tag:theconversation.com,2011:/us/topics/coronavirus-testing-83981/articlescoronavirus testing – The Conversation2022-12-12T13:37:37Ztag:theconversation.com,2011:article/1961792022-12-12T13:37:37Z2022-12-12T13:37:37ZChina’s loosened COVID-19 policies – following years of aggressive lockdowns and quarantines – have left the country vulnerable<figure><img src="https://images.theconversation.com/files/500103/original/file-20221209-29029-7l4vwf.jpg?ixlib=rb-1.1.0&rect=0%2C195%2C5202%2C3392&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Chinese government has loosened restrictions designed to limit the spread of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/epidemic-control-workers-wear-ppe-as-they-walk-to-disinfect-news-photo/1447909402?phrase=china%20zero%20covid%20&adppopup=true">Kevin Frayer/Stringer via Getty Images</a></span></figcaption></figure><p>After nearly three years of aiming to eliminate <a href="https://www.theguardian.com/world/2022/nov/29/china-zero-covid-policy-explained-30-seconds-lockdowns-outbreaks">COVID-19 through</a> mass lockdowns, robust contact tracing programs and international travel bans, the Chinese government has announced it is rolling back the “zero-COVID” policies that helped <a href="https://go.gale.com/ps/i.do?id=GALE%7CA618606601&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=00280836&p=HRCA&sw=w&userGroupName=mlin_oweb">suppress the spread of the coronavirus</a> in the country. The Chinese Communist Party <a href="https://www.nytimes.com/2022/12/07/world/asia/china-zero-covid-protests.html">announced these changes</a> on Dec. 7, 2022, as <a href="https://www.nytimes.com/interactive/2021/world/china-covid-cases.html">rates of COVID-19 are on the rise</a> in major cities, following <a href="https://www.nytimes.com/2022/12/07/world/asia/china-zero-covid-protests.html">protests</a> demanding the end of zero-COVID policies. </p>
<p>The situation in China stands in stark contrast to the trajectory of the pandemic in the U.S. SARS-CoV-2 emerged with a bang, but thanks to a strong vaccination effort and the fact that a large portion of U.S. residents have been infected with the coronavirus, COVID-19 cases seem to be reaching somewhat of a steady state and <a href="https://doi.org/10.1056/NEJMp2004361">normal life has mostly resumed</a>.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=YCsTY4sAAAAJ&hl=en&oi=ao">medical anthropologist</a> who studies <a href="https://www.sup.org/books/title/?id=23706">public health trends in China</a> from an epidemiologic and social perspective. </p>
<p>After largely <a href="https://www.nytimes.com/2020/08/23/world/asia/china-coronavirus-normal-life.html">containing the coronavirus in 2020</a>, China began enforcing a strict <a href="https://www.nytimes.com/2022/01/21/world/asia/china-zero-covid-policy.html">zero-COVID policy</a> leading up to the Beijing Olympics in 2022. The result is that China has not followed the standard path of a pandemic where people slowly gain immunity through exposure or vaccination, allowing society to open up over time. Combined with <a href="https://doi.org/10.1136/bmj.n969">questions about the efficacy of China’s vaccines</a> and comparatively low vaccination rates, many public health experts think that China will be hit hard by the coronavirus as the country rapidly <a href="https://www.nytimes.com/2022/12/02/health/china-covid-lockdowns.html">lifts its zero-COVID policy</a>. </p>
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<a href="https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A health worker checking a traveller at a checkpoint." src="https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500104/original/file-20221209-41828-65pkn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">After the coronavirus first emerged in late 2019, the Chinese government severely limited travel in the region of Wuhan.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakChina/5fffda0e9b8841e8923776fefe4a693b/photo?Query=china%20lockdowns%20wuhan&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=261&currentItemNo=9">AP Photo/Ng Han Guan</a></span>
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<h2>China’s initial reaction to COVID-19</h2>
<p>Public health campaigns and control of emerging disease in China are entirely reliant on and directed by the government, which promotes health both for the <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0486-6">good of the people and the nation</a>. When COVID-19 emerged, the Chinese government was quick to institute mask-wearing policies and testing regimens, and it <a href="https://www.cnbc.com/2020/04/08/coronavirus-china-ends-lockdown-of-wuhan-city-where-outbreak-started.html">locked down the city of Wuhan and the surrounding region</a> where the coronavirus originated. With only the aid of these <a href="https://doi.org/10.1016/S0140-6736(20)31278-2">nonpharmaceutical interventions</a>, the Chinese government was very successful in containing the spread of COVID-19 after the initial wave hit Wuhan. </p>
