COVID-19 tests that can be used anywhere, provide results in less than an hour, and potentially cost a few dollars or less are being mass produced. Connecticut has received close to 300,000 thousand such kits from one source, and expects to receive 1.07 million within a few months. Can these be used to quell the epidemic?
While development and manufacturing of these tests has been rapid and dramatic, relatively little attention is being paid in the U.S. to using this technology to control the epidemic. But Europe is ramping up tests of mass testing as a strategy for controlling the pandemic. What about Connecticut?
Two parallel efforts are needed: projects to refine and better understand the capabilities of the rapid antigen tests as used in the community, and use of information technologies to provide individuals with credentials that make optimal use of test results.
To capitalize on these advances in technology, projects need to be undertaken to 1) adapt these tests for home testing; 2) determine accuracy of the home tests in the community, 3) conduct studies of the impact of using these tests by all at risk individuals in a community to stop the spread of the virus.
Many of the antigen tests are currently only authorized to be used by providers. Yet they are as simple to use as a home test for glucose monitoring or pregnancy testing, and some require no equipment. While press coverage seems to emphasize that some of the antigen tests are less sensitive than the gold standard PCR tests, in reality PCR tests — any tests — are not always in agreement. If the test is not consistent with the symptoms and other data, it should be confirmed by further testing. So let’s get testing out of the parking lot and into the home.
In parallel with understanding the capabilities of these tests, computer and smartphone technology applications need to be developed to record results and allow individuals to use their test results as a credential. These programs would aggregate information from incorporate information on an individuals history of COVID infection, vaccine use, and antibody levels as well as laboratory and home tests, contact tracing, symptoms, and other sources to provide a credential similar to a boarding pass. The “Covid Credential” could summarize results and be available for several purposes: 1) verification of an individual’s status for their school or workplace; 2) admission to facilities, events, and resources for travel; 3) reporting test results for public health surveillance.
Examples of the potential of using this approach to control the epidemic and minimizing the impact of the pandemic on the economy follow:
UNIVERSAL TESTING: Early in the course of the pandemic, Sir Richard Peto and others advocated universal testing for COVID-19 coupled with appropriate quarantine as an approach to controlling the pandemic (The Lancet, 395, May 2, 2020). Peto estimated that a study with 200,000 people with 90% compliance would “enable policy to be based on real-time evidence.”
When Peto made this suggestion, limitations on the number of available tests and their cost, coupled with requirements for the use of tests for clinical care made it not feasible to implement it. With the capabilities provided by the availability of massive numbers of tests, this strategy deserves serious consideration. And while Peto discussed using the testing in a truly universal way – testing everyone in the U.K. – it would be more feasible to use it to control COVID hotspots – by mass instead of universal testing, or test a subset of people who are at high risk.
A fraction of the Connecticut’s kits could be used to test all individuals in communities with a high incidences of COVID. All individuals in test areas would be provided with self-administered testing kits, or use other sources of testing as they choose. Test results would provide them with a credential if negative; or ask that they quarantine if positive. It would be most informative if individuals could use the COVID Credentialing App to provide follow-up for studies of universal testing. Even without it, at a community level outcomes will be available for direct reporting by following COVID rates by zip code from the state’s data reporting system.
COVID CREDENTIALING: A second application of this technology would dramatically impact travel and use of restaurants and other facilities. For travel, using home testing kits, it would be relatively easy to send testing materials to travelers in any part of the country. Travelers could then be required to undergo testing prior to their entry to an airport or other public transportation facility. If all travelers are verified to be COVID free, current concerns about the safety of travel could be dramatically reduced.
Rather than the current requirement that individuals entering the state undergo quarantine or testing upon arrival at Bradley International Airport, everyone entering the airport — whether from ground transportation or incoming flights — should be required to test negative. A demonstration project at Bradley could provide Connecticut notoriety and practical advantages for its airport.
Two strategies have been emphasized in our attempts to curtail COVID: masks/social distancing, and vaccines. While our heterogenous society has limited the impact of masks/social distancing, and we await the impact of vaccines, advances in testing and reporting technology could stop the surge in the pandemic more rapidly and more effectively than social distancing or vaccines alone. For the next several months they should be pursued with the urgency given to campaigns about masks/distancing, manufacturing ventilators, and vaccines.
Developing and implementing tests of universal testing and COVID credentialing will require buy in from sources of test kits and a multifaceted effort involving consortiums of individuals with different expertise. Expertise will need to include: test modifications, study modeling, statistics, logistics, project design and management, information technology and others.
Until vaccines are available, the current recommendations for masks and social distance should be joined by “Get tested” and “A test kit in every home!” And if vaccines are 95% effective, over 15 million could still be without protection. Going forward they benefit by what we learn about mass testing and credentialing.
Richard B. Everson, MD, MPH, lives in Farmington.