The World Has Crossed The One Million Mark Of Confirmed COVID-19 Cases
Almost twenty-five percent of the COVID-19 cases in the world are in the United States
In a recent briefing by the White House coronavirus task force, Dr. Deborah Birx said there were half a million tests available that are not being utilized. To any reasonable person such numbers will suggest that we have a horribly inefficient/uncaring/ healthcare system, that promotes the spread of COVID-19 by not identifying infected individuals through testing. But you would be wrong. What Dr. Birx neglected to mention are the details.
What are the details?
Dr. Birx went on to wonder, “how do we raise awareness so people know that there’s point of care, there’s Thermo Fisher, there’s Abbott testing, and there’s Roche? And if you add those together, that’s millions of tests a week.” Let’s ignore the maths for a moment (how did half a million tests that were not utilized become “millions of tests a week”?), and try to understand what is going on.
Not all testing platforms are alike. Assuming all the tests Dr. Birx mentioned use the same swabbing system to collect patient samples, the training required to gather those samples while necessary, is not extensive. Consequently, assuming a steady availability and supply of swabs (which is not always the case), sample collection can be achieved without too many hiccups. But the next step varies based on the platform.
At the time of writing, the RT-PCR(reverse transcriptase-polymerase chain reaction), the next step in the process, requires kits that are primarily sourced from Thermo Fisher and Roche Diagnostics; the kits designed by CDC in February were problematic, but were subsequently fixed. All these RT-PCR kits can be used to test patient samples using a variety of different instruments, each of which has unique specifications with regards to processes.
First, the virus (if present in the swab) is chemically broken open and the RNA (the genetic material of the virus) is collected. Next, using an enzyme called reverse transcriptase, the viral RNA is converted to DNA. Following this, the DNA is copied over and over using the enzyme polymerase, and the formation of new copies of this DNA is monitored by the machine in real time, using a fluorescent dye. If the fluorescent DNA signal crosses a defined threshold, then the sample is considered positive for the virus.
In some instances, such as in the Cepheid test, the swab material goes into a proprietary cartridge that fits into the company’s machine, and 45 minutes later you have the results — one cartridge per sample. Although some models of the machine can handle multiple sample cartridges at a time, it can’t match the multiplicity of a traditional machine that can handle as many as 900+ samples at a time; but the processing time is much longer. The recently unveiled Abbott machine, like the Cepheid machine, carries out essentially a one-pot reaction, but uses a very different biochemical reaction yielding a result in 15 mins (a positive result takes only 5 minutes, but in the absence of it, the negative test readout can be confirmed at the end of 13–15 minutes).
Although the staff in hospital and private labs are familiar with the tools required to run the COVID-19 tests, the tests must be validated in each lab, because the tests are exquisitely sensitive, and because of the unique way COVID-19 samples must be handled. Further, because of the extraordinarily large number of samples — they outstrip the number of samples handled in pre-COVID times — in all likelihood more lab technologists are required, some who might not have been previously trained in that particular lab activity. These are not minor issues. If you think about driving — once you’ve learned to drive a car, most people would be able to adjust to and drive any other car irrespective of the manufacturer or the model. However, if you’ve only ever driven cars with automatic transmissions, driving a car with a manual transmission requires time to learn the perfect rhythm between the clutch, accelerator and brake, in order to have a smooth ride. Let’s widen that analogy to include driving a U-haul truck, and an eighteen-wheeler— with every different type of transmission system, dashboard layout, and other features of a vehicle, it takes some time to get used to and comfortable with the change, and to avoid accidents and achieve an ultimately smooth ride.
Other details to keep in mind when looking at all the impressive interactive data dashboards reporting cases and deaths: the flood of cases one sees from time to time is not necessarily because there were that number of new cases on a particular day; rather, it is usually the number of results released that day from the tests that were conducted from swabs that may have been collected many days prior. In other words, although you may have provided your nasopharyngeal swab on a particular day, it could have been tested either that very day or even several days later, depending on the availability of testing resources. In other words, at any given time we have a population of symptomatic and asymptomatic individuals in communities, and the number of these are revealed only when test results are released. Without a central database that aggregates test results, reporting of the data to the public is yet another handicap in this pandemic, because the level of preparedness relies on the numbers.
Facts, science, and truth
While it might be expedient to ignore the details when trying to counterpoise Trump’s massive inexcusable lapses back in January, Dr. Birx is doing a disservice to the scientific community, and the public. Having worked in a lab, Drs. Birx and Fauci, have a deep understanding of what needs to happen before a clinical test can be rolled out to the public in a reliable manner. One can only hope that the observed exponential growth in her adulation of Trump, has a pragmatic basis. Perhaps her experience from working with politicians over many decades to successfully implement healthcare and public policy has led her to believe that without such adulation, it is impossible to get anything accomplished — that the means justify the end. But it’s unclear how such adulation is going to improve the availability of resources that are in demand not just here but across the world — from personal protective equipment (PPE), to swabs, to reagents for analyzing the material collected on the swabs, to ventilators. Will we be reduced to supplicants of the highest bidder in this poorly resourced time? Building tents with hospital beds is not going flatten the curve, or fix the holes in the rest of the COVID-19 response and treatment system. Nor is incessant belligerent posturing by Trump.
As the medical community struggles to provide the best care possible under the current circumstances, it’s important to recognize why it is struggling. It is struggling because the people in power ignored facts. It is struggling because the people in power ignored science. It is struggling because the people in power ignored the truth and lied.
Carl Sagan rightly said, “We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science and technology.” Having reached this point in the COVID-19 pandemic, it is hardly the time to ignore facts, science, and the truth. It is also a time to stay home, reduce community exposure and implied community transmission, and to give the healthcare community a chance to help us while also maintaining their well being.