<p>From the time China started recording cases in late December 2019, until the government ended its initial period of lockdown in April 2020, <a href="https://www.cnbc.com/2020/04/08/coronavirus-china-ends-lockdown-of-wuhan-city-where-outbreak-started.html">the government documented </a> 82,000 cases of COVID-19 and just over 3,300 deaths. Though not officially called a zero-COVID policy at the time, the control measures were born out of a goal of <a href="https://doi.org/10.2471%2FBLT.20.254045">eliminating COVID-19</a> from the country. </p>
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<a href="https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A line of people waiting to be swabbed for COVID-19." src="https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500105/original/file-20221209-41225-k8glwk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In the months leading up to the 2022 Beijing Olympics, China began ramping up zero-COVID measures, including mandatory testing requirements.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakChina/f24fab8b8eae4ee4a90c714caadbf960/photo?Query=china%20zero%20covid&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=796&currentItemNo=230">AP Photo/Mark Schiefelbein</a></span>
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<h2>Ramping up zero-COVID</h2>
<p>Life returned to normal in China after the initial wave of COVID-19 ravaged Wuhan. For most of 2020 and the first half of 2021, Chinese people were <a href="https://www.theguardian.com/world/2022/nov/29/china-zero-covid-policy-explained-30-seconds-lockdowns-outbreaks">out and about</a> in shopping malls, restaurants and bars. </p>
<p>During this same period, the coronavirus was rampaging across the U.S, Europe and other regions of the world, leading many health experts to say that the lockdowns in China, though brutal, were <a href="https://go.gale.com/ps/i.do?id=GALE%7CA618606601&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=00280836&p=HRCA&sw=w&userGroupName=mlin_oweb">successful</a>. Between May 2020 and August 2021, people in China saw COVID-19 as a <a href="https://www.newyorker.com/news/news-desk/what-chinese-people-think-of-their-governments-zero-covid-policy">distant threat</a> and supported the government’s actions. </p>
<p>The situation changed in August 2021 when the Chinese government officially adopted what it calls the “<a href="https://www.ijbs.com/v18p5314.htm">Dynamic zero-COVID</a>” strategy to combat the new delta variant. This strict prevention policy included provisions for mass lockdowns <a href="https://doi.org/10.1016/S2213-2600(22)00142-4">aimed at eliminating</a> the disease in a particular region, even if just a small number of cases were found. </p>
<p>China <a href="https://www.newsweek.com/omicron-march-beijing-strains-china-zero-covid-policy-before-2022-olympics-1667828">ramped up enforcement of the policy</a> as the 2022 Winter Olympics approached. A <a href="https://www.theguardian.com/world/2021/nov/02/china-locks-down-shanghai-disneyland-and-tests-34000-visitors-after-single-covid-case">single case</a> could trigger a massive lockdown where the government would severely limit people’s movement and enforce quarantines, as occurred several times in Shanghai Disney. In some instances, people were held in stores or office buildings for <a href="https://www.nytimes.com/2022/01/21/world/asia/china-zero-covid-policy.html">several days</a> after exposure to an infected person. </p>
<p>Summer and fall 2022 were relatively quiet, with only around 1,000 confirmed infections per day. But since early November 2022, COVID-19 cases in China <a href="https://www.nytimes.com/interactive/2021/world/china-covid-cases.html">have climbed steadily</a>, with more than <a href="https://www.nytimes.com/interactive/2021/world/china-covid-cases.html">35,000 new cases detected per day</a> in the first week of December. </p>
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<a href="https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chinese president Xi Jinping with people in masks behind him." src="https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500106/original/file-20221209-34427-s6fynh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Following a wave of protests in late November and early December, the Chinese Communist Party announced that it would roll back some of the strictest travel limitations and quarantine requirements.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakChina/1ca47c62c5f94606bc1a2586088c1d71/photo?Query=xi%20jinping%20zero%20covid%20&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=76&currentItemNo=47">Jack Taylor/Pool Photo via AP</a></span>
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<h2>What happens next?</h2>
