Tests were the first major new tool we had during the COVID-19 pandemic. Then came treatments like that from Gilead Sciences Inc.
Remdesivir (now called Veklury) and the monoclonal antibodies. And the grand finale? A range of super potent vaccines.
But even as vaccination rates go up day by day and the number of cases and hospital admissions go down, Dr. Michael Mina doesn't think it is time for labs to shut down. The Assistant Professor of Epidemiology at Harvard T.H. The Chan School of Public Health still believes that we should continue to focus on testing, although we need to get smarter about how and for what purpose we test.
"Things need to shift more to what I call peace surveillance," Mina said during an interview on May 24th. “The pandemic is not over yet. Everyone just wants it to be over. But as much as we want it to be over, we can't pretend that millions and millions of cases are not happening around the world. "
And part of that depends on getting rid of that unified approach to testing. PCR, antigen or rapid molecular tests each have a different task. But 15 months after this pandemic, they are still not being used properly. For the future, through the light summer months and into a possibly harder autumn and winter season, a better testing strategy will be required.
"We need to put systems in place to determine if there is a silent outbreak that could ultimately affect the unvaccinated," he said.
Read on to understand why Mina thinks we should all have one or five COVID-19 tests at home this winter, what he means by "test to stay" and why it failed, too many Put emphasis on PCR tests instead of rapid tests.
Market observation: Can you describe how PCR and rapid tests are currently used in the US?
Dr. Michael Mina: It's a hodgepodge of semi-useful approaches. What we are seeing is this massive confusion because the CDC swung 180 degrees almost overnight, from actively asking people to continue mitigation strategies and saying, a few weeks later, don't. We don't want you to test anymore. This runs the risk of confusing a lot of people.
(Editor's note: U.S. health officials flipped the script on the country's COVID-19 testing guideline last month, telling the majority of Americans who have been fully vaccinated that they no longer need to get tested for the virus if they see someone who tested positive for SARS-CoV-2. This came just two months after Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention, urged Americans to start mitigation measures like wearing masks and socializing Distancing to remain patient.)
But we want to keep testing and making sure we don't miss any outbreaks. We need to put systems in place to see if there is a silent outbreak that could ultimately affect the unvaccinated. Perhaps it happens to both vaccinated and unvaccinated people.
Things need to move more to what I call peacetime surveillance. The pandemic is not over. Everyone just wants it to be over. But as much as we want it to be over, we can't pretend there aren't millions and millions of cases around the world.
We missed the boat by using tests to slow the spread. We failed miserably as a country. But now we have the opportunity to use tests more appropriately. Tests will be associated with a lot of trauma; it is associated with that terrible year of COVID. But only when we test do we know where the virus is. It's just our eyes. It doesn't have to be a big process with big connotations.
Market observation: Would this be essentially a public health surveillance system?
Mina: That is exactly right. There are many different ways to do this; The more passive, the better. Of course, when we have a test of sewage systems it is very passive. This is not your average, everyday joe. But we will still need reactive tests.
So far we haven't really set up dynamic systems. They all said we either test or we don't test. It was just a terrible, terrible mistake to look at testing this way. If you don't have cases in your community, why should you test all of them in your community twice a week? And if you have a lot of cases in your community, why not test everyone every day for 10 days and remove them completely from the community?
Hopefully we'll see that in the future. If cases arise in a school or workplace, then a workplace would have a supply of rapid tests. Instead of closing because we have an outbreak, we can just test each one every day for five days. At the end of five days, we'll know we've caught everyone who had to be caught. And we would have driven the outbreak away. That is the idea of "test to stay".
Then you can say there's an outbreak, but we don't have to close the whole school for a week. It is extremely damaging to society when you do something like this. We could keep it open and test all of them. The only reason we close entire things during an outbreak is because we don't know who is positive. But if we know who is positive and who is not, then we don't have to close. The next wave of cases that could arise in the fall and winter will be "Test to Stay". This is my hope.
Market observation: If this is the case in the fall and winter, then could things stay open more consistently?
Mina: We're not going to have these big pandemic waves across the country. We will likely see a resurgence of cases in November. But it won't be this massive overwhelming spate of cases. It will put out small fires one at a time. These tests will help us with that.
Market observation: Is the US relying too much on PCR testing right now?
Mina: We have this weird infatuation with PCR in the US in that we don't allow tons of potentially much more accessible, much cheaper, rapid tests. One of the most damaging things about this pandemic is putting so much weight on the PCR test. There was a time when test results were delayed by 10 days and millions upon millions of people were tested or were waiting for a test that would come back 10 days later. Every single one of these tests was 100% useless in terms of slowing down the transmission.
The White House is going to much more effort to get contracts with PCR laboratories. It's a massive mistake. I helped build what is now the highest throughput PCR lab in the country at the Broad Institute. I have nothing against PCR. But when it comes to meeting a population where they are, we want tests that people can easily do in their spare time.
