Can the economy be saved by your right to choose COVID testing?

Guest commentary: Free virus and antibody testing for all Americans would more than pay for itself

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Combined virus and antibody testing is our best opportunity to identify those who can immediately but carefully return to work, and in doing so restart the economy while minimizing the epidemic’s resurgence.

We argue that free testing for all citizens will more than pay for itself, and it wouldn’t have to be mandatory to make a difference.

Recent modeling data from Georgia Institute of Technology in Nature Medicine predicted impressive results for a “shield immunity” strategy that would use serological data “to identify and deploy” recovered individuals and reduce the length and burden of disease.

We have previously advocated for the combined use of tests for SARS-CoV-2, the virus that causes COVID-19, and tests for antibodies, that should be available via home kits.

In addition, we have made the case that there are times when it is in the best interest of public health for FDA to expedite approval of technology that can bring great benefit, so long as the agency monitors real-world outcomes and quickly takes steps, such as withdrawing the technology, to mitigate potential harm.

In this scenario, that technology is at-home virus and antibody tests.

Simply waiting for better tests will result in more deaths and considerable additional damage to the economy.

We acknowledge that the quality of virus and antibody tests is not completely understood, nor is how they should be used in population management. The WHO has emphasized the unknowns about COVID immunity. Partly because of the lack of widespread testing, there is limited knowledge about what antibody level confers what degree of immunity.

However, years of immunology teach us that individuals that have recovered from COVID-19 are capable of fighting the disease, and therefore face a lower risk than individuals with no antibodies.

The pace of innovation and interest in testing, aggressive FDA surveillance, and the expectation that individuals will be tested multiple times strike us as the right ingredients for a sound quality-improvement strategy.

Monitoring how an individual’s test results tie to their behavior and health outcomes will be invaluable to creating better tests and optimizing return to work.

We believe FDA is the best organization to oversee widespread testing, using an adaptive, real-world framework for safety and efficacy.

We also believe that everyone should have the opportunity to be tested, and to use that information to guide their own decisions about when to go back to work and how to manage their risk for infection versus the economic and other health risks of remaining in lockdown.

Fruits of mass-scale testing

To date, testing has been limited and inconsistent, and pandemic maps likely vastly understate infection numbers. Recent small-scale antibody testing in hotspots suggests that from 15% to over 30% of populations might have antibodies, but we do not really know.

This means data to segment risk is incomplete.

For example, reports from Massachusetts and six other states suggest that almost half of COVID-19 deaths are from people in nursing homes and similar facilities, but many locales do not report this information.

Through widespread testing, additional risk hotspots could be identified, and we could better focus deployment of follow-up testing, physical distancing, personal protective equipment, and other resources. Also, once identified, high-risk populations could efficiently provide statistically meaningful results about the spread of COVID and treatment efficacy.

Testing at home, or even just home sampling, with use of interoperable apps could dramatically expand its reach given current physical distancing rules.

This is not a trivial undertaking, but the severity of the situation necessitates actions such as a balanced, “good-enough with corrective monitoring” approach to FDA approvals.

An effective testing strategy, based on quality tests, could be made available much sooner than a vaccine.

While not a panacea, testing would allow reduced restrictions for those who are not a risk to others.

For example, in one scenario, individuals with a negative viral test result and a positive antibody test result could be considered low risk for infecting others or being infected themselves. In another scenario, individuals negative for the virus and for antibodies are at low risk for infecting others, though their risk for becoming infected is not known.

In either case, the negative viral test means they are a low risk for infecting others. Armed with that information, those individuals can guide their own interactions according to the level of risk they can tolerate by applying competent government (local, regional and national) to their own personal circumstance. Those who are sero-positive but negative for virus would likely have the most favorable risk-benefit profile for returning to work.

Fears remain that COVID-19 will re-emerge and many expect the virus to ultimately become endemic - puttering along at a low level, claiming those with weakened immune systems as victims.

However, in the absence of widespread testing results, or a vaccine, we have no option but to keep physical distancing rules in place for everyone. Compliance with these rules will be greater when individuals are aware of their own and family members’ vulnerability.

Calculating the value of back to work

The Congressional Budget Office recently estimated 15% unemployment in 2Q20 and 3Q20 and a 7% decline in GDP in 2Q20, but it warned that the decline could be even worse.

In 2019, the U.S. GDP was over $21 trillion, so a 1% decline for all of 2020 would be about $210 billion.

To illustrate the value of reducing unemployment, we use a simple approach of assuming that a 1% decrease in employment decreases GDP by roughly 1%, which ignores factors such as spending from savings and welfare programs.

Using this approach, increasing employment by one percentage point for one month increases the GDP by about $18 billion. If testing allows enough individuals to safely return to work to reduce unemployment by three percentage points (from 15% to 12%) for one month, the U.S. economy would gain about $54 billion.

Testing all 330 million Americans at a hypothetical $20 per combined test would cost $6.6 billion, or nearly $20 billion if tested three times.

Whether large-scale testing can be delivered at much lower cost, such as the cost of pregnancy tests, which are about $0.20 per test, remains to be seen.

Not everyone may need three tests as those found to be serologically positive may be able to forego further testing. Restricting the multiple use of tests to workers would also dramatically reduce costs, without sacrificing economic gains.

However, whether all Americans are tested or a large subset, widespread testing is a small price in the context of stimulus funds approaching $2 trillion.

And the benefits of making testing available to everyone would go beyond employment. It would have immense intangible value for non-workers such as students, informal care-givers, and parents, allowing them to return to their routines.

Widespread Testing Can Achieve Population Health

We are calling for free mass testing. Although it is currently unclear who should be tested and how often, the essence of good science is randomization and a testable hypothesis.

FDA is providing guidance to test sponsors, but interim tests can be used in the meantime.

Simply waiting for better tests will result in more deaths and considerable additional damage to the economy.

Our approach would plot a manageable path forward as we learn more about the virus and how to mitigate its damage. These actions, and science- and data-based policies, will boost trust in the public policy decisions they engender, transcending normal politics.

Along with repeat testing, tracking results on a mass scale through interchangeable apps will be necessary. This will be possible with locator apps on cell phones and can be individually anonymized.

Rapid deployment, assessment, revision, and data gathering will require a population health approach, including FDA approval, test deployment, test result reporting and data compilation.

Widespread testing is likely to be popular because it would empower individuals to make informed choices, suggesting no government mandate would be needed.

Making this vision of widespread testing and rapid gathering of critical information a reality would require decisive federal leadership, public education, and investment, but the gains for the American people and economy would be well worth it.

Bruce Pyenson is an associate clinical adjunct professor at New York University’s School of Global Public Health and a principal and consulting actuary at Milliman Inc. Gillian Woollett is an SVP at Avalere Health.
Signed commentaries do not necessarily reflect the views of BioCentury.

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