COVID: The Way Forward
Jessica Mason, MD and Mel Herbert, MD
Rethinking Covid-19 Test Sensitivity — A Strategy for Containment - https://www.nejm.org/doi/full/10.1056/nejmp2025631
TWiV 640: Test often, fast turnaround, with Michael Mina - https://www.microbe.tv/twiv/twiv-640/
Coronavirus (COVID-19) Update: FDA Authorizes Antigen Test as First Over-the-Counter Fully At-Home Diagnostic Test for COVID-19 - https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-antigen-test-first-over-counter-fully-home-diagnostic
Ian L. - September 10, 2021 5:04 AM
It will be helpful to know your antibody level just like your blood group . People with good antibody levels are relatively safe and this is done in blood donation and transfusion screenings . Still viral load exposure is important and there will need to be cough etiquette magic masks and better ventilation either outdoors with shade or in air car and public transport travel . Fresh air but filtered fresh air many areas of the world have mosquitos .
Byron F. - September 11, 2021 4:46 AM
Testing is not the "way out". The sensitivity of the antigen tests does not allow for yes/no decision making. People with symptoms could get a negative test and think they are not infectious.
The main problem with covid is pressure on the health care system, and mitigation of this demand is the way out. Mandatory vaccinations is the best form of mitigation. Eventually, all the people who will get sick enough to be hospitalized will be. There will be excess death in the unvaccinated, but still a relatively low mortality overall. When Covid has burned through the susceptible, hospitals will be able to return to normal and society at large.
I agree with vaccine mandates wherever the government can mandate. People who chose not to be vaccinated put the health care system at risk, and they should have consequences such as not being able to work or attend group events.
Robert A. - September 11, 2021 6:07 AM
I like the idea of daily testing, but I think the vaccinated need to accept that the unvaccinated-by-choice are beyond help and we need to let this pandemic play out however it will (including the collateral damage of variants, and the unvaccinated-not-by-choice infections). There is a portion of the population who short of arrest and forced vaccination will never take these vaccines--unfortunately especially with delta that portion is large enough to prevent any chance of herd immunity. I doubt they will take daily antigen tests even if they were free.
I know this sounds terrible and that it makes me a monster. However, we do this with patients who have substance abuse disorders and we accept it. Each time they come in we offer beyond life saving help, offer treatment etc. but in the end if they choose to leave the ED and go back to substances we let them until they're either ready to change or their disease becomes fatal--sometimes they even harm others while intoxicated (drunk driving, theft etc.).
The same will need to happen with the antivax. Some will change as we make life harder for them (mandates, passports, vaccination for concerts etc.) or they experience the loss of their close contacts, some will not. Again I know this makes me a monster, but this is the conclusion I've come to with ~50% of my extended family choosing to remain unvaccinated.
John V. - September 11, 2021 9:10 AM
According to the Kubler-Ross model for the stages of grief there are 5 steps. COVID-19 has taken our peaceful normal and we are collectively grieving. People around America and the world are currently sorting through this at the different stages but the truth is smiling right at us.
Stage 1 Denial - Some who aren’t vaccinated.
Stage 2 Anger - Some political, media figures, and even ordinary people talking about shunning those who are unvaccinated or aren't following strict protocol when ill.
Stage 3 Bargaining - Those who create these elaborate ever changing algorithms and try to follow rules that set an unrealistic standard for human cooperation and existence. Those who attempt to play by those unrealistic standards.
Stage 4 Depression - Many physicians and scientists who due to delta variant realize that 10-15% of their ICU’s covid burden is with the vaccinated and that this pandemic is becoming a still deadly endemic that cannot be efficiently eradicated like polio. Many who contemplate a future where they must add swabbing their nose to tooth brushing and hair combing every morning before work. Mothers who have to choose working or being available for child care after quarantining for the third time in a month. All of us who contemplate never seeing half of our coworkers and clients faces again. Never shaking another hand or hugging grandma without a tinge of uncertain guilt…
Stage 5 Acceptance - Many people whether they are vaccinated or not who realize that part of life is death and refuse to live in fear. They realize that expecting to live past 40 is only a recent human development. They realize that every year, despite elaborate human constructs, hundreds of thousands of people die from cars, alcohol, tobacco, starvation, war, and all other sorts of seemingly preventable aspects of the “human condition.” Not to mention those who die from a litany of other infectious diseases despite excellent healthcare.
