Our entire planet is paralyzed by this pandemic. The novel Coronavirus has overtaken our hospitals and overwhelmed our heroic health care workers, killed tens of thousands of people, derailed the global economy, displaced hundreds of millions from their jobs, caused a humanitarian crisis on top of a health and economic crisis, and the truth is we still do not truly understand basic facts about this virus!
Over the last several weeks I have talked to foremost scientists, heads of foundations dealing in this space, public officials, and devoured everything I can find on this topic. And as far as I can tell, nobody actually has the most vital information necessary for our governments to be able to formulate policy.
For example, we don’t know whether the number of asymptomatic people that were infected by the virus but didn’t even realize it is 25% of those infected, or as little as 5%, or as high as 50%. Relatedly, because not everyone that has symptoms is tested, we don’t actually know whether the contagion rate is exponentially greater (some have suggested 5X-19X in certain localities) than those who were tested after registering mild, serious or critical symptoms.
This information is vital, because if asymptomatic and unreported cases are in the lower range, then not only are the elderly at huge risk (as high as 27% death rate for those over 85) but even those ages 50-69 have 1-4% chance of dying. In that scenario, while young people would fare mostly fine, upwards of 50% of the population would have severe enough risks that the disease would force us all to continue pursuing forceful national or global quarantines and extreme social isolation strategies until a vaccine or other cures are more apparent.
But if the virus has spread exponentially more than we realize and a vastly greater number of cases went unreported either because they were asymptomatic or with mild enough symptoms, then the numbers of potential fatalities as a percentage of total infected, while tragic, should permit for society to slowly relax our separation measures once 3-4 weeks of isolation have enabled us to slow down the spread of the virus. From that moment we would continue to need to protect the more vulnerable segments of our population, and to discourage large non-essential gatherings, while allowing others to be get back to work and provide sustenance to their families and loved ones.
We also don’t know whether people who were exposed to the virus and developed antibodies are thereafter immune or resistant to getting infected again.
And we don’t have reliable data on when people start and stop shedding virus. There is anecdotal data from a friend who runs a lab that a man whose fever and symptoms had ended 14 days prior was still shedding the virus. But we don’t know if this is a rare exception or not. There is growing evidence that people start shedding the virus several days before they start developing symptoms, but we don’t know what percentage of those infected they represent.
So even if we do contract tracing as we should be doing, we won’t know who to guide into quarantine, or for how long.
Without answers to these and many other related questions, we are at a loss to formulate policy.
It is pathetic that our governments have not led better. By now China, which had its first case in November and knew about the virus epidemic by December, should have performed enough transparent, verifiable, wide and systematic testing to provide answers to the above, but it is hard to trust the Chinese government given reports that they underreported fatalities in Wuhan and Hubei province by as much as 3X, and that they have not been frank about the situation in the rest of China.
Some countries like Iceland and South Korea have done remarkably wider testing. As of March 13, South Korea had tested 3,600 people per million, compared to the United States which was at a globally low rate of 5 per million. But no country as far as I have been able to find has done a thorough systematic test to help us truly understand what we are dealing with. (Germany seems to be closest, but from what I have gathered, they have not planned on this simple but comprehensive test I propose below).
Our own government here in the United States should have gotten its act together and started preparing to compile proper data back in January or latest February (the CDC did finally authorize the beginning of what could be important data gathering), but it is hard to expect much from an Administration that was claiming this was a “hoax” into March and that did nothing to procure N95 masks or ventilators months ago, when it had the advance notice and possibility for leadership.
If we actually had global leaders, the best thing they should have done in early March would have been to coordinate a global lockdown – so, after a week to allow everyone to prepare, we would all have gone into home isolation for 2-3 weeks, at the same time, across the world. As it stands, we will be playing a game of Whack-A-Mole because of the different timetables being observed. The deficiencies of federal or world leaders is exposed during times like these.
So it falls onto the States and public institutions to do a Randomized Sample Study that tests BOTH for the presence of the virus (done through a nasal swab) AND for the presence of antibodies (done through a blood test).
An ideal test would include about 1,000 people selected in a way that is representative of the broader population and gather the following data:
- Presence of antibodies against COVID19, which indicates prior exposure and potential immunity (serology/blood test; finger pricking technology widely available);
- Presence of Live Virus, indicating infectiousness (antigen test/swabbing for presence of virus; strained supply, but increasing sources have started coming into market);
- Whether the subject has felt ill or had any symptoms over the last couple of months or at present (survey filled out by patient);
- Whether the subject has co-morbidities or aggravating medical history (survey filled out by patient);
- Age, gender, and ethnicity (survey filled out by patient).
If we repeat the above test once a week, for a course of 3 weeks, we would be able to discern so much information that we currently do not have, such as:
- What is the actual contagion in the broader population, and thus what is the actual death rate (not of those tested, but of those who actually are exposed);
- What is the percentage of the population group who have developed antibodies;
- What is the % of those exposed that experienced any symptoms;
- What is the % of the population group that is shedding virus, and how long do they shed virus, and what % do so without symptoms or after they have recuperated;
- How are different age groups, ethnic groups, genders, people with and without co-morbidities reacting?
Organizing a Randomized Sample Group like this is very hard, and many have stumbled along the way. Epidemiologists and statisticians are daunted by what the “Denominator” should be (ie, what is the population group being tested, and how do we make sure the testing will be representative). But we should not make perfection be the enemy of the good when we have such vital needs. Any of these population groups could do:
- Literally gather volunteers from the White Pages and invite them to participate;
- Invite a neighborhood like New Rochelle, NY to participate;
- Come up with an advanced algorithm and rely on a State’s agency to put together a representative group;
- Ideally partner with a State agency or Medical institution in an area with enough exposure to COVID-19, such as NY State, Washington, Louisiana, etc;
Relative to all the impact we could have for our world, testing costs are minimal (by my rough calculation after having researched the costs of the antigen tests and the serology tests, along with all the administration and analysis, under $1mm).
For those that think we need to leave all tests to the frontlines, let’s be clear here: we are endangering hundreds of millions of people by not having done this study already. It is not sustainable or achievable for every health care worker to be tested every day for months to go (it would require an exorbitant number of tests and administration and by the time you get those results, immunocompromised members of the family would have already been exposed).
We need to better understand the virus in order to properly tackle it.
This randomized test would help us map out a strategy exponentially better than the blind way in which we have been proceeding for 4 months now. I only wish we had started doing this a couple months ago. But time is of the essence so let’s go now!
LinkedIn Article Published April 8, 2020