Market observation: Should PCR testing be reserved for diagnosis prior to treatment?
(Editor's Note: Gilead said it is up to the prescribers to decide who will be treated with Veklury, although patients must have tested positive before being treated with therapy. The Monoclonal Antibody Therapies, developed by Eli Lilly & Co.
Regeneron Pharmaceuticals Inc.
and Vir Biotechnology Inc.
require a positive test, either PCR or antigen, before treatment is initiated.)
Mina: It could be, but I would say if it is going to be a couple of hours before you get your result back, why not do a quick test first? If it's positive, you'll have your answer in 10 minutes instead of three or 10 or 12 hours. Sure, you can get a PCR test if you want, but you can start treatment right away. If it is negative and you want to give remdesivir and you want to be sure that the symptoms are truly COVID related, then do the PCR test. We stay in this boat of thinking, it's either this or that, but a quick test is so cheap and so easy.
There is another class of tests that I think will be important. There are the rapid molecular tests, and they are not necessarily as sensitive as a real laboratory PCR. But they're more sensitive than an antigen test and will give you results in half an hour or so. Every school nurse should have 10 of these new rapid molecular tests on hand and have them on hand when a child walks in. You don't want to take a swab and send the child home. Take a swab right away. Let the child sit in the chair for 30 minutes. And then in half an hour you will have really accurate results that are almost laboratory quality.
There is no real need for PCR testing in a lab anymore unless you are in a hospital.
Market observation: Given the surge in vaccination rates in the US, how is the way individuals and organizations should think about testing changing?
Mina: I think everyone is confused there. CDC has not helped on this front. What to do if 70% or 60% of your workforce is vaccinated? We have really entered a new era of use that no longer consists of suppressing fiery outbreaks. This boat has sailed. In many companies and many schools and universities, they all tested very frequently to either stop the outbreaks from spreading or the risk was so high that they tried to prevent new outbreaks from spreading on a daily basis. We saw that in colleges all year round. That actually worked quite well.
But with 60 to 70% vaccinations and seasonal declines in cases, we see less need for this type of proactive testing. The way businesses and society should start thinking about testing now is reactive – but effective reactive – testing. We don't want reactive tests.
While it's as simple as anyone who works at Company X, you have five tests at home. Well-funded companies can. And when we have an outbreak, we may do it floor by floor, wherever your potential contacts are. When you have a potential contact who is positive, test yourself and your family for the sake of it. Test yourself at home for the next five days before going to work. It takes 30 seconds. You don't have to store thousands of them.
Maybe there comes a point where we believe who cares if you are vaccinated and get infected? We will reach a point in this pandemic where we will have the luxury of being able to say that exposures can indeed be viewed as a benefit. If you don't get sick from it and are already protected, consider it a natural booster.
This is how our body works naturally. That's how children work. You start with a cold. When they're five or six years old, they'll stop having a runny nose. When they're 30 or 40 the same little people are all grown up and you or I can go and we can go to a daycare full of these little coronaviruses and not get sick. Not because these coronaviruses cannot make us sick, but because we have been naturally fortified hundreds of times in our lives. There is something to be said when you get to a point in a pandemic where you have enough people protected that the vaccinated will say it's not that bad. I've just been exposed. I didn't get sick at all. Until we get to the point where we don't make other people around us sick, like when we go to a nursing home, we can't take that approach. We have to be a little more cautious.
We are not all Superman and can run into a room full of SARS-CoV-2 and say, I am being super strengthened here. That’s a bad idea. But I think we'll make it someday. It is important to remember that people have to live with viruses like this. Our ultimate goal shouldn't be zero cases. There should be zero deaths. They are different things. And they will require different levels of testing.
Market observation: It sounds like the US can leave this kind of one-size-fits-all-for-all American approach behind and find ways to specialize in who gets a test, what type of test and in what scenario?
Mina: That is exactly right. One size doesn't fit all. So far we've just taken pretty much the least scientific approach to testing in this pandemic that we could have taken. If we had introduced different types of tests earlier, in September, we could have stopped the massive outbreaks of winter and saved hundreds of thousands of lives. We didn't do that. But I hope we learn slowly. We're going to leave this unscientific approach to testing behind.
These questions and answers have been edited for clarity and length.
Read more A word from the expert interviews:
• Breakthrough infections in people who received their COVID-19 vaccination are very rare. But because of this, Rick Bright wants the CDC to restart sequencing of all virus strains.
• "The envy of the vaccine is real," says a Cleveland Clinic pediatrician. Here's what she tells parents and teenagers about the COVID-19 vaccine
• How 6 Feet Became 3: Meet a doctor in the emergency room who has research showing kids are still safe with the new standard of social distancing in school