We have one last chance to get COVID-19 testing right. Since the start of the pandemic, we have tested too little, too late and in the wrong way. Last spring, outdated regulations, strained supply chains and political denial forced us to fly blind as COVID-19 gained a foothold. Then, as cases surged, we chose the wrong tool for the job: We needed fast, frequent tests — but instead we relied too much on slow and expensive PCR, leaving us constantly one step behind the virus.
Now, as vaccination begins to make gains against the virus, a dispute is intensifying between two visions for the future of testing. The “COVID zero” idealists envision a world free from SARS-CoV-2, which would require testing and tracing nearly every case. Meanwhile, a growing circle of laissez-faire proponents call for an end to testing outside of hospitals and clinics altogether.
Following either path would just add another chapter to our national saga of botched testing strategies. The dispute is not so much about testing as it is about how the pandemic should end. The COVID-zero and laissez-faire strategies are both rooted inunrealistic visions for the future of COVID-19. We have only successfully eradicated one infectious disease, and SARS-CoV-2 won’t be the second. We have beaten back other diseases from the borders of wealthy countries — a selfish and narrow measure of “success” — but for a virus as infectious and genetically variable as SARS-CoV-2, local elimination isn’t sustainable in the long run.
Meanwhile, COVID-19 is still wreaking havoc in places that have previously seen high rates of transmission and where many people have been vaccinated. For the laissez-faire approach to make sense, we must be convinced that SARS-CoV-2 has already done all the damage it can. The current global situation shows definitively that it hasn’t.
Vaccination will help us to manage the worst effects of COVID-19 and to buy back many of the liberties we enjoyed in pre-pandemic life, but vaccination alone will not be enough. Recognizing this is the first key step in developing a rational testing policy for living with COVID-19 in the post-vaccine era.
What should such a testing policy consist of? There must be three central priorities: protecting the vulnerable, managing hotbeds of spread and scanning for future outbreaks.
We know who is most vulnerable to COVID-19: the elderly, the immunocompromised, those with cancer, diabetes and obesity, to name a few. Often these conditions coincide in individuals who live in group settings where devastating outbreaks can spread.
Rapid tests for visitors to long-term care homes, regardless of vaccination status, will be needed for the foreseeable future, as will regular testing (weekly at minimum) of residents and employees. For vulnerable individuals who live independently, rapid tests must be cheap and accessible so that they and their caretakers, friends and family can monitor themselves regularly for infection.
Such tests are available for purchase in the United States, but they are still too expensive. We should also work to develop rapid tests for entire panels of pathogens, including influenza and other coronaviruses, that remain significant threats to these same individuals.
Second, we must manage potential hotbeds of contagion. Superspreading has been the main driver of COVID-19 transmission and can occur wherever large numbers of people gather. Superspreading is especially likely in bars, clubs, concert halls and restaurants, as well as schools, homeless shelters and prisons — some of which overlap with communities where vulnerable people are also found.
In these places, testing recommendations should be linked to local prevalence: when cases are low, testing will be more disruptive than helpful, but as cases rise, testing can tamp down outbreaks before they spiral out of control. For this to succeed, we must develop policies and infrastructure to manage cases when they occur. If a child tests positive at school, we must concretely support parents who may need to take time off work. We must also conduct enough baseline surveillance to detect new rises in cases that would trigger these testing protocols.
This brings us to the third priority: surveillance testing for SARS-CoV-2 is indispensable. We can, and must, make such testing as unobtrusive as possible. We should immediately expand our infrastructure for wastewater surveillance, which has provided critical early warning of outbreaks on college campuses and in communities.
Simultaneously, we should conduct periodic, randomized testing for both virus and antibodies. A person might receive a letter once each year asking them to report to a local testing site — a bit like epidemiological jury duty. We should use rapid tests at airports to monitor international travelers for possible introductions of infection. We should use rapid tests again to free quarantined travelers as soon as they repeatedly test negative. Otherwise, testing guidelines, especially for vaccinated individuals, can be largely relaxed.
To be clear: These recommendations apply only to testing for public health purposes. For patients who require medical attention, testing is and should remain at the physician’s discretion. A subset of these clinical tests should be sequenced to track the virus’ ongoing evolution. Along with the strategies outlined here, we must improve indoor ventilation, maintain reasonable and effective mask guidelines, and improve access to medical care for underserved populations. No amount of vaccination or testing can excuse us from these pressing responsibilities.
Despite the heroic and self-sacrificing efforts of so many individual Americans, America’s pandemic response has been lackluster. Now is the time to change course. We have a few precious months to right the course before COVID-19 surges again this winter. If we are successful, we will protect those within our borders and provide a roadmap for the rest of the world for testing in the post-vaccine era. Supporting rational testing policies, at home and abroad, should be a central priority as we move forward. America has the chance to reclaim its status as a global leader in public health. Let’s not botch it this time.
Stephen Kissler is a postdoctoral fellow of immunology and infectious diseases at the Harvard T.H. Chan School of Public Health. He has published various scientific articles on pandemic influenza and COVID-19. Follow him on Twitter: @StephenKissler.