The truth is that COVID is going nowhere and neither are 97+% of people. Over decades covid will evolve to be less deadly and surviving humans will have offspring more likely to survive. We have to live our lives as efficiently and normally as possible because that is all the natural world demands of us. We as a species have been through worse plagues. Researchers widely report that 8% of the typical human DNA sequence are inserts from viruses humans have been contracting since time immemorial. Covid is simply just another tiger whose presence in the jungle of life we must come to ACCEPT.
Edward M. G. - October 13, 2021 6:06 PM
'surviving humans will have offspring more likely to survive' would only happen if covid killed individuals prior to our procreation phase. The only natural selection pressure we face prior to parenting is the ability to dodge intoxicated drivers. In the absence of selective pressure our species is not driven toward fitness; but instead drifts toward decay. Our collective action and inaction has been rough on the planet. Someday the world may be better off without us. Until then it sure is fun helping individuals when we can. I'm looking forward to my next shift.
Dallas H. - September 12, 2021 12:31 PM
The BinaxNOW test is $11.50/ test.
Surveillance antigen testing makes sense for asymptomatic people. As another listener pointed out, these tests are not good enough to say a symptomatic person doesn't have COVID.
Even cheap, widely available tests will not solve the COVID problem because just like vaccination, there is a subset of the population who refuse to take any person responsibility to prevent the spread of COVID and would not test themselves regularly. For those of us who understand science, routine surveillance testing, vaccination and masking are probably the best way forward. My hospital offers free, rapid testing for employees but I prefer to use the at home tests for convenience. I test myself every week. There will never be zero risk again so we each need to determine our personal acceptable level of risk. I have started traveling again because it's important to me but I'll probably never go to a large indoor event like a concert again. I setup a home gym because I don't foresee going to a public gym any time soon and masking while working out is unpleasant.
Justin E. - September 12, 2021 12:33 PM
Absolutely love this Jess! Great points!
Dan F. - September 12, 2021 3:04 PM
please continue to bring Dr. Mina's plan to the public. It makes so much sense. He is an epidemiologist who understands the numbers and he has stated from the beginning we don't need 100 % participation to make an impact. D FreemanMD
Gayle L. - September 13, 2021 6:14 AM
Hi Dr. Mason,
I feel frustrated that so many people (including the leaders of our country and my health care institution) have just given up on getting most people vaccinated. I try to talk to almost every patient about it, and most unvaccinated people are guided by misinformation or anxiety. I tried to get a bright shiny and informative brochure (one piece of paper) debunking vaccine myths to hand to patients from my health care institution, and was told it's not in the budget. I would like to have passing on good information about vaccines be a regular part of our care. Now that unvaccinated staff will be forced to leave, I kind of hope that this will be a more regular thing rather than me fighting my own fight in the neighborhoods where the culture deems vaccines as what-we-don't-do.
Regarding the home testing kits, I don't think that's a widespread answer, in that only the people who take this seriously like yourself will do that.
Thank you for bringing this up: it's a good thought to try to see a way forward, through or past anger, sadness, frustration, and all of that.
Norine M., MD - September 27, 2021 10:23 AM
Gayle, I agree. I ask all of my patients if they are vaccinated. If they are, I give a visible and audible cheer. If not, I have a conversation. I've found that most are open to being vaccinated (granted I do live in Seattle). Some just want information, and seem glad to get it from me. The ones that are strident anti-vaxxers, I leave them alone. I just don' have the energy anymore.
Gayle L. - October 2, 2021 3:48 PM
Yay for the retention of some hope! I do think that to just say the people who haven't gotten vaccinated are a lost cause and it's their decision to crash and burn is too fatalistic and also underestimates the educability of most humans, given the right circumstances. (Not to mention, Robert A., that that thought ignores the children.) Good thoughts.
Joseph B. - September 17, 2021 4:11 PM
Agree with others here - testing only helps highly motivated conscientious people who believe in COVID. Definitely not the way out.
Disagree that changing what care is offered to the unvaccinated is "disgusting". It is not analogous to addition which is a disease. This is informed refusal of a easy safe and effective preventable health measure. I would suggest a process where the unvaccinated have an appointment with their primary care provider to discuss vaccination. If they make an informed refusal, they also accept they will decline resource intensive care (hospitalization/ICU) when those resources are limited or affecting downstream care of other patients. They could be offered evidence based home treatments where applicable/available (dex at home, home O2). In general this approach still respects the basic ethical principles (justice, beneficence) that guide us in resource limited/disaster/pandemic situations.
