Just tellin’ it like it is COVID-19 Series #1: We need to wake up and tackle this together
Note: This is a repost of my original LinkedIn article published on November 1, 2020.
Disclaimer: For the purposes of this article, pre-symptomatic and asymptomatic will mean one and the same because who gives a damn if you’re already sick because of a failed detection system.
<Figure 1: 7-Day change of COVID-19 cases as of October 31, 2020 (Source: WHO; License: CC BY-NC-SA 3.0 IGO)>
It’s no secret we are in a mess of a situation with COVID-19 management right now. As I write this, most of the world is experiencing a new wave of cases (Figure 1) with only a handful of exceptions. By now, almost all nations have stabilized in public health policies and testing capacities, but the number of new cases keep accelerating (Figure 2). Obviously, what we are doing is just not as effective as it needs to be.
<Figure 2: Daily global COVID-19 cases up to October 31, 2020 (Source: WHO; License: CC BY-NC-SA 3.0 IGO)>
With all the things we are doing to stop the spread of SARS-CoV-2 and now with months of experience with the measures, we can boil down the current containment failure to three root causes: human stupidity, viral mutation and asymptomatic spread.
There is literally nothing we can do about COVIDiots and the virus mutating because both are natural phenomenon that are impervious to human intervention, and not the least for the lack of trying, especially with the former. But we can do something about asymptomatic spread. We just simply are not.
Here’s reality for you.
The World Health Organization (WHO) COVID-19 Q&A (9 July 2020) admits that asymptomatic cases happen although “more research is needed in this area”, and “infected people appear to be most infectious just before they develop symptoms.” South Korea’s Ministry of Health and Welfare COVID-19 FAQ repeats this sentiment. But the US CDC came around and revised SARS-CoV-2 testing guidance on 18 September 2020, stating “Due to the significance of asymptomatic and pre-symptomatic transmission…” and the UK NHS has published a sample pooling protocol for asymptomatic samples on 28 September 2020. The European CDC also plainly lists the many studies supporting the significance of asymptomatic transmission. (References not provided as they can be easily searched online)
(I do find it quite interesting that the countries reporting issues with testing turnaround are the ones actually admitting to the significance of asymptomatic spread)
It’s no secret that experts were pointing out the significant population of asymptomatic cases as early as June, ranging from 18% to 45% (Nikolai LA et. al). With recent reports of SARS-CoV-2 positive cases lacking core symptom development (i.e. cough, fever, loss of taste/smell etc.) reaching up to 86.1% (Irene Petersen and Andrew Philips), it is pretty clear shit hit the fan a while ago and it is starting to rain down on all of us.
What I find astonishing is the fact that, despite such a clearly defined unmet need and urgency, how little we are actually doing to deal with it. Achieving herd immunity without a vaccine is a pipe dream that looks dumber every day, while sustained lockdowns (sorry UK) will probably harm more people by crushing them under debt or poverty. So it’s actually going to take some more work to figure out a solution. What a surprise.
I must first establish that only a screening program would be capable of detecting asymptomatic cases, since, by definition, all modern-day diagnostic procedures are undertaken only with reasonable suspicion of injury or illness - which in this case is symptoms.
Not to mention there is a serious physical limitation on how many tests can be run with PCR since it requires a whole infrastructure around it. I understand when certain public health authorities with PCR as the near-exclusive testing option choose not to pursue screening programs for asymptomatic cases due to resource constraints and cost-benefit situations. As great as molecular testing is for confirmatory diagnosis (and it is the best technology), there are simply not enough resources in the world to roll out a PCR-based screening program of the magnitude required, even after considering pooling tactics.
Rapid serological tests are a better option than PCR since it is lighter in weight. Abbott, among developers are attempting to bridge the gap by developing instrument-free point-of-care tests, but so far regulatory approval has only been for a professional healthcare setting.
There are many reasons requiring professional healthcare infrastructure for a COVID-19 asymptomatic screening program is bad. First, you are actively congregating a bunch of healthy people and sprinkling a few infectious individuals in their midst. Secondly, the elapsed time before developing symptoms, then going to your healthcare provider, get the order for testing, then get sampled, then wait for results while the laboratory slogs through a backlog all adds up to a stupid result of encouraging infectiousness to develop – the very thing the system was supposed to prevent (McAloon C et. al). If you even develop symptoms at all. Then there is the issue of backlogs or bottlenecks in testing at a limited number of facilities, the reality that testing cannot occur 24/7 in most of these locations due to staffing issues etc. Yeah, impossible.
At-home rapid serological testing is the closest existing viable alternative, and there are certainly several developers, many experts and a few elected officials screaming at the top of their lungs to get inexpensive, instrument-free rapid tests approved for home use. But there is a current deadlock with regulatory authorities due to the issue of risk associated with an inevitably lower-performance diagnostic ending up in the hands of billions of people that have no idea how to properly interpret the test results. (How I view this issue will be addressed in a later post)
I found that MIT is working on an AI-based COVID-19 diagnostic by differentiating coughing sounds and XPRIZE has a Rapid COVID Testing competition currently underway but further searching high and low in the internets and listening through my professional grapevine have revealed nothing. Sure there are the developers trying to repurpose rapid tests for home use, but those of us in the IVD industry know how difficult it is to develop a one-step rapid test and more difficult still to produce an instrument-less testing scheme – both crucial for widespread home use - and still maintain reasonable performance.
I don’t know if it is technology entrenchment by legacy IVD developers, the rigidity of regulatory authorities, the fact that COVID-19-related grants have almost all been spoken before the time of this writing despite the fact that even today new discoveries are being published that may have provide clues into better diagnostic approaches, or if there simply isn’t enough money or glory in it for our best and brightest to pursue. (Although I must admit that claiming to have developed a cure for COVID-19 sure sounds hella glorious) Whatever the reason – and it’s probably a bit of all of them combined – we simply are not doing enough to stem asymptomatic transmission of COVID-19. And isn’t stopping the spread the best way to get rid of this plague?
If you happen to be a member of the healthcare industry and are expecting that vaccines alone will magically solve COVID-19 you are being irresponsible if not outright delusional. It’s about time that more of us gave this problem of asymptomatic spread of SARS-CoV-2 a serious look and all pitched in to solve it.
Other topics to be in the series (not in order):
What makes an ideal COVID-19 screening test and why? (Risk-benefit, intended use and important considerations)
A different take on how to deal with COVIDiots (We should also be assholes too)
COVID-19 passport: The pandemic equivalent of the flying car? (Reality and considerations)
My proposal for a COVID-19 screening program (shameless plug)
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