Testing was the first important new tool we had during the COVID-19 pandemic. Then came treatments like Gilead Sciences Inc.’s
remdesivir (now called Veklury) and the monoclonal antibodies. And the grand finale? A set of super efficacious vaccines.
But even as vaccination rates rise day by day, and case counts and hospitalizations tumble, Dr. Michael Mina doesn’t think it’s time for labs to close up shop. The assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health still thinks we should stay focused on testing, though we need to get smarter about how we test and for what purpose.
“Things have to transition more to what I call peacetime surveillance,” Mina said during a May 24 interview. “The pandemic isn’t over. Everyone just wants it to be over. But as much as we want it to be over, we can’t pretend like there are not millions and millions of cases happening across the world.”
And part of that comes down to getting ride of this one-size-fits-all approach to testing. PCR, antigen, or rapid molecular tests each have a distinct job to do. But 15 months into this pandemic and they’re still not being used correctly. Going forward, through the easy summer months and into a possibly tougher fall and winter season, will require a better testing strategy.
“We’re going to need to have systems set up to be able to identify if there is a silent outbreak happening that ultimately could start affecting the unvaccinated,” he said.
Read on to understand why Mina thinks we should all stock a COVID-19 test or five at home this winter, what he means by “test to stay,” and why putting too much emphasis on PCR tests rather than rapid tests was a failure.
MarketWatch: Can you describe how PCR and rapid tests are being used in the U.S. right now?
Dr. Michael Mina: It’s a hodgepodge of semi-useful approaches. What we’re seeing is this massive confusion, because the CDC, almost overnight, swung 180 degrees from actively pleading with people to continue mitigating strategies to a few weeks later, saying, don’t do it. We don’t want you to test anymore. That runs a risk of confusing a lot of people.
[Editor’s note: U.S. health officials last month flipped the script on the nation’s COVID-19 testing policy, telling the majority of Americans who have been fully vaccinated that they no longer need to get tested for the virus if they are exposed to someone who has 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 remain patient with mitigation measures like mask-wearing and social-distancing.]
But we still want to keep testing up and going to ensure that we are not missing outbreaks. We’re going to need to have systems set up to be able to identify if there is a silent outbreak happening that ultimately could start affecting the unvaccinated. Maybe it’s happening amongst both vaccinated and unvaccinated.
Things have to transition more to what I call peacetime surveillance. The pandemic isn’t over. Everyone just wants it to be over. But as much as we want it to be over, we can’t pretend like there are not millions and millions of cases happening across the world.
We missed the boat on using tests as a way to slow spread. We failed miserably as a country at that. But now we have an opportunity to use tests in a more appropriate fashion. Testing is going to be associated with a lot of trauma; it’s going to be associated with this terrible year of COVID. But the only way we know where the virus is if we test. It’s just our eyes. It doesn’t have to be a big process with large connotations associated with it.
MarketWatch: This, essentially, would be a public health surveillance system?
Mina: That’s exactly right. There are lots of different ways to do that; obviously, the more passive, the better. If we have a test of wastewater systems, that’s obviously very passive. That’s no effort on the average, everyday Joe. But we’re going to need reactive testing still.
Thus far, we haven’t really had dynamic systems set up. They’ve all been like, we’re either doing testing or we’re not doing any testing. That’s just been a terrible, terrible mistake to look at testing in that way. If you have no cases in your community, then why test everyone in your community twice a week? And if you have a lot of cases in your community, then why not just test everyone every day for 10 days and rout it out of the community altogether?
In the future, that’s what we’ll see, hopefully. If cases start to happen in a school or in a workplace, then a workplace would have a stock of rapid tests. Instead of closing down, because we have an outbreak, we can just test everyone, every day for five days. At the end of five days, we will know that we’ve caught everyone that needed to be caught. And we would have routed out the outbreak. That’s this idea of “test to stay.”
Then you can say there’s an outbreak happening, but we don’t have to close the whole school down for a week. That’s extraordinarily damaging to societies when you do that kind of thing. We could keep it open and test everyone. The only reason we close whole things down during an outbreak is because we don’t know who’s positive. But if we do know who’s positive and who’s not, then we don’t have to close down. The next wave of cases that might happen in the fall and winter, it’s going to be “test to stay.” That’s my hope.
MarketWatch: If that is the case in the fall and winter, that would allow things to stay open more consistently?
Mina: We’re not going to have these big pandemic sort of waves across the whole country. As we move into November, we’ll probably see a resurgence of cases again. But it’s not going to be this massive overwhelming tidal wave of cases. It will be putting out little fires one after another. These tests will help us do that.
MarketWatch: Is the U.S. relying too much on PCR tests right now?
Mina: We have this strange infatuation with PCR in the U.S., to the extent that we are not authorizing tons of potentially much more accessible, much cheaper rapid tests. One of the most damaging things in this pandemic is putting so much weight on the PCR test. There was a time when test results were delayed 10 days, and millions and millions and millions of people got tested or were waiting in line for a test that would come back 10 days later. Every single one of those tests was 100% useless, as far as slowing transmission.