<p>As of early December, COVID-19 rates in China were still relatively <a href="https://www.nytimes.com/interactive/2021/us/covid-cases.html">low compared to many places, including the U.S.</a>. But China faces some unique challenges thanks to low levels of immunity in the population and a disease control strategy that prioritized nonpharmaceutical interventions like mask-wearing, social distancing and <a href="https://www.nytimes.com/2022/06/14/business/china-covid-testing.html">frequent testing over vaccine administration</a>.</p>
<p>To date, 90% of the population in China <a href="https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html">has been vaccinated</a>. Older people have been more reluctant, though, and only <a href="https://www.cnbc.com/2022/11/29/china-says-covid-vaccination-rates-for-seniors-has-climbed-over-the-last-two-weeks.html">66% of those over 80</a> have received two doses of a vaccine. A further concern arises from studies indicating that China’s vaccines may <a href="https://doi.org/10.1136/bmj.n969">not be as effective as the mRNA vaccines</a> used in the West. So far, China has <a href="https://www.cnn.com/2021/12/13/china/china-western-mrna-vaccine-mic-intl-hnk/index.html">not been willing to import</a> and administer Western mRNA vaccines. </p>
<p>In addition to concerns over vaccination, the zero-COVID policy has, to a large extent, successfully suppressed the coronavirus in China. The result is that since most people have not been exposed to the virus, they have not had a chance to develop immunity. This has likely <a href="https://www.theatlantic.com/health/archive/2022/12/china-zero-covid-wave-immunity-vaccines/672375/?utm_source=substack&utm_medium=email">left the country very susceptible</a> to a large outbreak. </p>
<p>There is also a social dimension to the problems facing China today. <a href="https://www.cbsnews.com/news/china-lockdowns-zero-covid-policy/">Recurring lockdowns</a> over the past year have damaged the economy and lessened <a href="https://www.nytimes.com/2022/12/03/opinion/china-covid-protests.html?smid=nytcore-ios-share&referringSource=articleShare">peoples’ patience</a> with restrictive policies. Despite government efforts to <a href="https://www.theguardian.com/world/2022/nov/28/china-censors-maskless-crowd-footage-in-world-cup-broadcasts">limit access to outside information</a>, people in China are learning that most other countries are functioning normally. Maintaining stringent zero-COVID policies has become increasingly difficult, as they <a href="https://www.nytimes.com/2022/12/01/opinion/china-covid-protests.html">wear on a populace</a> that wants life to return to normal.</p>
<p>The Dec. 7 announcement to ease COVID-19 restrictions is a continuation of a trend a few weeks in the making, but has been seen by many as a <a href="https://www.nytimes.com/2022/12/07/world/asia/china-zero-covid-protests.html">response to the widespread protests</a>. Testing centers <a href="https://www.nytimes.com/2022/12/01/world/asia/china-covid-protests-restrictions.html?utm_source=substack&utm_medium=email">are closing</a> and infected people are now allowed to <a href="https://www.reuters.com/world/china/china-allow-some-positive-covid-19-cases-quarantine-home-sources-2022-12-01/?mc_cid=b8f3c7dbfb&mc_eid=d60d414cea&utm_source=substack&utm_medium=email">quarantine at home</a> for the first time since the pandemic began. The digital health passes, issued to people who tested negative through daily PCR tests, are <a href="https://www.washingtonpost.com/world/2022/12/07/china-covid-easing-restrictions/">also no longer required</a> to enter public places. </p>
<p>In much of the world, COVID-19 has followed that <a href="https://www.jstor.org/stable/20025233">natural trajectory</a> of a pandemic. The story is different in China. The relaxation of zero-COVID policies may bring China more in line with the rest of the world in terms of what the people there can do, but the virus also gets a chance to run its natural course now that government actions will not suppress the spread. It is likely that in the coming months, the Chinese people will face the pain and suffering that many other places experienced in 2020 and 2021.</p><img src="https://counter.theconversation.com/content/196179/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elanah Uretsky does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Strict lockdowns, quarantines and testing have prevented many people in China from catching COVID-19. With concerns over Chinese vaccine efficacy and uptake, China may be facing a looming COVID-19 surge.Elanah Uretsky, Associate Professor of International and Global Studies, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1580822021-04-06T04:58:39Z2021-04-06T04:58:39ZScientists invent home COVID-19 test using coffee machine capsules<figure><img src="https://images.theconversation.com/files/392792/original/file-20210331-15-k7x70i.jpg?ixlib=rb-1.1.0&rect=53%2C0%2C6000%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nespresso machines, which brew espresso and coffee from coffee capsules, can be used for covid tests.
