Schools And Tests

First: tests.

Last week I posted a 17-minute video I thought everyone should watch. It explains that ten-minute at-home tests could be printed by the hundreds of millions for a buck each (they’re just little strips of paper that turn a color if your spit contains the virus) — and this would solve all our problems!

Because . . . although they’re not terribly sensitive (and thus have up to now been characterized as “unreliable”) . . . they’re sensitive enough.

Rapidtest.org makes the case in a single page that will won’t take you 17 minutes.

And if you’re still dubious, there’s this from Harvard Magazine:

. . . “[W]e have a system for coronavirus testing…which is flailing, with raging outbreaks occurring.” What the country needs instead are rapid tests, widely deployed, so that infectious individuals can be readily self-identified and isolated, breaking the chain of transmission.

To do that, Mina says, everyone must be tested, every couple of days, with $1, paper-based, at-home tests that are as easy to distribute and use as a pregnancy test: wake up in the morning, add saliva or nasal mucous to a tube of chemicals, wait 15 minutes, then dip a paper strip in the tube, and read the results. Such tests are feasible—a tiny company called E25Bio, and another called Sherlock Biosciences (a start-up spun out of Harvard’s Wyss Institute for Biologically Inspired Engineering and the Broad Institute in 2019) can deliver such tests—but they have not made it to the marketplace because their sensitivity is being compared to that of PCR tests.

Mina says that is beside the point. “Imagine you are a fire department,” he says, “and you want to make sure that you catch all the fires that are burning so you can put them out. You don’t want a test that’s going to detect every time somebody lights a match in their house—that would be crazy: you’d be driving everywhere and having absolutely no effect. You want a test that can detect every time somebody is walking the streets with a flame-thrower.” . . .

FOR PUBLIC-HEALTH PURPOSES, speed and frequency of testing are vastly more important than sensitivity: the best test would actually be less sensitive than a PCR test. As Mina explains, when a person first becomes infected, there will be an incubation period when no test will reveal the infection, because the viral loads are so low. About “three to five days later, the PCR test will turn positive, and once that happens the virus is reproducing exponentially in a very predictable fashion.” At that point, critically, “even if a rapid test is 1,000 times less sensitive than a PCR test,” Mina says, the virus is increasing so rapidly that the test “will probably turn positive within eight to 15 or 24 hours. So the real window of time that we’re discussing here—the difference in sensitivity that makes people uncomfortable”—is so small that public-health officers would be missing very few asymptomatic people taking the test in that narrow window of time. Given that the current testing frequency in most states, using highly sensitive but expensive and delayed PCR tests, is not even once a month, he points out—“Really, it’s never.”

So even though a saliva-based paper test wouldn’t register a positive result for as long as a half or even a full day after the PCR test, it would have great value in identifying pockets of infection that might otherwise be undetected altogether.

The strength of this system is that it would actually abrogate the need for contact tracing, says Mina. “If your goal is not to have a heavy hand over the population” (implementing onerous public-health restrictions on businesses and recreational activity), this is the way to do it, he explains, because it strips away “all of that complexity.” Most people who test positive will have done so before they become infectious, and can easily self-quarantine for the six days or so until they cease being infectious. Even if some people don’t quarantine, and the test cuts off just 90 percent of all the infections that might spread, “you’d immediately bring the population prevalence of the disease to very low numbers, to the point where all of a sudden society would start to look safe again.”

MINA HAS BEEN PREDICTING the advent of more widely available, cheaper tests for months. But those tests have not materialized, largely because of regulatory risk, he says: manufacturers cannot meet Food and Drug Administration (FDA) templates for test sensitivity that use PCR as the standard. The FDA—whose approval process is stringent because it is designed to test the efficacy of clinical diagnostics—has no jurisdiction over public-health testing. But at the moment, there is no alternative regulatory process for tests designed to ensure population-level wellness—such as a certification program that might be run through the Centers for Disease Control (CDC), the agency charged with safeguarding the public health.

