Jeremy Samuel Faust is an emergency physician at Brigham and Women’s Hospital in the Division of Health Policy and Public Health, and an instructor at Harvard Medical School.The views expressed are solely those of the author.
Hospitals around the country are scrambling to meet the demand for identifying SARS-nCoV-2, the virus that causes covid-19. The need is clear: We need enough tests for every single American. But right now, the important thing is how we select who gets tested, how and where we perform the tests, and how we follow up.
From what I’ve seen on the front lines of this outbreak, and what I have gleaned from observing the responses around the world, we need to establish thousands of pop-up facilities — outdoor assembly lines and tents — to administer the tests immediately. They need not be adjacent to hospitals, and they certainly must not be embedded in emergency rooms.
In most cases, patients with suspected illness should be swabbed, sent home and told to stay there until test results are available. Only patients who are seriously ill should be evaluated and treated in emergency departments. If, when and where this virus becomes prevalent, there will be many who badly need medical treatment. At that point, it will be crucial that hospitals not be overwhelmed by people with milder symptoms — or by frightened people just seeking to be tested.
Our colleagues in South Korea have shown us the way. By carrying out large-scale testing, they have measured a credible fatality rate of 0.7 percent. That number is far lower than other estimates from around the world, and certainly far lower than the 3.4 percent often — and misleadingly — cited after a World health Organization official relayed the percentage of deaths among patients who were already known to be ill. In South Korea, the testing strategy was proactive and hassle-free, and involved a much wider range of the population. Health officials went into communities, finding people where they were instead of making them come to them in to health-care facilities. In some areas, drive-through testing was available.
This strategy clarifies the two major benefits of early and large-scale testing.
First, the more patients are tested, the lower the measured fatality rates are. This makes sense mathematically, because when tests are available and administered broadly, they pick up people with mild symptoms, or none at all — and who, therefore, are far more likely to get well. The South Koreans detected far more cases than other nations, not because they failed to prevent the spread of coronavirus, but rather, because they had the good sense to try to detect it and the courage to reveal the true number of cases they were finding. Of course, large-scale testing does not itself alter the actual fatality rate of the disease — but the lower figure it reveals is likely to be far closer to reality. This alone might help alleviate fears and even stabilize economic markets.
Second, the discovery of mild and symptom-free cases may lower the number of serious cases over the course of the outbreak, and might even save lives. This is not only because early treatment is effective, but because early detection informs relatively healthy and even symptom-free patients that they need to isolate themselves. It also helps public health officials track the virus and identify specific areas where social distancing may be warranted.
The Centers for Disease Control and Prevention’s current recommendations indicate testing only people who meet specific guidelines — including having had contact with a person with laboratory-confirmed disease. But, as I have heard from colleagues around the country, this actually works against our ability to detect the outbreak of cases in new sites. The CDC approach is understandable because of the limited number of test kits available. But it is not sustainable. We need more information about more people. Currently, the bar is too high.
Given the global economy and ease of travel, it was only a matter of time before a virus this contagious reached the United States. We knew this was coming and should have been prepared with greater systemic testing capabilities.
Pointing fingers and assigning blame achieves nothing now. But it is not too late to demand that public health officials at all levels move quickly to expand our systemic testing capacity, and how to use those tests in the most effective manner. If we take these steps, we will not only save ourselves from the psychological and logistical effects of our own anxiety, we may stave off a breakdown of our overwhelmed health system, reduce damage to the economy and prevent many fatal illnesses.
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