Recovery Choice Planning, Part One: Testing and Tracing

RECOVERY CHOICE PLANNING SERIES:

What form does recovery take? What is the right strategy for government, companies, and our families as we begin to reopen but the virus is still on the loose? When and where do we citizens under lockdown regulation get a chance to engage in shaping societal decision choices whose efficacy is a matter of debate? This blog article is one in a series of recovery choice reviews that looks at some of the lessons learned from the first months of the COVID-19 pandemic and examines what alternatives exist about how Canada might move forward with various aspects of recovery.

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The Issue

Our many needs as a virus-shell-shocked society include:

  • (a) get people working;
  • (b) get the economy going;
  • (c) trace and track the infected;
  • (d) test for infection;
  • (e) get those test results to health planners for proactive monitoring and helping to fight the spread of disease.

This blog article explores two questions:

  1. What are the challenges to rolling out an effective, reliable and helpful tracking, tracing and infection testing program?
  2. What testing alternatives – mandatory or voluntary; universal or selective– make the most sense, and why?

Contact Tracing and Testing: Trends and Challenges

Contact tracing is the process used by public-health departments to identify, assess, and manage people who have been exposed to an infectious disease in order to prevent onward transmission. Contact tracing involves identifying people who have an infectious disease (cases) and people with whom they came in contact (contacts) and working with them to:

  • (a) interrupt disease spread,
  • (b) control (though not eliminate) the virus.

Tracing steps include:

  • (a) asking people with COVID-19 to isolate;
  • (b) asking their contacts to quarantine at home voluntarily, and
  • (c) following people who may have been exposed to COVID-19 daily for 14 days from the last point of exposure.

For differences between tracing and tracking, see the EthicScan Blog “The future: The Ethics of Tracking” (May 21, 2020).

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Testing is seen as the key to controlling the virus and allowing escape from lockdown. The World Health Organization (WHO) sent a clear message to all countries in mid-March that the more tests that are conducted, the easier it becomes to track the spread of the virus and reduce transmission. Many countries followed the advice, identifying a greater number of cases at an earlier stage, isolating infected individuals, and limiting the spread of the disease to others.

As of July 6, Canada as a country ranks tenth globally in testing per one million population. Our rate is half that seen in the United Arab Emirates, the UK, Russia and Qatar. Among other countries most severely impacted by the pandemic, we lag behind Spain, the USA, Belarus, and Italy. The U.S. has conducted almost 37.6 million COVID-19 tests.

There are at least five requirements of an effective COVID-19 testing program:

  • Equipment:   the necessary antibody test kits, swabs, reagents and equipment used to test. Testing capacity around the world has become stretched, and many infections are going undetected. Iran, Brazil and (at least initially) Canada are countries that have suffered due to a shortage of critical supplies, including test kits and face masks. Fortunately using nasal swabs to find and isolate asymptomatic  carriers sharply reduces the spread of the virus even though it is not accompanied  by tracing of the carrier’s contacts;
  • Staff:  Antibody testing has already started, but it can’t ramp up overnight. The contacts that help administer the tracing program need to be provided with education (typically one day’s interactive training), information, and support to help them understand their risk, what they should do to separate themselves from others who are not exposed, and how to monitor themselves for illness. In addition, they are informed of the possibility that they could spread the infection to others even if they do not feel ill;
  • Infometrics:  a suitable information exchange platform to allow it to work. Real-time tracking is critical to enable effective delivery. Traditional monitoring systems cannot do this job, because of the low frequencies and lengthy time lags of data collection and processing (for example, most countries will not find out until July 2020 what happened with GDP growth in the first quarter of 2020). Two tools can help governments make more effective decisions throughout the crisis:
    • (a) dashboards with non-traditional, advanced analytics and data (updated daily or weekly) and
    • (b) regularly conducted surveys of core segments of households and businesses to check their pulse and identify any need for course correction;
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  • Sample size: a realistic estimate of how many Canadians has been infected by the virus. Within a couple of weeks, a national COVID-19 Immunity Task Force (ITF) may be able to provide a more accurate picture of how many Canadians have been infected by the novel coronavirus. The ITF has been testing thousands of blood samples for coronavirus antibodies, which should help predict a more precise rate of infection. Similar research in other countries has placed the infection rate at 10 to 20 times more than the official number of confirmed cases. As of July 6, there were more than 105,000 confirmed cases of COVID-19 in Canada; and
  • Funding:  Even if the coronavirus test itself is provided free, the health system is still be on the hook for other medical costs related to testing or treatment. These costs can include:
  • (a) a visit to the emergency department or urgent care center,
  • (b) other blood tests, including flu testing,
  • (c) contact tracing involving others, and
  • (d) medical services if the case diagnosis is positive.