John P. - September 18, 2021 1:48 AM
How do we get back to normal? I vote for John V stage 5 level measures.
If you're vaccinated, or a low risk pediatric person, I think you should be as close to normal as you can be at this point. Your risk for severe illness requiring hospitalization or worse is reasonably low, and you should go about your daily activities with hand hygiene, masking as required, etc. Let the vaccines work their way through the wickets for pediatric patients, see if the risk outweighs the benefits for them, and go from there.
If you're not vaccinated, my guess is you have no interest in any of the risk mitigation measure in place as they are. We should continue to encourage them to be vaccinated, but we should not limit our usual activities in an effort to protect them from something they already have had an oppurtunity to protect themselves from.
I do believe we should have some kind of mandate for vaccines in the US. The surge has a real impact on unrelated healthcare otherwise and I believe the government has a compelling interest to protect scarce resources for the population as a whole. I think more people would go along with it even if there weren't any significant repercussions if it was mandated.
Garrick S. - September 19, 2021 9:08 AM
I think John V. has it right. Testing, quarantines, masks and the rest of it may stave off COVID for a time, but the only way out is immunity, vaccine or natural. Within a year or so, it seems highly likely that COVID will burn through the unvaccinated population which will make their acceptance or denial of the vaccine a moot point. Many will pay a price for that decision, but we'll all end up in the same place eventually. Daily testing might work for some individuals, but there's no way it could be implemented on a large population scale.
The way back to normal is not more mandatory testing or mandates--it will never feel normal when we're constantly told what to do. It's not blame or bitterness for people's personal decisions--it's acceptance and patience. Everyone will decide for themselves, based on their own risk tolerance, what their new normal looks like. Travel or not. Gym or not. Daily testing or not. And when everyone is comfortable with their own life choices and free to make their own personal decisions, THEN we're back to normal life.
Scott K. - September 21, 2021 9:50 AM
Getting back to our “normal life”? That normalcy included a health care system that took apart community hospitals forcing everything to referral centers. Covid and a nursing shortage, that hasn’t been attended to by hospital systems for decades, has demonstrated the flaw in this model. ED’s are stagnant. We require constant flow thru our EDs to remain healthy. So, yes, more testing, and more vaccines, but also repair a broken corporate healthcare model, restore community hospitals to previous specialty representation, and let nurses know how much we value an RN and they don’t all need to become NPs or PAs to be valued. Just pushing back Covid by itself would leave us with too many problems ignored and pushed down the road for the next crisis to bury us again.
Richard U. - September 28, 2021 2:56 PM
There is no going back to normal. We, the medical complex, and the political class have been less than humble. The Faucis of the world have vacillated and obfuscated; moreover, they have ignored the science. The political class have exercised their controlling/ authoritarian tendencies. We, the Impetuous American flinched and our liberties have again been reduced. Not unlike the 'emergency and temporary' measures after 9/11; the power grab of the political class will not be temporary. Australia is great example of how policies to 'protect' have gone wrong. COVID-19 have exposed the inadequacy of our hodgepodge healthcare system and the woeful state of health of the American public. Also, the economic damage that has been done will rippled for years to come. I would like to be hopeful that the powers that be will take this opportunity to fix some of these issues. However, New York is firing nurses; from heroes to zeros...Now worries. Back to what you were doing because it matters.
Shu-Haur O. - October 18, 2021 5:57 PM
Sorry, can you elaborate on Australia and how "policy to protect went wrong"? We are currently getting high vaccination rates, the COVID affected states are moving out of lockdowns, and we hope that the current COVID zero states get vaccinated before they are delta exposed. Has there been economic damage? Absolutely. Yet what is the economic damage from rampant COVID in the prevaccine era? Tell me Richard U what was the impact economically in the US experience, let alone the unnecessary loss of life? How many health care providers caught COVID due to lack of PPE. No where in Australia had to reuse PPE or wear garbage bags as substitute PPE.
The major failure of the Australian response from a health care perspective was telling people vaccination was "not a race" and the undermining of the AZ vaccine which we could make locally. From A victorian perspective you can add in hotel quarantine system which was botched and failures hidden due to politics. The lives lost from that (some 800+) were predominantly in people with significant age and comorbidity.
SO in answer to Jess' question, in Australia we look towards a > 90% vaccination rate, and we hope to replicate the approach of Denmark and Portugal where one no longer cares about COVID or COVID restrictions.