Andrew Cuomo, governor of the US coronavirus hotspot of New York, had a dire warning for state leaders eager to restart their shuttered economies.
“People will die if we get cocky about reopening,” he said.
As the rate of Covid-19 deaths and hospitalisations have declined in the US, states are finding that reopening their economies is more difficult than closing them. They are being hampered by the same problem that has plagued the fight against the pandemic all along — a lack of data.
Some American politicians think it is time to start returning to normality. Georgia’s governor has opened nail salons and tattoo parlours, and the mayor of Las Vegas says she wants the city to become the “control group” to see what happens when there is no social distancing.
But the clearest sign the US is not doing enough testing to open up is the rate of tests that come back positive. Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security, said it is hovering around 20 per cent, far higher than the 2 per cent in South Korea and 7 per cent in Germany.
“We’re primarily finding people with severe illness, who have very clear symptoms,” she said. “But what we need to do is find not just people with severe illness but also people with mild illness, and ideally even people who are asymptomatic.”
Experts believe the US needs to at least triple the amount of testing it is doing in the coming weeks. Now, it does about a million tests a week but the Rockefeller Foundation says in less than two months, the country will need 3m a week and that number will rise to 30m in the next six months. Researchers at Harvard believe it needs to go from 45 tests per 100,000 a week to 152 per 100,000 people per week.
Instead of just testing the sick, the US will need hundreds of thousands of contact tracers to track down and test everyone they met. Some states such as Massachusetts have recruited everyone from community healthcare workers to Peace Corps volunteers brought back from abroad to work the phones, delivering bad news to people who did not suspect they had the virus. Experts believe apps to trace people’s movements will not be enough on their own.
But the biggest challenge will be to learn the lesson of the response so far: that the federal and state governments must co-operate.
Mike Pellini, a diagnostics expert who helped write the Rockefeller plan, said the US testing challenge is not a technology problem. “It’s a co-ordination and logistics challenge, period,” he said. “And perhaps the most frustrating thing of all is that we did not have to wait for an invention or a reinvention of any of anything.”
He is already seeing signs of states and federal agencies working together on Rockefeller’s recommendations, which include identifying spare lab capacity at universities and changing rules for insurers so they will pay for tests at any lab, not just those in their network.
To increase testing, the federal government will need to help the states by easing bottlenecks in the supply chain, which it was slow to do with previous shortages.
Mr Cuomo is doubling New York’s testing capacity to 40,000 a day. He went to the White House this week to ask the federal government to secure supplies to make the tests. He has charged Mike Bloomberg, former New York mayor and presidential candidate with creating an army of contact-tracers for the tri-state area, to discover who needs the tests.
Washington state is trying to expand its capacity to test people with more mild symptoms, including getting the National Guard to assemble testing kits, but its public health authority said lack of supplies including chemical reagents could limit the number of tests they can do.
Dylan George, an infectious diseases expert who advised the Obama administration during the Ebola epidemic, said the US needs a “nationally co-ordinated effort” to prevent the kind of competition between states that has occurred for ventilators and personal protective equipment. The federal government may even need to deploy the defence production act to compel companies to make more supplies, he said.
“What we’re hearing from our sources on the Covid Taskforce is that we have enough capacity,” he said. However, he added that is for “defensive mode”. “If we’re going to go on the offence and root it out of these communities, we need to have a much higher level of testing,” he said.
Some have put their hope in antibody tests, which identify people who had the virus and recovered. Analysts at Citigroup said they thought there could be enough antibody tests for 60 per cent of the US working age population by the end of April, more than 120m, which they hope would help people to get back to work.
But out of the 90-odd companies and academic institutions making antibody tests, only four have received emergency use authorisation from the Food and Drug Administration. Although the 90 are allowed to market these tests, the US Association of Public Health Laboratories say they may create more uncertainty than answers.
“Having many inaccurate tests is worse than having no tests at all,” said Kelly Wroblewski, director of infectious disease programmes at the APHL.
Of the four approved test makers, none told the FT that they would have millions ready in the next week. By the end of May, Chembio said it would be able to make a million a month, Ortho Diagnostics said it could have several million, and Mount Sinai, the New York hospital, said it would partner to distribute its tests by June. The fourth, Cellex, did not respond to a request for comment.
Even if the antibody tests were more accurate, we do not know how immunity to Covid-19 works and how long it may last, making some cautious about the idea of ‘immunity passports’ to allow people to freely move around.
Rajiv Shah, president of the Rockefeller Foundation, said the priority for the US is robust diagnostic testing. “There are places like Iceland and Germany and even South Korea that we think are out in front on antibody testing, but they’re all doing that as a baseline of having pretty good diagnostic testing systems already in place,” he said.
Eric Topol, director at the Scripps Research Translational Institute, believes testing and tracking, while necessary, may not be enough. He said we need to use technology to try to detect infection before people become symptomatic; for example, using wearable tech to watch when people’s heart rate ticks up, a sign they could be fighting an infection.
Without such an early warning system, the US would be left needing to test people again and again to see if they are becoming sick. “You can’t just do 10 million tests a day for two years,” he said.
Ultimately, the mayor of Las Vegas is right on one thing: opening up will be a grand experiment.
Tom Frieden, former director of the Centers for Disease Control and Protection, said it will have to be very “gradual”, because if the virus picks up speed it will take two weeks for people to get seriously ill and three before deaths begin to mount.
“You’ll only know if you’re safe enough if you wait three or four weeks between the different phases of gradually opening the faucet,” he said. Some activities might be out of bounds for the long haul. “I don’t think my 90-year-old mother is going back to choir any time soon.”