What now for COVID-19? Alternatives?

The rhetoric after the latest COVID-19 update has changed, slightly. The discussions are, appropriately, about the burden of COVID-19, but, also, about how we get back to normalcy. I admit I am optimistic about this contagion. It is not polio, small pox, or HIV. People were paralyzed, died, or got AIDS. The frequency of serious outcomes was nearly 100% for each person infected. COVID-19 is not like these, which is reassuring, at least in comparison. COVID-19 is serious but looks more like the 2009 H1N1 flu pandemic than it looks like those mentioned above. 

The reports of death and burden of illness are daunting to hear. I understand the public’s concern as I share it. My other concern is, though, that the reports are burdened, themselves, by uncertainty. In my last post I pointed out that plans for testing must be concerned with the imperfections of the test, overestimating, perhaps the burden of illness. I hoped that knowing of those imperfections of testing might be reassuring.

However, I am not a social psychologist, and I am not sure if that knowledge is helpful to you. I remember a poignant example of a movie depicting a nuclear accident (The Day After), shown one week before a national survey about risk perception, being blamed for an overestimated risk of dying of a nuclear accident. The movie was seen by over a million people, influencing, it appeared, the public’s perception. 

The point is that our perceptions are susceptible to fear, even if unreal. Knowing the imperfections of testing is a truth, but is it helpful to know that reports of COVID-19 may be inflated by error?

I admit, I don’t believe that knowledge, alone, is the cure for our fear and that knowing more will be the impetus to return to normalcy. We may be so sensitive to reports of those dying we may need to hear of none before we move on. The problem with this is that the reports will continue, unless the contagion recedes, but we can’t continue to act as we are as a society until it does recede. 

So, here are some other ideas, suggested by our leaders, that we must ponder as we decide what to do. I will offer my opinion as a starting point for debate. And, then, I will offer what I think we need to do to end our isolation from our social response.  

• Get a serum antibody test on everyone.

The serum antibody test is being touted as an answer to a return to normalcy. Some think that it would be soothing to learn that we have been infected, but survived. Some think that if we have survived and have the antibody, we may be COVID-19 immortal and be given an “immunity passport”. This test, then, may give us hope to return to work, or back to normalcy. 

These are hopeful, but not necessarily true suppositions, and the test, even, is not yet available. Hence, these hopeful ideas are, presently, unfounded.  First, we do not even develop life-long immunity to flu, a contagion we all are familiar with. We keep getting it seasonally, so we may, also, face the same with COVID-19. Second, just because antibodies are present for COVID-19 does not mean they confer immunity. Consider the fact that antibody testing after the 2009 H1N1 flu epidemic found that only about 50% of people had antibodies six months after being infected (worse in those only vaccinated; about 30% had antibodies at six months). 

Third, the antibody test is imperfect, with estimates of 5-10% false positives and 5-10% false negatives. The companies dueling to produce the test report varying true/false rates but none has faced clinical scrutiny. If we want to assure that it is safe to return based on a test result, can we afford an imperfect test? The imperfect test means that some with the disease will test negative potentially continuing to spread the disease, while some will test positive but will have a false sense of security.

Hence, immunity may be fleeting, and when to test becomes an important consideration before wide-spread, unplanned testing. While immunity may, alternatively, be long-lasting, the antibody test will not tell us that. There should be some serious research planning before wide-spread use of a test that may not help us.

• Better science using random samples with gold standard tests.

An alternative to the present reports is to improve science. This suggestion goes like this. If we could accurately assess the burden in the well and ill, we could plan with confidence. An astronaut recently commented that the way he learned to be calm in space was to be fully informed and knowledgable. He, too, equates calm with knowing.

This suggestion to improve the science of epidemics warms. It may surprise you to know that we don’t even have a scientific plan for assessing when flu is here, or how big is the burden. Testing for flu, even, is haphazard. If we were to improve our ability to know the true burden of any malady, people would be able to plan fearlessly. 

The way to scientifically test the burden in the well is to perform gold standard tests (positive only in diseased people) on a random sample, not all people. We don’t have enough high quality tests to test all, so we have to test fewer. Choosing who, then, must be done randomly to circumvent the problems of using inferior tests in everyone. 

The place to do random testing would be, for one, the work force. If the prevalence is low, workers might be assured to return to work while following universal infection control practices. The potential problem with this idea, however, is that the prevalence may be high. However, this might be equally reassuring if many are positive, but well.

Both the idea to stop all testing in the well due to imperfections in the test, and a call for random sampling to accurately assess the prevalence, require fewer tests. The second requires an improved research structure, and, perhaps, this experience with COVID-19 will push us to restructure the NIH and CDC to be better science agencies for epidemics and disease burdens. There is no reason to not have the capability to do random samples of disease burdens in the workforce, or any public domain. I have written essays asking for better science, and suggesting how to do that. Maybe COVID-19 will spur a better scientific response to the next contagion. 

• Test only the ill, and test for every infectious virus.

This idea has merit. Presently, we do not uniformly know how to assign a cause of death, and to assign a cause of death to a specific infection in the middle of an epidemic of that infection will inflate COVID-19 as a cause. Also, right in the middle of all this, the CDC notes an uptick in flu. What infection is causing death? We won’t know this unless we test everyone who dies for all viral agents. The hypothesis is that COVID-19 is not the only dangerous culprit out there, and if the public knows this, they may develop a better understanding of the natural history of COVID-19.

• Wait until we get a treatment, or a vaccine. 

These are hopeful, but unhelpful recommendations. First, it took years to find a treatment for HIV, and we can’t be at home for years waiting for a COVID-19 treatment. We don’t know how long it will take and waiting for a treatment is untenable.

Also, the vaccine is far off. RNA viruses can be tough targets for vaccines. We still don’t have a vaccine for HIV, for example, despite years of efforts. Will the COVID-19 vaccine come sooner? Also, while we have a vaccine for flu, it is not universally effective. The CDC estimates, some years, that the vaccine may only be 10% effective. I assume a vaccine will be available for COVID-19 one day, and, based on other epidemic experiences, that the vaccine will not be perfect. But, for sure, we can’t sit in our homes letting our jobs go while waiting for a vaccine.

I look forward to comments on these opinions. The public deserves better data and fewer speeches, maybe blogs, too, to be fair. Maybe the public will learn to better assess risk when they are given better estimates. But, we must also consider that science will move too slowly, or that poor science is already so much the norm that we won’t believe anything until reports of those dying diminish.

Ultimately, perhaps, it will take the courage of our leaders to return to normalcy just like those who have already bravely faced the contagion in the workplace. It would be nice to see our President, CDC leaders, NIH leaders, pundits in the workplace delivering food, fist pumping and showing their leadership where it matters most. The people who were forced to normalcy in the workplace during this epidemic, those in grocery stores, driving buses, delivering food at the curbside, or keeping goods delivered, may be the ones we should not only honor, but follow?