Dr. Redfield: Where is the CDC guidance for widespread testing of potential asymptomatic carriers of COVID-19?

Where is the CDC’s guidance for the expanded program of COVID-19 testing and contact tracing necessary to allow states to safely relax restrictions on public gatherings and “reopen” their economies? If the CDS has issued such guidance, I sure cannot find it – any help would be appreciated.

My theory: Despite its clear obligation to do so, the CDC will not issue such guidance because to do so would expose how inadequate the current supplies of test kits are to do the testing necessary to implement such a program. And the inadequate number of test kits would in turn underscore the greatest single mistake of the Trump administration’s generally inept pandemic response – the failure to adopt a national strategy to produce, acquire, and distribute critical medical supplies, including test kits and PPE.

The CDC is the repository of the nation’s expertise in how to establish a program of surveillance testing, widespread screening, and contact tracing customized to COVID-19 that would allow states to safely reopen their economies. It is nothing less than a gross abnegation of its core mission for the CDC not to get out in front of  this key step in controlling the pandemic.  

I discussed what such an adequate testing regime would look like in a prior post, referring to an article  in The Atlantic.  It involves much more widespread  testing than called for by the CDC in its current guidance.

The goal of surveillance testing, done by sampling, is to determine rate of infection in a given population. The use of tests for screening is done to accomplish a specific goal, such as making sure that only virus-free nursing home employees have close contact with residents. And it involves testing asymptomatic people – a subject that the CDC has avoided.

Controlling COVID-19 is particularly challenging because it can be transmitted by asymptomatic carriers of the disease, the so-called “silent spreaders.” These silent spreaders can be pre-symptomatic, spreading the disease in the days before symptoms appear, or they can be carriers of the virus who never have any signs or symptoms of the disease. Estimates now are that as much as 40% of the transmission of COVID-19 is from asymptomatic carriers.

The authors of the Atlantic article point out that a widespread testing program designed to make it safe to reopen society must focus on potential asymptomatic carriers of the disease, interdicting transmission of the disease at the points at which it is most likely to be spread and at which it is most dangerous. They recommend widespread periodic screening for COVID-19, and they group people into four general categories in order of testing priority.

The first priority for screening is health care workers, including nursing home workers, and medical first responders. The second includes people who also interact with many other people and are vital to keeping the country going, such as grocery and postal workers and police officers. The third group is for anyone who routinely comes into contact with large groups of people either in the course of their employment or family life. The final group includes everyone returning to their workplaces.

The authors suggest that testing of people in these groups would occur about once a week. That is a lot of testing and estimates of the number of tests necessary to carry out an adequate program of testing range from 500,000 into millions per day.  Any plan similar to the one described in the Atlantic would have to be phased in, beginning with the high priority groups.

It is fair to add that many experts believe that the plan proposed in the article is too ambitious and is unrealistic. To my knowledge, however, none have said that a comprehensive testing program that includes testing of asymptomatic people is unnecessary, and that social distancing alone will be sufficient to safely reopen society. The risk simply is too high that the pandemic will come roaring back if the virus is allowed to spread undetected.

California apparently will be the the first state to adopt its own program of more widespread testing that includes asymptomatic people, beginning with screening of health care workers. It is limited (including by shortage of test kits), but it is a start. And it is an absolute sin that states have been left to their own devices on this. That does not mean that there would not be deviations from a CDC-designed program to account for local conditions, but the basic program must be based on scientific and public health best practices – in other words, an undertaking that is in the wheelhouse of the CDC.

Finally, this note to Robert Redfield, head of the CDC: Dr. Redfield, I don’t care if it highlights the failure of the federal government to take charge of making adequate number of test kits available and embarrasses the president, you have a duty here. And that duty is to render your best advice on a program of comprehensive testing and contact tracing that will protect citizens as the economy is reopened. Think of us as your patients, doc. Don’t we deserve your best medical advice?

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A footnote on my earlier post about the failure of the president to use the Defense Production Act (DPA): To reprise, I pointed out that the greatest single dereliction of federal responsibility (among a whole host of screw-ups in the federal pandemic response) was the failure by the Trump administration to design and implement a national strategy to produce, acquire, and distribute critical medical supplies, including test kits and PPE. Claims by the Trump administration that it was not a federal responsibility are wrong, and reprehensible.

Only the federal government has the power, through the Defense Production Act (DPA), to ensure production of sufficient quantities of supplies and equipment, control and stabilize supply chains, eliminate price gouging, and make sure that distribution is made to where it is most needed. If the DPA had been used in a timely manner, the shortages of PPE and test kits would not exist.

There is an excellent article in Politico titled “Inside America’s unending testing snafu.” It is worth reading if a bit overwhelming in its description of a complex problem. Suffice it to say that the “snafu” that test kit availability has become is the best evidence of why federal officials should have taken charge of this task as soon as they knew that the pandemic was headed our way.

A task of this magnitude and complexity can only be managed centrally. And that means the federal government. And I am absolutely certain that people with relevant expertise and experience told that to the president or his staff at the outset of the pandemic. As I said before, only a congressional investigation will find out why this ball was dropped.

The problems described in the story sound complicated, and they are. But they are the type of problems that logisticians spend entire careers training for and working on. There are about 26,000 employees and a lot of expertise in managing supply chains, interoperability of equipment, and ensuring that multiple moving parts work together to produce the desired results in the Defense Logistics Agency (DLA). There is similar expertise in FEMA.

The president decided to let all of that skill and experience sit on the sidelines and to make acquisition of test kits a “state responsibility,” meaning that he made availability of test kits subject to the vagaries of a market in chaos. There is considerable suspicion that his decision was influenced by manufacturers and suppliers who benefit from such dog-eat-dog sellers’ markets, where states and even individual hospitals are bidding against each other. In any case, it was a horrifically stupid, unjustifiable decision that is costing many lives and will force lengthy delays in safely reopening the economy.

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