Reminiscences of my prior experience in epidemiologic practice might influence some bias to current approaches in COVID-19 epidemic.
My first job after medical school, as a doctor, was an epidemiologist position back in Russia, in Karelia near the Finland border in late 1960s. A rural place with scattered collective dairy and fur farms, lumber forest harvest factories surrounded by abounded GULAG camps. Periodic local epidemics were casual as fact of life. Dysentery, hepatitis A among people, sporadic anthrax, tularemia, foot-and -mouth disease among animals. Every epidemic had been managed from the start according infectious epidemiology rules: isolation, testing, hospitalization, local quarantine, disinfection, sanitary. In some occasions, the efforts to decrease the epidemic failed despite all standard efforts. One of the suspected culprits was the continuation of testing. When the testing was limited only to clinical necessity, the epidemic abruptly subsided. Until today, I do not have a rational explanation. Hypothetical thoughts are still lingering.
Some excerpts from basic epidemiology
Common sense and humans experience determine one of the main infectious epidemiology rules as the detection of infected to isolate from the population, as a rotten apple. Testing is an apparent solution. This post is intended to explore the testing notion as epidemiology tool to overcome the spread of COVID-19 epidemic in the USA.
Testing of patients, which require hospitalization or other clinical actions, is an apparent necessity for the differential diagnosis and effective treatment. The rest of testing is the epidemiology work routine. The diagram below presents main directions of this work. Testing with a clear plan of actions, which is following positive or negative result, only are part of them.
The importance of each component is different depending on infection, local conditions, morbidity, mortality etc. etc. In the case of COVID-19 epidemic, immediate contact testing prevails institutional contacts, while screening testing within a particular facility is incomparably more significant than the exposure testing to individuals. The latter issue requires special detailed discussion, a special post.
Below is the excerpt from PRIORITIES FOR COVID-19 TESTING section Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19) by Center Disease Control and Prevention (CDC). Revisions were made on May 3, 2020
The entire document is pointing in the wrong direction from the epidemiology perspective. The serious objection would be on the division for High priority and Priority. The division itself and the content of the document reflect, in my view, misunderstanding by CDC strategic goals of actions in the current epidemic.
Practical epidemiology perspective
Below are my considerations regarding priorities in testing based on my prior experience as a practical infectious epidemiologist.
Hospitalized patients with symptoms are already isolated in the hospital. Their test should be done for the differential diagnosis followed by appropriate treatment.
Healthcare facility workers, workers in congregate living settings, and first responders with symptoms are already ill. Their testing is not a priority, but isolation them from contacts during their professional duties would be a priority with following testing just for clinical handling them as patients.
Residents in long-term care facilities or other congregate living settings, including prisons and shelters, with symptoms are really a high priority for separation them from the rest although this epidemiologic action would be right to do immediately even without a testing.
The testing of contacts is the necessity for localization of the source of infection. Although in a case of COVUD-19 epidemic this is a difficult task as usually in an airborne infection, an attempt would be justifiable.
“Persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to: public health monitoring, sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans.” These groups are a real priority for testing from the epidemiological approach, although they are in the end of the list of priorities. The main problem is that there are not local plans for such prioritizing, at least they are not in the public domain. For example, from Michigan Department of Health and Human Services
This document adds critical infrastructure workers category. The rationale is to diagnose in time infected and take them out for quarantine. When? How often? How? Etc. This document is in line with Michigan medical officials’ uninformative briefings.
Summary of epidemiological aspect of COVID-19 testing
First. Separation of the clinical and epidemiologic lines of testing should be clearly formulated in plans and actions.
Second. From the epidemiology perspective, the indication for testing of contacts includes two main groups: immediate contact with a clinically ill person and determination of individuals for testing in a contacts group. Aggressive and fast testing of infected and especially contacts in congregated living, public, and work settings is effective in the beginning of the epidemic. Screening is important in the case when the source of infection’s spread is unknown. However, screening brings mixed results when the epidemic is to some degree contained.
Third. 100 million tests per month as a maximal goal and 1 million tests per day is considered a realistic number. Unexperienced tracers, reluctant or over scared subjects of tracing, delayed or misdirected test results, and numerous other details brings only chaos. Testing become an exercise in futility. Lines of people seeking a test are also a way of potential virus shedders concentration. Most of them came for test due to the pandemic of scare, but some for a reason.
Fourth. The number of tests, as evidence of success in curtailing the epidemic, inevitably leads to relaxation of specimen’s collection, transportation, and the tests’ quality. The latter is accepted by the society as the Sun’s rise on the East. This issue will be discussed in a separate post.
The epidemiology theory orthodoxy should be adjusted to the current local conditions, economy and population attitude. My experience with epidemic on the ground suggest that the mass testing in wrong. It is a pretention of doing something with minimal positive results for an individual and maximal negative results for society: draining resources, expending the bureaucratic segment in the society, temptation of intrusion in private life under the pretense of common good, and increasing population’s anxiety. The epidemic will go by its own way determined by the rules of biology when society can correct it through diminishing the clinical damage to vulnerable people.
Everything in this epidemic is knead in sticky dough of politics. Only vaccine can compete with testing as a political issue, while the mask wearing is undisputable champion of the political divide.
Perhaps, the last. Testing infatuation already has taken a toll on the society’s mental health. Do we want to wince by our or somebody else sneeze? Do we want to measure the body temperature on permanent basis? Especially, we know how relative is this physiological parameter. Eventually the chronic fatigue syndrome will be the most frequent diagnosis.
I do not have an illusion that this post will change the course of actions during the current epidemic. Hopefully, my remarks regarding testing during an epidemic might be useful for infectious disasters in the future.