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-usa-october-6-2019-1550333501">Manu Padilla/Shutterstock</a></span></figcaption></figure><p>Transitioning to home working had its challenges for us all, but when your job involves researching biological applications for nanotechnology, those trials are a little more complicated than juggling the household’s broadband usage. So barred from his lab, you might reasonably expect the research by organic chemist <a href="https://www.wur.nl/en/Persons/Vittorio-dr.-V-Vittorio-Saggiomo.htm">Vittorio Saggiomo</a>, from the Bionanotechnology group at <a href="https://www.wur.nl/en/wageningen-university.htm">Wageningen University & Research</a> in the Netherlands, to have come to a grinding halt. </p>
<p>But Saggiomo is a creative, imaginative type, and so he began to wonder if he could turn common household appliances to good use in the fight against COVID-19. More specifically, could he create a cheap, highly sensitive home test for the virus? It turns out he could. His team has now posted the idea on a <a href="https://chemrxiv.org/articles/preprint/CoroNaspresso_A_Cheap_Rapid_and_Simple_Home_Test_for_Nucleic_Acid_Amplification/14224481?file=26840993">preprint server, ChemArxiv</a>. The paper is yet to be reviewed by other scientists. </p>
<p>At the moment, there are <a href="https://theconversation.com/covid-19-tests-how-they-work-and-whats-in-development-134479">two main types of COVID-19 test</a>: the PCR test and the lateral flow test (LFT). The gold-standard PCR test checks for the presence of the virus by detecting its genetic material known as RNA. But there are vanishingly small amounts of viral material in a swab, so the material has to be converted into DNA and amplified before it can be detected. And this is achieved by the “<a href="https://discoverysedge.mayo.edu/2020/03/27/the-science-behind-the-test-for-the-covid-19-virus/">polymerase chain reaction</a>”, which is what PCR stands for. </p>
<p>The process involves repeated cycling through a range of temperatures between 50°C and 90°C. During each cycle, the amount of DNA doubles, so after 30 cycles over a billion copies of the viral material can be created from just one strand of starting material. The amplified material is then detected with fluorescent labels that attach themselves to the viral DNA sequences. </p>
<p>As such, PCR is a highly sensitive technique, but it needs specialist materials and equipment to perform. This is why the tests are sent off to a lab, and it takes a day or two to get the result. </p>
<p>The second common test is the <a href="https://www.dur.ac.uk/coronavirus/lft/">lateral flow test (LFT)</a>. These work by detecting fragments of viral protein shells. Embedded within the strips of the LFTs are antibodies that bind to the virus. These antibodies are labelled with tiny gold particles, which appear red, allowing you to see them on the test device. The labelled antibodies accumulate on distinct bands on the LFT depending on whether the virus is present or not. </p>
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<p>The LFTs are fast, cheap and easy to use, making them ideal for community and home testing. But they are <a href="https://www.bmj.com/content/372/bmj.n706">nowhere near as sensitive</a> as the PCR tests – they will only identify people with high viral loads. This means many people who are infected will get a false negative result from such tests.</p>
<h2>CoroNaspresso tests</h2>
<p>Ideally, we need a home test that’s as easy to use as the LFTs but as sensitive as the PCR test. An excellent candidate is a method called <a href="https://international.neb.com/applications/dna-amplification-pcr-and-qpcr/isothermal-amplification/loop-mediated-isothermal-amplification-lamp">loop-mediated isothermal amplification (Lamp)</a>. This works along very similar principles to PCR, producing multiple copies of the starting genetic material – which you can get from a swab – but has some key advantages. </p>
<p>For example, it can be combined with a handy “colour readout”. When the Lamp reaction occurs, it causes an increase in the acidity of the sample. That means you can add a substance that changes colour according to pH value in the reaction mix, providing a visual indication of a positive or negative result. Another advantage is that Lamp reactions are carried out at a fixed temperature (about 65°C) instead of needing constant cycling through a range of temperatures.</p>
<p>Nevertheless, Lamp still needs fine temperature control. Temperature control systems – be they in a PCR machine, a Lamp instrument or household oven – are usually achieved with electronic thermostats. However, making and shipping new electronic devices specifically designed for home Lamp tests is impractical (especially in the middle of a pandemic). So Saggiomo tried to find a way around this. He hit upon substances called <a href="https://www.sciencedirect.com/topics/materials-science/phase-change-materials">phase change materials</a> that absorb energy (heat) as they melt and so maintain a constant temperature. </p>
<p>After finding a wax made of such a material that melted at exactly the required temperature, Saggiomo set about constructing a device to house the Lamp reaction tubes and chunks of wax. This then needed to be inserted into some other material that could be heated. The perfect housing turned out to be staring him in the face while making his morning coffee: Nespresso coffee machine capsules.</p>
