Why the right testing strategy will help us reopen our medical facilities amidst COVID-19 pandemic. By Rashid A. Chotani
To meet COVID-19 head-on, the American medical community has had no choice but to make the pandemic our primary focus. We have been forced to retool our hospitals by opening more beds, canceling elective procedures (including non-emergent surgeries), converting operating rooms for intensive care units, and a whole lot more.
But we are beginning to see that turning our attention away from other illnesses and conditions comes at a serious cost; an analysis by The New York Times demonstrates that more Americans have died of non-COVID-19 causes in the first one-third of 2020 than in the first one-third of 2019. Were these deaths also the result of COVID-19, and simply not recorded as such? Or have we been paying so much attention to COVID-19 that we have neglected other threats?
As we continue our fight against this pandemic, we must adapt to meet the needs not only of those infected with SARS-CoV-2 (the coronavirus that causes COVID-19), but also of those Americans who necessitate medical help unrelated to the pandemic.
A vital step forward is reopening our hospitals and clinics for elective surgeries and other procedures that cannot be handled via telemedicine. But is this a step we can safely take? A recent report from Nature suggests that as many as 40% of infections occur in the days before patients become symptomatic themselves; in order to safely reopen our hospitals, we need to make sure that doing so won’t precipitate the resurgence of the disease.
We argue that a vital approach to keep this risk down is to adopt an intelligent testing strategy for SARS-CoV-2. This strategy must achieve two goals: We must test patients to keep our hospital staff safe, and test hospital staff to ensure infection does not transmit from the hospital back into the community.
The first challenge is to reduce the risk that an asymptomatic patient will accidentally spread the virus when coming in for an elective procedure. The currently available tests will not catch every such case, but they can identify the vast majority. When coupled with the use of personal protective equipment (PPE) – which is no longer as scarce as before – such screenings could make a considerable difference in our ability to reopen.
Testing asymptomatic patients requires that we use different types of tests and interpret them together to achieve higher accuracies. The Polymerase Chain Reaction (PCR) testing for viral RNA is the first test to become positive, doing so around 4-5 days after infection, but it also has a high false negative rate and becomes less accurate over time. By contrast, antibody testing typically starts to catch positive cases by day 7 after infection, but becomes increasingly accurate over time. By testing patients on the day before or day of their procedures, we are more likely to catch asymptomatic cases.
Testing medical staff represents a different challenge. Regular testing of large asymptomatic groups can entail a logistical and financial burden upon the hospital or clinic. To meet this challenge, two plausible solutions are point-of-care antibody testing and pooled testing.
The point-of-care (POC) antibody testing approach has the ability to test large numbers of suspected cases even without swift access to a central laboratory. Although positive POC antibody test results would require confirmation by PCR or laboratory testing, the team can take provisional protective actions while awaiting those results. Additionally, antibody screening can reveal the prevalence of prior infections and shed light on the prevalence of SARS-CoV-2 in the overall population being examined.
The alternative solution entails the use of “pooled testing” that enables the testing of large groups with relatively few tests. The concept is simple: instead of testing each individual separately, the samples from a large number of individuals are divided into a few groups, so that fewer need to be run. If the test is negative, the entire group is considered free of the virus; if the group is positive, subgroups are then tested until the positive individual or individuals are successfully identified.
Recent experience shows that a single positive result from RNA testing will still test positive after the addition of 63 negative samples. Once we have tested enough to understand which populations are at a higher or lower risk, we can then tailor the size of each testing group accordingly, thereby further minimizing the number of tests. The use of pooled testing shall enormously reduce the burden on healthcare amidst this pandemic.
There is no doubt that for our health system to work, it must not only meet the demands of COVID-19 patients, but concurrently be able to continue to treat other unrelated illnesses and injuries. Hospitals and clinics must reopen. But to reopen safely, they must employ intelligent testing strategies that embrace both viral RNA and antibody testing. Only then can we provide great care that defies SARS-CoV-2.
Dr. Rashid A. Chotani is a physician scientist and infectious disease epidemiologist. He holds appointments as the Medical Director at IEM and VP Medical Affairs at CareLife Medical, with extensive experience in outbreaks, epidemics and pandemics. Contributing Team:
Syed S. Ashraf, Charlie Maze, Faisal H. Cheema, & Terry Clark Dr. Syed S. Ashraf is a Board-Certified Internist and Managing Partner at Carelife Medical in Northern Virginia providing clinical guidance and expertise for COVID-19 screening process. Dr. Charles Mize is the Chief Medical Officer for U.S. Health Defense and is an Emergency Medicine specialist with extensive international and medical policy experience. Currently he is providing emergency medicine care in Alaska and is actively involved in developing COVID-19 treatment protocols for different organizations.
Dr. Faisal H. Cheema is a physician scientist, specializing in basic sciences and transitional & clinical research. He holds a research leadership position in a large health system and also has a faculty appointment at the University of Houston College of Medicine Dr. Terry Clark is a General Surgeon, Fulbright Scholar, Executive VP, & Chief Medical Officer for Boston Biopharma. Boston Biopharma is providing point of care antibody testing test-kits for COVID-19.