The Great Pause Week 102: Testing
"It's all about optics."
No one is safe until everyone is safe.
— Dr. Daniel Griffin
This is the third in a multi part series that began with this post.
In early February 2022, Nature Medicine published a University of Washington study of the database maintained by the U.S. Department of Veterans Affairs, the nation’s largest integrated health-care delivery system. The researchers created a controlled dataset that included health information of 153,760 people who had tested positive for Covid-19 sometime from March 1, 2020, through Jan. 15, 2021, and who had survived the first 30 days of the disease. Very few of the people in the study were vaccinated prior.
Statistical modeling was used to compare cardiovascular outcomes of the Covid group with a control group of more than 5.6 million patients during the same time frame; and a control group of more than 5.8 million people who were patients from March 2018 through January 2019, well before the pandemic.
People who contracted Covid were 72% more likely to suffer from coronary artery disease, 63% more likely to have a heart attack and 52% more likely to experience a stroke. Overall, those infected with the virus were 55% more likely to suffer a major adverse cardiovascular event, such as heart attack, stroke and death.
“Our data showed an increased risk of heart damage for young people and old people; males and females; Blacks, whites and all races; people with obesity and people without; people with diabetes and those without; people with prior heart disease and no prior heart disease; people with mild Covid infections and those with more severe Covid who needed to be hospitalized for it,” the researchers said.
Warned of the coming storm in December, 2019, the CDC set its rapid response back by at least one month, possibly two. Given the nature of exponential progressions and what we now know about lingering cardiac damage, that may have contributed to a million or more deaths. For reasons that can only be explained as jingoism, aka “exceptionalism,” the agency did not adopt any of the PCR tests already in wide use. It did not issue mask guidelines or temperature checks like those already deployed with success in Singapore, Taiwan, Japan and Korea. The US instead insisted on creating its own test, and once that had been developed, it sent it out to an exceedingly corrupt, greed-driven manufacturing system that was inefficient, expensive, and slow. Result: widespread test failures and then recalls. A long delay.
The CDC created new disasters, again and again. Rather than telling people to mask, CDC told people NOT to mask, worrying about creating a shortage in N95s for critical care workers.
It now appears that early on, its administrators concluded SARS was not containable, and so they made no serious attempt. That is what we call in permaculture a Type One error — you are stuck with it.
“It’s all about optics.”
— Charity Dean, California Public Health Officer, referring to CDC.
As with WHO, CDC’s advice changed week to week. Cloth masks versus N95s. KN95s? KN94s? Fomites: an issue; not an issue? Droplets? Aerosols? Seasonality? Which vaccines? Maybe children don’t need vaccines at all. Do teachers need to be vaccinated before schools can reopen? CDC said yes. The White House said no. CDC said no. In January 2022 CDC issued guidelines saying testing was no longer important. This came right after the Delta wave and in the midst of the Omicron wave, when nothing could be more important than testing. CDC said 4 weeks between shots. In February 2022 that was revised to 8 weeks. Ooops! Other countries had been using 6 to 8 weeks from the beginning. Some monoclonal antibodies — the kind that saved Donald Trump, Boris Johnson and Chris Christie — worked for one variant but not for another. Although they were in short supply and expensive to make, State governors demanded they be allowed to use them for the wrong patients at the wrong times. CDC offered no guidance.
Ironically, the United States makes the equipment that sequences genomes, and yet it is 30th in the world in sequencing. The price of running one sequence has dropped from thousands of dollars five years ago to one cent or less. US hospitals’ software would not let them purchase these tests even if they were offered for free because they were too cheap for the software to allow! Frustrated, California asked CDC to genetically ID for variants every sample they sent. CDC refused. Without genomic testing, doctors could not know what to prescribe. Nor could counties or states know which variant was dominant and what monoclonal antibodies may or may not work.
“This will go down as a colossal failure of the public health system of this country…. It is a slaughter….”
— William Foege, former CDC Director, letter to CDC Director Robert Redford, Sept 23, 2020.
New York hospitals sent blood to be tested in State labs but doctors were never returned the results, they just went into an anonymized database. It hardly mattered, since life-saving monoclonal antibodies were only available in limited supply and those went to wealthy private hospitals in big cities, leaving rural areas and poor public hospitals with no access. Whether they were the right antibodies for the variant was irrelevant, because without access the poor and rural simply died in larger numbers.
California ordered 100,000 nasal swabs for PCR tests through the Federal strategic inventory and POTUS held a press briefing to congratulate himself for helping a state that had not voted for him. When the swabs arrived they were just useless Q-tips.
At first, Long Covid was discounted: those symptoms were unrelated to the infection, were psychosomatic, or were just short-term side effects. As it became apparent that Long Covid was a thing, scant resources went to cataloging its manifestations or numbers, never mind seeking therapies. That is slowly changing now, as it must. A large percentage of all children hospitalized for Covid — 50% in some US studies, 27% in Italy, 22% in Sweden—have developed Covid lasting more than four months. For many, it could be with them the rest of their lives. We still don’t categorize the wide variety of symptoms and modalities for Long Covid the way we should. This will come back to bite us.
US public health as a system was sacrificed on the altar of greed long ago and the US is still deluded into thinking it can do no wrong and everything foreign is inherently inferior.
In the early days, Nordic countries rushed to protect the most vulnerable in nursing homes, prisons, and institutional settings. Those populations got priority for everything — masks, separation, added caregivers, hospital ICUs, and later the vaccines. In the US these groups died in droves, and so did their attendants, nurses and guards.