The ITF should also be able to predict what kind of protection a recovered person has from future COVID-19 infection. However, researchers stress that understanding immunity will take longer to research than an estimate of national infection rates. Those whose blood samples are being used in the research will not be able to seek individual results.

The global demand for antibody test kits is huge. The kits are used to identify antibodies in a person’s blood sample. The presence of antibodies means the individual has been exposed to the SARS-CoV-2 virus and has developed antibodies to help fight it. Antibody tests are important in detecting infections in people who are asymptomatic (showing few or no symptoms). Asymptomatic carriers can unwittingly contribute to the rapid spread of the disease. For example, a school age child can bring it home to parents who are caring for live-in, elderly and possibly health-compromised, infection vulnerable parents or relatives.

The Prognosis for Antibody Testing

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Scientists are still in the early stages of needing to figure out exactly what to test for, and whether having these antibodies actually makes someone immune and for how long. While diagnostic tests can tell if someone is currently infected, testing for antibodies reveals whether they’ve ever been infected — even if they never felt sick.

Experts say these antibody tests, in the short term, can answer personal questions, like, “Was I infected?” It will take much longer to answer questions such as, “How long will immunity last after infection?” and societal ones, such as, “How dangerous is COVID-19 really?” Until we know the answers to those questions, we won’t really know the true value of having antibodies. While experts agree it doesn’t mean our lives will completely revert to the way they were before, those tests can help us get on that path.

Knowing how many people were actually exposed and developed antibodies should help officials understand how dangerous the virus truly is. While millions of people worldwide have been diagnosed with COVID-19, scientists say that many more have probably had it and were unable to get tested or didn’t even notice the infection. Some disease specialists believe antibody tests will also be essential for getting us out of our houses and back to work, and for easing the fear that has paralyzed the country.

Universal vs. Selective Testing

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Alarmingly, despite the call for testing of public health professionals, medical officers of health, and the WHO, no province in this country is committed to universal mandatory testing. The reasons are many. Testing is costly. Under our constitution, the federal government lacks authority over the delivery of health services. And Canada is not equipped with the dedicated staff or proven-effective testing supplies to do it on a national scale.

At what stage of developing tests should we as citizens weigh in on the merits of universal vs. selective testing? Should we require target testing for the probable and likely infected, or (alternately) essential front-line care providers and workers, and/or some other demographic? In flattening the curve to fight the first wave of COVID, we put lockdown restrictions on everyone, not just the ill.

In assessing the costs and benefits of making this universal versus selective, and mandatory versus voluntary choice, a conscientious citizen should be aware of the following evidence or arguments:

