Since COVID-19 first appeared in Wuhan, China, in early December 2019, the contagion has become a pandemic of global proportions. The ability of coronavirus to spread from asymptomatic infected individuals is particularly insidious. Health care systems, governments, and society have strained to keep up. Cypress River Advisors is acutely aware of this because we have contracted companies to produce face shields, which we are supplying to essential workers for free.
At the time of this writing, the US is one of the countries with the highest number of cases per capita.
For Cypress River Advisors' clients, the haphazard global response wreaked serious economic havoc. The service and manufacturing industries have recently suffered unprecedented disruptions to their supply chains and bottom line. In parallel to this business sector disruption, active misinformation campaigns and cyberattacks intended to sow discontent and public trust created further challenges to coordinated policymaking. Nearly half of the Twitter accounts pushing the reopening of America are bots. So how does American leadership decide the following critical questions:
Re-open offices and factories to employees or not?
How should vital public services be enabled while balancing the needs of citizens and civil servants?
Now that COVID is endemic, what to do when the second wave hits?
Ordinarily, we would turn to the data, but…
Private organizations spearheaded the data aggregation hubs effort due to slow federal response
Availability of Data
In the early stage of the pandemic, the only reliable source of reporting data was coming from state and local data sources. Unlike other countries around the world, the United States does not provide national health care services for its citizens and consequently aggregated data does not exist without considerable effort. In fact, the CDC provided early advice to researchers and policy makers, stating:
"States are reporting results quickly, and in the event of a discrepancy between CDC and state case counts, the state case counts should always be considered more up to date. "
The Johns Hopkins University Center for Systems Science and Engineering, The New York Times, and The COVID Tracking Project at the Atlantic led some of the more notable efforts to create and maintain open data repositories to ensure the accuracy of these numbers.
It is the opinion of Cypress River Advisors that these organizations have provided a vital and valuable public service through their data aggregation, validation, and open-source approach.
Definitions and testing
The crystal clarity of the Center for Disease Control (CDC) numbers provides a clear status check of where the pandemic stands, right?
Let's look at the definitions first. Cases appearing in the CDC datasets and reporting from journalistic outlets represent patient cases that meet a set of criteria deemed appropriate to consider a probable COVID-19 case. Based on current guidelines the COVID-19 position statement issued by the Council for State and Territorial Epidemiologists and referenced by CDC, the definition of a probable COVID-19 case are those in which one of the following is true:
Meeting clinical criteria AND epidemiological evidence with no confirmatory laboratory testing performed for COVID-19; OR
Meeting presumptive laboratory evidence AND either clinical criteria OR epidemiological evidence; OR
Meeting vital records criteria with no confirmatory laboratory testing performed for COVID-19.
It’s not as straightforward as you thought, is it?
So, what will it take to reopen America?
In short, lots of testing. Globally, healthcare experts and economists generally agree that re-opening is contingent on widespread testing to:
identify susceptible individuals,
rapidly identification and isolation of actively infected patients,
and facilitate contact tracing to identify people who might have been exposed from identified, contagious individuals.
However, the US has fallen woefully behind expanding testing capacity to meet recommended levels. But, before we get into that, let's examine a scatter plot that compares state-level data for COVID-19 cases versus the number of tests performed.
The plot shows a correlation between testing for cases and finding cases. However, the real picture is much more nuanced. (Please note, this is a population normalized chart.)
There are two different categories of testing technologies that are intended for different scientific and clinical purposes:
Diagnostic testing - confirmatory test for ongoing, active infection in a patient by the virus via nasal cavity swab
Antibody/antigen testing - detecting the presence of a particular molecular indicator (usually a protein) in a person or the presence of an antibody against the virus in the blood or tissue. Positive results to this class of test suggest that the patient has at some time been exposed to the virus but is not evidence for an active infection.
Why does "having" or "had" the virus matter?
This distinction between having or had the virus is crucial for understanding the progression of the epidemic. Still, many states and even the diagnostic criteria recommended by the CDC conflates these two categories when deciding whether a patient presenting in a healthcare setting is a probable "case."
The COVID-19 position statement issued by the Council for State and Territorial Epidemiologists on April 5, 2020 details in Section VI.A2 that diagnostic and antigen/antibody testing both satisfy the Laboratory Criteria recommended for classifying a "case."
Testing lags far behind what is needed
As we previously mentioned, healthcare experts and economists widely agree that any plan for re-opening requires a robust testing system in place to monitor workers on a rolling basis.
This means we need BOTH kinds of tests and at scale: diagnostic testing to detect outbreaks in a workplace or community, and antibody testing provides some evidence of purported workers' immunity to becoming infected and spreading the virus.
How much testing? Certainly more than what we are doing today. Harvard Global Health Institute has offered the most conservative estimate for daily tests that the US will need to safely re-open: 900,000 tests/day. This is a level that is more than double what is currently occurring (data source: The COVID Tracking Project at The Atlantic).
Again, the answer is clearly more testing is needed. At least 3-fold more than is currently possible, and at the current rate of increase, we are unlikely to reach that until midsummer.
One more complicating matter - politics and optics
Some reporting has recently revealed apparent resistance by state and local level officials to provide COVID-19 healthcare data available. The Tampa Bay Times has reported on state officials in Florida releasing heavily redacted forms outlining COVID-19 deaths: that were compiled by the state medical examiners. The paper also reported the same state official ordering coroners to stop releasing said data. Georgia has faced similar criticism after a claimed error resulting in a significant reduction in reported cases in the most beleaguered counties.
Moving forward: a science-based approach to reopening America and the world
Good decisions require good data. At the present time, building reliable forecasting models for COVID-19 cases and deaths has proven notoriously difficult. As leaders, we often need to make decisions under imperfect conditions, which is why we are issuing this management advisory note. The numbers you see on TV, conservatively speaking, reflect the bare minimum of actual cases in the US. Simply stated: COVID-19 testing is not where it needs to be. Data transparency at the state and local level are under threat.
Why should you care? Re-opening too early without the infrastructure to maintain social distancing, testing, and supporting your employees is a liability nightmare. You could, in a single staff meeting, severely impact your workforce or management team productivity.
From a human perspective, the team at Cypress River Advisors understands the uncertainty and fear essential workers have to keep American and the world's infrastructure going while most of the population is sheltering in place. We receive their requests for personal protective equipment and listen to their stories. Action is required by everyone. If we do not address COVID in a comprehensive manner on a global basis, economic and social recovery will occur in a halting manner. That’s bad business for everyone involved.
Hopefully, in the coming months, testing capacity will expand, and data transparency and reporting will improve to a sufficient degree. The reality is that we will need to act conservatively on reopening.