COVID-19 Testing and the Need for Ongoing Infection Prevention

The raging COVID-19 pandemic in the United States is a stark reminder of this country’s continued failure to take this virus seriously. The entire Pacific Rim region in Asia – comprised of 15 countries, including China, Australia, and Vietnam — is clocking in less than 9,000 new cases of COVID-19 a day. Yet, in the United States we’re breaking daily records — over 160,000 new infections per day — with cases continuing to increase across the country. We’re nearly 10 months into this global pandemic and, while we have made significant progress on several fronts, we are still treading water on many others. The United States has had the highest number of cases and mortality globally. As the country grapples with a dark winter ahead, with projections of America’s death toll to reach 300,000 by December, the general public remains divided on infection-prevention measures. Even as cases dramatically rise in almost every state, Americans have been lulled into a false sense of security, including putting so much faith in test results that they let their guard down in potentially dangerous situations.

Similar to the stark political division in the country, the public has never been so divided when it comes to basic, scientific public health measures. That’s because they have also become wrapped up in politics. The ongoing politicization of even the simplest behavioral measures — like mask-wearing — coupled with constant mixed messages from the start of the pandemic, coming from both within and outside of the scientific community, has created an atmosphere of distrust, confusion, anger, and noncompliance, leading to more people getting infected and dying. Meanwhile, we’ve seen countries like South Korea have much better compliance with public health measures — like wearing a mask, physically distancing, isolating when sick, and quarantining when exposed — because of good risk communication, the government speaking with one voice, and the provision of ongoing, transparent, and honest public health updates, things the U.S. government has failed to do.

This failure has been exacerbated by social media, which gives individuals access to hundreds of thousands of people, has motivated and allowed some people to seek their “15 seconds of fame” by claiming to have thorough knowledge on the subject matter, the so-called “COVID-19 expert.” Simultaneously mixed messages from leaders in various positions of power at local, state, and national levels has further fueled the national scientific divide in the United States.

As the pandemic gained momentum again over the last several weeks, the public’s trust has waned further due to mixed messaging, mistrust of local and national officials, the social/ economic impacts, and sheer pandemic fatigue after living under restrictions for so many months. People started to assure themselves that they were out of harm’s way and there was no imminent danger or threat to them. This has even been seen in the northeast, which was hardest hit at the pandemic’s outset, as community transmission remained low throughout the summer and gradual re-opening plans lead to more carefree behavior.

This included more social gatherings, events, and celebrations as people felt a false sense of security that they had, in fact, beat Coronavirus. Life was starting to have some resemblance of normalcy in parts of the country. As this transition to “normalcy” returned, so did the disregard for continued public health and infection-prevention measures. People relinquished their masks and congregated in crowds and gathered often.

Americans also observed that, even at the national level, during White House events hosted by the Trump Administration, for example, masks were not encouraged and the administration was relying solely on testing, rather than coupling it with other infection-prevention measures.

The trouble with this novel coronavirus is that it is highly communicable and transmissible, with the highest viral load production often happening 48 hours before symptoms develop, if they develop at all. Studies have also revealed that approximately 40 percent of people infected are asymptomatic and have the ability to transmit the virus to others. Because of this, it becomes very difficult to convey to people that although they feel fine, they may still be infected and able to transmit the virus.

As more point-of-care tests became available and rapid antigen tests were being used, people experienced an increased false sense of security and shrugged off preventative behaviors like social distancing and wearing a mask. However, the nuances in testing and virus acquisition and transmission are so profound that the medical community has not been able to effectively communicate this message to the general public: COVID19 antigen tests are a point in time, and individuals may be negative due to an undetectable viral load, hence the need for ongoing mask-wearing and physical distancing.

Whether it’s a molecular PCR test or a point-of-care test, such as a rapid antigen test, a single negative test on a particular day does not provide you a reliable answer for a virus with a particularly long incubation period and a wide spectrum of symptoms, or lack thereof. As seen with the White House outbreak when President Donald Trump became infected, despite all of his close contacts testing negative in the days prior, there was in fact contact with an infected person and transmission of the virus. This is partly because rapid antigen tests have lower sensitivity than molecular PCR tests, but can detect coronavirus cases when they are most contagious.

False negative test results can also be tied to the timing of testing. For example, if a person has been infected for more than five days, their antigen test could come back with a false negative due to lower levels of detectable antigen in the infected person’s body. This, however, does not mean that they are no longer infectious. The level of nuance in testing is complex and it demands the public understand and embrace the need for additive layers of infection-prevention. That means even with a negative test result, you still need to wear a mask and watch your physical distance from others, keeping six feet apart.

Of course, testing plays an essential role. Without wide-scale testing, the virus will continue to circulate and this vicious cycle will not be broken any time soon. With the first at-home COVID-19 diagnostic self-test granted emergency use authorization by the FDA, there will come progress but also more challenges going forward. The need for ease of testing and rapid result availability can promote better compliance from people toward testing and serve as public health tools rather than medical diagnostic tools. The challenges come from the cost of these tests, the need for a prescription from a healthcare provider, as well as the reporting of positive results. If we are to truly get out of this pandemic, we must increase testing capability and ensure those that test positive isolate, and those exposed to it, quarantine.

With 11 million cases in the United States in less than a year and an estimated 250,000 deaths, the country finds itself in its third peak in a persistently high first wave, with alarming new numbers every day and a stark national divide and strong push-pull between science and politics. Still, we must find a way for effective messaging to break through so that we can fight this virus together. Part of this is understanding that, less than a year into the pandemic, we can still say that testing is not absolute. The risk of virus acquisition remains based on a person’s behavior patterns, despite a negative test on a particular day. Even with advances in our testing modalities, a negative test result does not, in fact, provide allowance to forgo the continued use of precautions recommended for public health measures.

Image: A sign displays a new rapid coronavirus test on the new Abbott ID Now machine at a ProHEALTH center in Brooklyn on August 27, 2020 in New York City. Photo by Spencer Platt/Getty Images

 

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About the Author(s)

Dr. Uzma Syed

Board-certified Infectious Disease specialist, chair of the COVID-19 Task Force, and is the director of the Antimicrobial Stewardship Center of Excellence at Good Samaritan Hospital Medical Center. Follow her on Twitter (@DrUzmaSyed).

Dr. Syra Madad

Senior Director, System-wide Special Pathogens Program at New York City Health + Hospitals; core faculty in the National Emerging Special Pathogens Training and Education Center (NETEC); fellow at Harvard University’s Belfer Center for Science and International Affairs, Adjunct Senior Fellow at the Federation of American Scientists and part of their COVID19 Expert Taskforce. Follow her on Twitter (@syramadad).