As the U.S. heads into Thanksgiving and the holiday season beyond, new cases of Covid-19 are as high as they were in the first week of November 2020 and are quickly rising after two months of steady decline, even though the pandemic toolbox is fuller today than it was then.
One year ago this week, the Food and Drug Administration had just authorized the first at-home test and the first monoclonal antibody treatment, and there were no authorized vaccines. Hotspots flared across the nation as different states took different approaches to curbing the virus by requiring masks and limiting public gatherings.
It doesn’t fully make sense for the U.S. to be in this position today when we have an ample supply of safe and effective vaccines, we know how the virus spreads, and we understand the effectiveness of masks and distancing in limiting infection.
In many ways, the country is making progress. The fact that nearly 10% of children between the ages of 5 and 11 were vaccinated in the first two weeks they were eligible is heartening. Nearly all people who are hospitalized with Covid-19 are unvaccinated, underscoring the protective effect even for those with breakthrough cases. Yet disappointingly low vaccination rates in many areas means the virus retains its hold on the country. To end this pandemic, we must continue increasing vaccinations.
Unfortunately, increasing the number of Americans who are fully vaccinated is likely to be a slow process. Making reliable Covid-19 testing more widely available and better reported can help in the interim.
To improve a national Covid-19 testing strategy, it’s essential to distinguish between the various needs for testing and figure out how to meet them. First, as hospital emergency departments and doctors’ offices once again become crowded with people with respiratory illnesses, it is vital to distinguish those with Covid-19 from those with influenza or other respiratory diseases. Second, Covid-19 infection must be identified early in those who are at high risk of serious disease in order to respond with interventions such as monoclonal antibodies or the promising new antiviral pills the FDA is evaluating. Third, routine screening and surveillance testing must be increased across many settings and populations to identify new outbreaks. Fourth, it must be easy and affordable for every American to test themselves regularly to make family gatherings, social events, and a return to pre-pandemic activities safer.
In October 2020 — before vaccines and before the surge of the Delta variant — the AAMC Research and Action Institute, with which we are both affiliated, released its estimate for the number of daily Covid tests needed: more than 8 million tests a day. Yet as the virus surged through the nation once again through the fall and winter of 2020, there were never more than 2 million tests a day reported.
Today, the number of tests being conducted each day is unknown.
The availability of at-home tests has increased, but access to them is hugely variable and when individuals test themselves, the results are rarely reported to state or national public health authorities. Both of these problems must be fixed. Rapid tests have been difficult to find in many areas of the country and at most retailers cost $25 for two tests that are designed to be used by one person 36 hours apart.
While it’s a good idea to make a multigenerational gathering safer by testing everyone, testing 12 people on Thanksgiving morning is cost-prohibitive for most families, even at recently discounted prices. And a test that gives rapid results at home doesn’t require the intervention or knowledge of anyone other than the person taking the test. So unless someone seeks medical care for their symptoms or infection after testing positive, that positive result typically won’t be captured in the Covid-19 testing totals reported daily by the Centers for Disease Control and Prevention. Without knowing the scope of new cases identified by positive Covid tests, it’s impossible to understand with precision how progress is being made against the pandemic.
It will never be enough to know the number of tests that are made available or used nationally. It’s also important to know where they are being deployed and how they are being used and reported. For instance, use of 75 tests could mean one family testing each of three children weekly for the school year; one wedding where all guests are tested before entering; or 10% of the students in a large elementary school tested once. Only in the third scenario are the results likely to be reported to state public health officials.
Testing must be seen as a coordinated public health measure, not just something done to diagnose Covid-19 cases or for individuals wanting to clear themselves for travel, theater, and social events. To get through this winter, the U.S. will need more widespread and purposeful deployment of tests. Without a systematic testing strategy and local results of those tests, public health interventions such as masking, distancing, and travel recommendations cannot be effectively deployed.
The Biden administration’s announcement that it is expanding testing is a positive step. Now public health officials need a roadmap for increasing the number of available tests, clarifying how those tests are deployed, and ensuring that Americans have access to testing for the foreseeable future.
Understanding the scope of testing requires having a better idea of how tests and testing supplies are being distributed. Statistics describing the number of tests run or tests made available should clearly differentiate between those available to individuals for commercial purchase; those used in clinical labs; those purchased by companies to test their own workforces; those used for screening in academic institutions, public school systems, or other high-risk areas; or those used by hospitals and medical centers for diagnostic purposes.
Every American should have ready access to affordable or even free at-home tests and should also have clear, consistent guidelines on how often to test and what to do with a positive result. There is no uniform guidance or process on how to report infection. These gaps must be filled.
If living with the new normal means living with Covid-19, the U.S. should not be taking a haphazard approach to testing.
Atul Grover is an internal medicine physician and executive director of the AAMC Research and Action Institute. Heather Pierce is the senior director for science policy and regulatory counsel at the Association of American Medical Colleges and the director of policy for the AAMC Center for Health Justice.
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