The White House is still putting a lot more effort into setting up contracts with PCR laboratories. It’s a massive mistake. I helped start what is now the country’s highest throughput PCR laboratory at the Broad Institute. I don’t have anything against PCR. But when it comes to meeting a population where they’re at — we want tests that people can just do on their own time.
MarketWatch: Should PCR tests be reserved for diagnosing before treatment?
[Editor’s note: Gilead said it’s up to prescribers to decide who is treated with Veklury, though patients previously had to have a positive test before they were treated with the 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 initiating treatment.]
Mina: It could be, but I would say if it’s going to take a few hours to get your result back, why not do a rapid test first? If it’s positive, then you have your answer in 10 minutes instead of three or 10 or 12 hours. Sure, get a PCR test if you want, but you can start treatment immediately. If it’s a negative, and you’re wanting to give remdesivir, and you want to be sure that the symptoms truly are COVID-related, then get the PCR test. We keep being in this boat of thinking, it’s either this or that, but a rapid test is so cheap and so easy.
There’s another class of tests, which I think are going to be important. There are the rapid molecular tests, and they’re not necessarily as sensitive as a true lab-based PCR. But they’re more sensitive than an antigen test, and they give you results in a half hour or so. Every school nurse should stock 10 of these new rapid molecular tests, and have them on hand for when a kid comes in. You don’t want to have to take a swab and send the kid home. Take a swab right there. Let the kid sit in the chair for 30 minutes. And then you have really accurate almost lab quality results in a half hour.
There’s no real need for PCR testing in a laboratory anymore, unless you’re at a hospital.
MarketWatch: With vaccination rates increasing in the U.S., how does that change the way that individuals and organizations should think about testing?
Mina: That’s where I think everyone’s getting confused. CDC hasn’t helped on this front. What do you do if 70% or 60% of your workforce is vaccinated? We have truly entered into a new era of use, which is no longer to suppress outbreaks that are burning. That boat has sailed. In a lot of companies, and a lot of schools and universities, everyone was testing very frequently, in order to either stop outbreaks from continuing to spread or the risk was so high that they on a daily basis wanted to prevent new outbreaks from taking hold. That’s what we saw in the colleges all year. That actually worked really well.
But in the context of 60% to 70% vaccinations and seasonal declines in cases, we are seeing less need for that type of proactive testing. How companies and society should start to think about testing now is reactive — but effective reactive — testing. We don’t want reactive testing.
Even if it is something as simple as everyone who works at company X, have five tests at your home. Well-funded companies can do that. And if we have an outbreak, maybe we do it floor by floor, wherever your potential contacts are. If you have a potential contact who’s positive, test yourself for your own sake and your family’s sake. Test yourself at home for the next five days before you come to work. It takes 30 seconds to do. You don’t have to stockpile thousands of them.
Maybe it will get to a point where we believe who cares if you’re vaccinated and you get infected? We will hit a point in this pandemic where we’ll have the luxury of being able to say exposures can actually be seen as a benefit. If you’re not getting sick from it, and you’re already protected, then you can consider it a natural booster.
That’s how our bodies naturally work. That’s how kids work. They start with runny noses, By the time they’re five or six, they no longer have runny noses. By the time they’re 30 or 40, those same little people have grown up, and you or I can go and we can walk into a daycare full of these little coronaviruses and not get sick. Not because those coronaviruses can’t sicken us but it’s because we’ve been naturally boosted potentially hundreds of times in our life. There’s something to be said for getting to a point in a pandemic where you have enough people who are protected that the vaccinated people say, this isn’t so bad. I just got exposed. I didn’t get sick at all. Until we get to that point where we’re not sickening other people around us, like if we walk into a nursing home, we can’t take that approach. We have to be a little bit more reserved.
We’re not all Superman and able to run into a roomful of SARS-CoV-2 and say, I’m getting super boosted here. That’s a bad idea. But I do think we’ll get there eventually. It’s an important piece to remember that humans have to live with viruses like this. Our end goal shouldn’t be zero cases. It should be zero deaths. Those are different things. And they will demand different levels of testing.
MarketWatch: It sounds like what the U.S. needs to do is move past this kind of like one-size-fits-all-for-every-American approach and figure out ways to be more specialized about who gets a test, what kind of test, and in what scenario?
Mina: That’s exactly right. One size does not fit all. We have thus far just taken pretty much the least scientific approach to testing in this pandemic we could have possibly taken. Had we rolled out different types of tests earlier, in September, we could have stopped the massive outbreaks of the winter and saved hundreds of thousands of lives. We didn’t do that. But I do hope that we’re learning slowly. We will move past this unscientific approach to testing.
This Q&A has been edited for clarity and length.
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