Most countries tested to see if people were no longer infectious before releasing them from care or quarantine restrictions. Most countries used rapid antigen testing (30 minute return) every two days starting at Day 5 from onset of symptoms (Day 6 in the UK). Two days negative test result and you are no longer considered infectious. Since the US seldom tests and seldom quarantines, except in overcrowded ICUs, sometimes hastily erected in hallways, parking garages and tents and staffed by inexperienced National Guardsmen, infectious people circulate relatively freely with the uninfected or with the 20–50% unvaccinated population (depending on your Congressional District). It was a formula for exponential acceleration of the pandemic. It continues now. CDC remains mute.
This week The New York Times revealed that CDC withheld critical data on boosters, hospitalizations and wastewater analyses. The CDC isn’t publishing large portions of the Covid data it collects — data that could help front line doctors and State public health officials save lives.
Much of the withheld information could help state and local health officials better target their efforts to bring the virus under control. Detailed, timely data on hospitalizations by age and race would help health officials identify and help the populations at highest risk. Information on hospitalizations and death by age and vaccination status would have helped inform whether healthy adults needed booster shots. And wastewater surveillance across the nation would spot outbreaks and emerging variants early.
***
Some outside public health experts were stunned to hear that information exists.
“We have been begging for that sort of granularity of data for two years,” said Jessica Malaty Rivera, an epidemiologist and part of the team that ran Covid Tracking Project, an independent effort that compiled data on the pandemic till March 2021.A detailed analysis, she said, “builds public trust, and it paints a much clearer picture of what’s actually going on.”
***
The pediatrics academy has repeatedly asked the C.D.C. for an estimate on the contagiousness of a person infected with the coronavirus five days after symptoms begin — but Dr. Maldonado finally got the answer from an article in The New York Times in December.
“They’ve known this for over a year and a half, right, and they haven’t told us,” she said. “I mean, you can’t find out anything from them.”
***
Wastewater is also a much faster and more reliable barometer of the spread of the virus than the number of cases or positive tests. Well before the nation became aware of the Delta variant, for example, scientists who track wastewater had seen its rise and alerted the C.D.C., Dr. Scarpino said. They did so in early May, just before the agency famously said vaccinated people could take off their masks.
Even now, the agency is relying on a technique that captures the amount of virus, but not the different variants in the mix, said Mariana Matus, chief executive officer of BioBot Analytics, which specializes in wastewater analysis. That will make it difficult for the agency to spot and respond to outbreaks of new variants in a timely manner, she said.
“It gets really exhausting when you see the private sector working faster than the premier public health agency of the world,” Ms. Rivera said.
In 2020 the USFDA set an absurd and unscientific sensitivity standard that greatly delayed test kits from getting to market, setting back the manufacturing infrastructure by months. Despite a publication by (now CDC Director) Dr. Rochelle Walensky saying that even poor sensitivity tests, if widely administered, could prevent the spread of Covid, FDA required rapid antigen tests (which test for infectiousness and take 30 minutes) to be as accurate as slow PCR tests (which test for infection but take 24 to 48 hours for the lab to return). Infection and infectiousness are not the same. If what you are most concerned with is infectiousness, rapid antigen tests don’t need to be as accurate as a 2-day laboratory workup. Somehow this logic eluded the FDA, and so the US went a year without the inexpensive rapid testing widely available in the other overdeveloped, rich countries of the world.
Rapid antigen tests are today used throughout Latin America, Asia and Europe for getting on planes, entering workplaces, crossing borders, attending events, etc. These tests screen people 30 minutes BEFORE they contact others. They should have been widely available in the US nearly 2 years ago, but are only just now being sent out to citizens as home test kits. Even with that, the 500 million manufactured are just a fraction of what will be needed to quench the further spread of Covid, and efficacy against future variants is unpredictable.
The UK has been lauded by the World Health Organization for its broad tracking and sequencing efforts that contributed to global surveillance systems. Only a few countries, including South Africa and Israel, did so as intensively. And yet, last week the UK announced it was getting ready to scrap the weekly Covid-19 survey that costs the Office for National Statistics 400 million pounds ($545 million) a year. “This virus will continue to evolve, which is why we call on countries to continue testing, surveillance and sequencing, the WHO chief Tedros Adhanom Ghebreyesus said in response. “We can’t fight this virus if we don’t know what it’s doing.”
Despite its long-standing inability to test, or trace, or treat against long-term effects, the United States is now under political pressure, like the UK, to fill up its schoolrooms and subways again, open universities and offices without masking, and go back to normal in every way possible. But normal is gone. It is not coming back. People need to adjust to a new normal for zoonotic diseases (and also lab leaks) the way we need to adjust to a new normal for climate.
And then it needs to address the causes for such horrific losses, and why the United States scored worse than so many other countries when a real test of its health care system was administered by Mother Nature.
This series continues next week when we look at part four: Son of Covid.
References
Attia, Zachi I., et al. “Screening for cardiac contractile dysfunction using an artificial intelligence–enabled electrocardiogram.” Nature medicine 25, no. 1 (2019): 70–74.
Gurdasani, D., et al. “Long Covid in children,” The Lancet Child & Adolescent Health (Jan 2022).
The COVID-19 pandemic has destroyed lives, livelihoods, and economies. But it has not slowed down climate change, which presents an existential threat to all life, humans included. The warnings could not be stronger: temperatures and fires are breaking records, greenhouse gas levels keep climbing, sea level is rising, and natural disasters are upsizing.
As the world confronts the pandemic and emerges into recovery, there is growing recognition that the recovery must be a pathway to a new carbon economy, one that goes beyond zero emissions and runs the industrial carbon cycle backwards — taking CO2 from the atmosphere and ocean, turning it into coal and oil, and burying it in the ground. The triple bottom line of this new economy is antifragility, regeneration, and resilience.
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