely to most reliably deliver a positive result when someone is infectious.

So what do we really need to restart schools and other dense settings? It’s simple: We need to know, at the start of each day, who can be there. Not who had the disease ten days ago, or who will likely be infectious a few days from now – both of which a PCR test will reveal – but rather, who can attend today without infecting anyone.

Let’s walk through how it could work for schools, the clearest and most urgent example. Each morning, every student would spit on a paper strip, wait 10-15 minutes, and get a result. Everyone who tests negative goes to school. Everyone who tests positive stays home, and immediately qualifies for a high-sensitivity test. By systematically removing people as they are infectious, we achieve maximum benefit at minimal unnecessary disruption. Well kids attend school. Kids with COVID-19 don’t get a chance to infect others. 

It’s important to extrapolate out just a few months of such a plan. With rapid identification, each case would quickly stop spreading. Without community transmission in group settings, the virus will stall. We would have a chance to not just flatten the curve, but to crush it.

Two final points. First, you’re probably wondering: Do these tests exist? The answer is…almost. The technological building blocks are there to apply existing technology using paper strips to antigen tests, and several prototypes exist. Just last week, researchers at Yale School of Public Health received a so-called Emergency Use Authorization, a provisional regulatory approval, from FDA for its product SalivaDirect. The team is further validating the test with players and staff in the National Basketball Association.

Second, this is not my idea. The most articulate and outspoken advocate for this approach is Michael Mina of Harvard’s School of Public Health. Go to his web site Rapid Tests (rapidtests.org), where he provides additional background and simple tools for contacting elected officials. We need the clamor for this approach to become a deafening roar in ears of decision makers. With enough orders from the public sector, many companies could ramp up production and bring costs down. Yale’s initial estimates are $1.29 to $4.37 per test, and Mina believes we can push it down to one dollar per test.

This path is still new, but states are figuring it out. On August 4, Maryland and six other states announced that they, as a consortium, would circumvent the federal government and go straight to the companies developing rapid tests, placing an initial order for an early version. Under the deal, each state will procure 500,000 tests.

We can make this happen, but only if cities and counties ask their states, and if states work together, to make rapid and inexpensive tests a key part of our testing strategy. Call and e-mail your elected officials, share rapidtests.org with them, and tell them to jump on the rapid testing bandwagon. It alone won’t fix the pandemic; of course, we still need treatments and ultimately vaccines. But rapid testing will allow us to reopen safely, and with the confidence we all need to start living our lives again.

Joshua Skov teaches in the Lundquist College of Business at the University of Oregon, and has two school-aged children. He is also one of Governor Kate Brown’s appointees to the Lane Transit District board of directors. The views expressed here are his own.

References

Yale’s rapid COVID-19 saliva test receives FDA emergency use authorization, YaleNews

COVID testing: Cheap, quick, at-home rapid test is needed, experts say, USA Today 

SalivaDirect: Simple and sensitive molecular diagnostic test for SARS-CoV-2 surveillance, MedRXiv

Coronavirus (COVID-19) Update: FDA Posts New Template for At-Home and Over-the-Counter Diagnostic Tests for Use in Non-Lab Settings, Such as Homes, Offices or Schools, FDA

The explosion of new coronavirus tests that could help to end the pandemic, Nature 

https://www.rapidtests.org (Michael Mina’s web site)

Maryland, Virginia, Michigan, Ohio, Louisiana, Massachussetts form pact for rapid coronavirus tests, Washington Post

National Covid-19 Testing Action Plan – The Rockefeller Foundation

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