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Short of a breakthrough vaccine, our only sure way to end COVID-19 before it kills or sickens millions more of us is to test every American every day. Imagine if we could do that and quarantine everyone who tested positive until they were no longer infectious. The virus would be fully trapped within days. Without the ability to spread to healthy people, our modern-day plague, whose annual death rate exceeds that of any American armed conflict, would be ancient history.
Yes, we will have to continue testing everyone, including those entering the country until a vaccine is available. As for compliance, it doesn’t have to be perfect to eliminate the ability to spread the virus. In epidemiological parlance, R0 – the number of people infected by one infected person – would be driven well below the critical value of 1, at which point the virus quickly dies out.
Compliance would be exceptionally strong thanks to the private market. Same-day timestamped cell phone photos (videos if there is concern that person X is showing person Y’s test results) of a negative test – tests, which have been approved and provided for free to everyone by Uncle Sam – would be required to enter the workplace, board a plane, frequent a restaurant, enter a store, or attend a school, college, or university. If the home tests weren’t perfectly accurate, you’d probably need to show several days of negative test results. These requirements would be established by market players and not by government decree. But every company would adopt such restrictions to keep their employees, customers and students safe. Even friends and families would need confirmation of negative test results to attend social events.
As Harvard epidemiologist Michael Mina and I recently explained, rapid, daily, at-home COVID-19 tests, little different from pregnancy tests, could achieve this vision. An ideal test would be to lick a piece of paper with a protein strip. The band would turn green if you tested negative and red if you tested positive. Your answer to red would be to a) quarantine immediately, b) notify your doctor, and c) take a standard PCR test (the standard test currently used nationwide) to confirm the result. You would leave quarantine when your daily test becomes and remains negative for several days.
Such rapid, immediate, and inexpensive ($1-5) tests are being developed by a handful of companies and individual researchers. But to catch and kill COVID-19 before hundreds of thousands more Americans die or get sick, the administration must do four crucial things.
The first is to launch a Manhattan Project to develop rapid home COVID-19 tests. The administration is investing money in the development of viable vaccines. It must do the same with rapid home COVID-19 tests.
Second, once developed, the administration must mail or otherwise provide, free of charge, an ongoing supply of these tests to all Americans.
Third, the administration must launch a Test for America campaign to convince the public that daily testing for COVID-19 is its patriotic duty and vital to its own health and livelihood.
Fourth, and most important, the administration must direct the Food and Drug Administration (FDA) to approve tests and associated protocols that allow real-time detection of the virus. The FDA focuses almost exclusively on diagnosis and essentially ignores or inhibits, through its rules, detection. Ironically, detection can dramatically improve diagnosis since those with red bands would be directed to get the “gold standard” PCR test.
Diagnosing those with the disease can help infected people and protect healthcare workers, but it’s a strategy for treating the sick, not saving the healthy. Real-time detection is the product of three test functions: accuracy, frequency, and speed.
The PCR test involves a healthcare specialist inserting a long, somewhat uncomfortable swab deep into your nose. The swab is sent to a lab, where it stays for days before being analyzed, after which the results and a bill for $50 to $100 are sent to you. In the meantime, you may have spread the disease believing you were healthy. You may also have become seriously ill without knowing the cause.
This PCR test does a wonderful job of detecting COVID-19, even in those with very low levels of viral load (number of viral molecules), but it does an absolutely terrible job of fighting the epidemic. It’s unpleasant, expensive, inconvenient and slow. No wonder nine out of ten people infected with COVID-19 are never tested. Multiply PCR’s high accuracy rate by its extremely low frequency (zero for most people) and extremely low speed and you have extremely low real-time detection. You cannot detect, let alone defeat, an enemy flying blind. But that’s exactly what we’re doing by relying exclusively on PCR.
It’s time to fight this war with a super weapon, not to continue to rely on a test that has clearly failed in what should be the central mission of the FDA and the CDC – to detect, isolate and, therefore, destroy our fierce enemy, COVID-19.