  • If antibody testing could show who’s had COVID-19, even if they didn’t have symptoms, we might not have to worry so much about getting it. Companies could bring back recovered workers, and many health-care workers could breathe a sigh of relief. Such a test would reveal insights into a virus that has crisscrossed the world so fast that basic questions about it remain unanswered. And it would lead to better vaccines;
  • The province of Ontario’s plan for a mobile contact tracing and notification system app meant to help prepare for “a potential second wave” of COVID-19 in the fall will not be launched this month as planned. In a statement issued last week, a spokesperson for the Minister of Health confirmed the new app is not yet available to users, that the provincial government is working with federal partners, and that they “expect it to launch shortly.” No reason was provided for the delay and no alternative date for the launch was given;
  • Volunteers who responded to an altruistic appeal to apply federally to be trained as tracers have been told that their application referral would be made to the appropriate province but have never heard back again;
  • The province of Ontario squandered a billion dollars on a failed e-health information platform. It therefore still relies on an antiquated manual data-entry, telephone and fax machine, non-digital system (iPHIS) in order to monitor and exchange testing and tracking data;
  • Most citizens have neither the life sciences information (nor likely the scientific method training and experience) they might want to help make an informed decision, nor the power to affect decision-making in a time of emergency rule.
  • The use of digital testing platforms needs to be coupled with stringent security measures, such as raising user awareness on data leakage and increasing monitoring capacity to prevent cyber attacks and fraudulent access of relief funds. Certain countries have already fallen victim to fraudulent parties gaining access to public records and funds;
  • If and when we develop a safe and effective vaccine that is, say, 65% effective, (and we don’t yet have this for SARS (2003) or MERS (2012) – COVID’s older cousins) many citizens who have been polled say they may likely refuse to take it.

Alternative Renewal Choices

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Here are three tracking and testing alternatives that are possible. The first closely resembles where we are at today.

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Variable Renewal One Renewal Two Renewal Three
Concept Voluntary Targeted testing Universal testing everyone, likely every two weeks
Pre-requisite Idiosyncratic re-opening not tied to mandatory testing Stop virus cold first: South Korea, New Zealand New localized lockdowns and quarantine instruction as needed
Precedents Ontario, Quebec British Columbia China, South Korea
Who gets tested Voluntary Government surveillance and oversight to make choice Mandatory for many or all
Priority Anyone with reason who asks Essential front line workers, vulnerable populations Everyone
Testing kit supplies Still being developed; supply shortages Need sign contracts with suppliers Dollars enough to tamp down even a high infection rate
Testing Manpower Training commitment needed Train and enlist support volunteer tracers—perhaps use some of bailout money to gainfully employ those laid off Mix of professional and volunteer tracers

Conclusion

We need remember the second wave of the Spanish flu of 1918-1919 was bigger/worse than the first. In real time, genuine testing and tracking choices need to be made. Your personal or professional comments are welcome.

Further Resources

Centers For Disease Control and Prevention – Contact tracing is key to slowing the spread of COVID-19 and helps keep you, your family, and your community safe:
https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/contact-tracing.html

EthicScan Blog – The Future: Tracing, Tracking and Ethics:
http://ethicscan.ca/blog/2020/05/21/the-future-the-ethics-of-tracking/

WebMD – What Can Antibody Testing Really Tell Us About COVID?:
https://www.webmd.com/lung/news/20200416/what-can-antibody-testing-really-tell-us-about-covid

CTV News Toronto – Ontario will use contact tracing app to prepare for possible second wave of COVID-19:
https://toronto.ctvnews.ca/ontario-will-use-contact-tracing-app-to-prepare-for-possible-second-wave-of-covid-19-1.4989441

Forbes – Tests For COVID-19 Are Expensive, But They Don’t Have To Be:
https://www.forbes.com/sites/williamhaseltine/2020/04/08/pricing-and-profiteering-from-covid-19-tests/#111833051ccb

USA Today – Fact check: Cost of COVID-19 testing is complicated, varies by patient:
https://www.usatoday.com/story/news/factcheck/2020/06/09/fact-check-cost-covid-19-testing-complicated-varies-patient/3139091001/

Statista – Rate of coronavirus (COVID-19) tests performed in the most impacted countries worldwide as of July 8, 2020 (per million population):
https://www.statista.com/statistics/1104645/covid19-testing-rate-select-countries-worldwide/

David Nitkin
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