“It is time to stop allowing diagnostic definitions to get in the way of absolutely essential public-health interventions,” says Mina, for whom explaining the distinction between the two types of test, and the different ways they can be used, has been an uphill battle. But it is one that he desperately hopes to win—and that the country needs him to win—for public-health measures to stand a chance of reining in the outbreak as schools and other institutions move toward reopening this fall.

. . . “We’re putting billions more into developing therapeutics [treatments for COVID-19] which is really, really difficult.” With rapid testing, by contrast, “We have solutions, sitting in front of us right now, that are cheaper, would be much quicker to build, and much less risky to actually introduce and roll out. And the only thing standing in the way is that there just doesn’t seem to be the will to bring a public-health tool to market.” . . .

So there’s another reason to visit Rapidtest.org: it provides a tool to email or text your governor, senators and congressperson.

Second, and harder: what to do until we print billions of those tests and make schools safe by keeping infectious kids and staff home?

The first thing I think we can agree on is that it doesn’t help, as we seek the least-bad courses of action, either to minimize the risks or to exaggerate them.

Complacency — like Trump’s — has proven disastrous.

But neither is it helpful to exaggerate the risks.

In tweet after tweet, the head of the teachers union is leads with “risking the lives of children.” What parent can think rationally in the face of such an awful threat? Yet the head of the CDC says that the risk of a school-age kid losing his or her life to COVIS is one in a million. Even that one is, of course, one too many. But it’s far lower than the (still extremely low) risk of kids dying of the ordinary flu . . . a risk we’ve always just lived with, because we had to. (What were we going to do: shut down all the schools?)

As concerned as parents should be for themselves — and for school staff and grocery clerks and UPS drivers and anyone else who leaves the house — at least they should be comforted that the risk of losing their kids is “one in a million.” As I’ve suggested before, that’s good news that no one, regardless of political leanings, should feel compelled to reject.

Still, it leaves two big questions.

The first I am not remotely competent to answer: what if, a year or ten or thirty from now, kids who were seemingly unharmed by contracting COVID turn out to suffer some long-term damage? Certainly something to worry about. But so is the enormous damage to kids not going to school — especially kids from low-income families.

The second is the risk of infecting vulnerable adults, spreading a virus that’s already out of control in many parts of the country.

That risk argues for thinking differently in places like New York, that at least for now have low rates of infection, versus places where the numbers are much worse.

Several of you sent me the New York Times piece headlined, “When Covid Subsided, Israel Reopened Its Schools. It Didn’t Go Well.” And for sure there are some good lessons to be learned from their experience (ventilation!). But only when you get to the end of a very long article do you encounter this:

But Israel is plunging ahead. Only one option has been ruled out: closing the schools.

I think it’s fair to say that Israelis care about their kids. And that they’re pretty smart about a lot of things. So while the headline suggests we shouldn’t reopen our schools, based on their experience, that’s not the conclusion they’ve drawn.

I think that’s worth noting, as we struggle to find the least-bad way forward.

(Also worth noting, from the U.K.: No known case of teacher catching coronavirus from pupils, says scientist. There have definitely been staff deaths here in the U.S., but few — and few still among staff without comorbidities. And I’m not sure we know that even those tragic infections came from the kids.)

Yes, vulnerable staff should be paid to work from home until going to work is safe. For sure! But it’s not clear to me that healthy young staff are anything but “essential” workers with a crucial role to play.

Yes, vulnerable parents should have the option to keep their kids home, if they deem it necessary.

Yes, older kids should wear masks, and windows should be kept open, and smart teachers and administrators should come up with other risk-mitigating strategies, like “pods.”

But I think that’s what the discussion should be about: the kids are not at risk . . . what are the smartest ways to mitigate the risk to vulnerable adults?

Lots more to say, but let me end with something that can’t be said often enough:

We never should have been forced to make these tough trade-offs in the first place. A competent administration would never have pulled back the forward-deployed CDC teams designed to “fight diseases there, so we don’t have to fight them here” — or ignored more than a dozen urgent warnings.

The idea that anyone would vote not to fire the incompetents who let this happen simply staggers me.