With cases continuing to surge across the US, it is clear that we need a different approach. In the US, we never really effectively implemented an entire arm of Covid control basics, namely identification of the virus through border control, testing, wastewater surveillance, and genomic surveillance and then isolation of those exposed, through contact tracing which takes advantage of digital technology and supportive quarantine systems which could eventually be replaced by prophylactic drugs.
Biden’s recent vaccine mandates are sorely needed to increase vaccination rates. With a wealth of vaccines available, only 53.2% (as of September 13) of Americans are currently fully vaccinated. Yet is it is clear from the example of Israel that we need more than vaccines to control this ever-evolving virus. Despite having one of the earliest vaccine rollouts and leading the way in vaccinating children and rolling out boosters, Israel is now experiencing a surge of infections, hospitalizations and deaths. Israel acts as the canary in the coal mine for us all. No single public health measure or medical intervention will accomplish perfect results or will be solely responsible for controlling outbreaks. Instead, we need to build layers of protection through a multimodal strategy for long-term Covid control. Relying on vaccines alone is part of what has lead us back to this crisis point.
Our focus needs to shift to prevention and protection working in tandem with medical interventions. The first priority should be protecting your own country via stronger border controls, mandatory testing for both domestic and international travel along with temporary closures for high risk countries. Quarantine for both vaccinated and unvaccinated should be mandatory on arrival from high risk countries. The second priority is effective masking, testing and tracing systems to contain outbreaks within the country. Vaccination and other medical interventions should be the final layer of protection, not our sole modality.
Countries such as China, New Zealand, and Taiwan that have instituted rigorous border control, testing and tracing, and quarantining systems, have been successful in controlling Covid outbreaks even in the wake of highly infectious variants. In a population of almost one and half billion, daily cases have not spiked in China above 150 all year. By comparison, the US is averaging 150,00 daily cases. Research from the University of Georgia found that with a robust contract tracing team in place, an outbreak in Zhejiang was suppressed by isolating cases within five days and a third of infected contacts quarantining for the entire virus incubation period. Implementing these measures in the US in combination with high vaccination rates and other medical interventions is the best defense we have against this ever-evolving virus.
Biden’s recent announcement to use the Defense Production Act to increase production of rapid tests, including at-home tests, and dramatically reduce their price, is a welcome change. I have long advocated for the use of mass rapid testing throughout the pandemic. Yet the increased capacity and accessibility to test means nothing if there are no consequences for a positive test. A mass testing push will not succeed without effective tracing and quarantine systems.
Contact tracing is almost non-existent in the US, not only do we not have the capacity to effectively trace exposures but there are no consequences when those exposed and infected have been identified. Quarantining after exposure or infection is based on the honor system and there is also no support given to those who may struggle to effectively quarantine. In many cases, people fear losing their jobs and steady income by missing work. I have long advocated for a federal cash incentive to replace lost income and encourage participation among those who might otherwise be hesitant to report that someone in the household was infected. Families and roommates living with those infected should all quarantine together and receive the same benefits.
If there isn’t a suitable way to quarantine at home, alternative accommodation needs to be available. Free quarantine hotels are only presently available in a handful of cities across the US such as New York, such a program needs to be available nationwide. A study from New Zealand shows that isolating 50% of contacts with 100% effectiveness gives a much larger reduction in onward transmission than isolating all contacts but with only 50% effectiveness.
In the future, we may be able to replace quarantine with the use of prophylactic antiviral drugs in pill form which have such a high safety profile they can be used by anyone potentially exposed to the virus. Two such drugs from Merck and Pfizer are currently in mid to late-stage clinical trials with many more in the earlier stages of development. The antiviral drugs would work in a similar way to Xofluza, an antiviral used for Influenza that reduces transmission by 80% in a close-quarter family context. These drugs would be particularly effective in congregate living situations such as nursing homes, college dorm rooms, shelters, and prisons. By attacking the virus before it has a chance to replicate we have the opportunity to prevent the spread of infections and mutation of future variants. However, until these drugs hit the market, we will need to build supportive quarantine systems.
We need to ensure that states across the US do not reduce their contact tracing and testing capacity as soon as cases begin to recede. This leaves them woefully unprepared and under-resourced when a new outbreak inevitably resurfaces and ravages a community. Israel once had a robust and effective contact tracing system. Yet false confidence from low daily cases rates and the swift vaccine rollout led them to close the army’s contact-tracing center, in May, transferring the responsibility to the Health Ministry and slashing staff. They now find themselves without the capacity to trace the nation’s highest daily number of coronavirus cases for the duration of the pandemic.
To relieve the burden on human contact tracers we need to take advantage of QR codes and Covid tracing apps that have been effective in other countries. With smartphones ubiquitous in our society, we have an advantage over past epidemics and infectious disease outbreaks. We need to incentivize Americans to understand that the threat to their health is greater than the threat to their privacy. In times of plague, we shouldn’t take an approach of individualism but instead, think about how we can protect our broader community, the health of one is the health of all.
Wastewater surveillance is also an underused yet cost-effective, non-invasive mass testing strategy that can detect virus shed by symptomatic and asymptomatic people alike. Wastewater surveillance can complement or provide an alternative to contact tracing. A study from UC San Diego demonstrates that wastewater surveillance can detect Covid-19 in a single infected, asymptomatic person living or working in a multi-unit dwelling such as a college campus building. People infected with SARS-CoV-2, Covid-19, are known to shed in their stool and urine, even if they aren’t experiencing any symptoms. Unlike individual testing, wastewater surveillance paints a broader picture, detecting exactly when new viral variants enter a community, providing valuable data and an early warning to public officials. Time is one of the most valuable modalities of infectious disease control. Wastewater testing can predict new outbreaks with a lead time of one to two weeks.
The CDC has partnered with other federal agencies and states to develop a National Wastewater Surveillance System and pilot systems are underway in 31 states. This will be a valuable investment that will also be helpful in tracing other stool-borne pathogens, including influenza in the future. But this surveillance can and should be prioritized at the hyperlocal level to facilitate a safe return to college campuses, schools, and workplaces.
Some may argue that a lack of compliance due to pandemic fatigue will hamper efforts to prioritize this missing arm of Covid control. As difficult as it may be to comprehend, we need to shift our mindsets into thinking about Covid-19 in a long-term capacity. If we don’t the cost, will be the endangerment of all our lives.