<p>The final step was just finding the right way to heat the capsules. After trying the dishwasher (it worked but samples kept getting lost), the microwave oven (failed, because the tubes overheated and lids popped off) and cups full of hot water (not enough control on the temperature), Saggiomo settled on a simple pan of simmering water on a stovetop. The resulting “CoroNaspresso” device, when tested by other members of the team, with swabs from six people, correctly identified three cases of COVID-19 (these had a different colour to the negative tests).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=435&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=435&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392828/original/file-20210331-15-1oj1vsh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=435&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Home covid test.</span>
<span class="attribution"><span class="source">Tweet by @V_Saggiomo</span></span>
</figcaption>
</figure>
<p>The test, including the capsules, phase changing wax and vials in which to insert genetic material, would be easy to produce in millions. People could then swab for genetic material at home and heat the capsules to get their results. These devices are also cheap (about €0.20), easy to make, easy to use and largely recyclable. Maybe we’ll see the CoroNespresso tests in our homes soon, just don’t get them confused with your regular coffee pods.</p><img src="https://counter.theconversation.com/content/158082/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Lorch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Wax, vials, a coffee capsule and boiling water are the main components of a brand new COVID-19 test.Mark Lorch, Professor of Science Communication and Chemistry, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1512812020-12-04T00:01:39Z2020-12-04T00:01:39ZAlmost half a million tests, zero positives: how statistics show we can be confident COVID-19 is gone from Victoria<p>How do you know that something you are looking for is not there? Looking for a needle in a haystack is fundamentally easy – however laborious and tedious – if you know it’s definitely there. Looking for something, not finding it, and therefore concluding it does not exist is a different problem. </p>
<p>In Victoria, at the time of writing, we have had <a href="https://twitter.com/VicGovDHHS/status/1334607473823674368?s=20">35 consecutive days</a> of zero newly detected COVID-19 infections. But, obviously, not everyone in the state has been tested. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-may-well-be-able-to-eliminate-coronavirus-but-well-probably-never-eradicate-it-heres-the-difference-137991">We may well be able to eliminate coronavirus, but we'll probably never eradicate it. Here's the difference</a>
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<p>So what does the lack of new cases tell us about the true frequency of infections in the Victorian population? Or, to put it another way, what is the maximum number of infections that could still lurk out there undetected?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372430/original/file-20201202-17-1yo7peu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Number of daily tests carried out in Victoria since October 31 2020.</span>
<span class="attribution"><span class="source">Michael Stumpf</span></span>
</figcaption>
</figure>
<p>These are what statistician call sampling problems. We do not test everyone, but instead rely on people with symptoms to come forward for testing. If everyone with symptoms gets themselves tested, this should give us a good idea of how many cases there are. </p>
<p>There are caveats: some people do not come forward for testing while others get tested several times; cases tend to cluster in families. But we can account for such uncertainties in the analysis framework that we use below.</p>
<p>Plenty of people are still getting tested. People check the Department of Health and Human Services’ social media feeds to see the daily “0” (the celebrated “doughnut”); some are concerned about the number of tests performed each day; and many people seriously worry about the chance of a return of the virus. </p>
<h2>Working out the probabilities</h2>
<p>However, we can estimate the probability the virus is still out there in Victoria. There are different ways to do it, but ultimately they all give very similar results. </p>
<p>One good way is to adopt a <a href="https://en.wikipedia.org/wiki/Bayesian_probability">“Bayesian” approach</a>, which also lets us work out how accurate the estimate is likely to be, given the uncertainties in our assumptions and inputs. We could do the calculations exactly (using a paper and pencil, or computer algebra software), but for making predictions we usually use simulations.</p>
<p>For our estimate we need to know a few numbers:</p>
<ul>
<li><p><em>N</em>: the total number of people in Victoria (about 6.5 million)</p></li>
<li><p><em>n</em>: the number of tests carried out</p></li>
<li><p><em>p</em>₀: what we think (or fear) the frequency of infected people in the Victorian population is, before we look at the testing data.</p></li>
</ul>
<p>With this we can estimate <em>p</em>, the frequency of cases, after taking into account that we found 0 positives among <em>n</em> tests. A <em>p</em> value of 1 would mean everybody in Victoria has COVID, and 0 would mean nobody does.</p>
<h2>Running the numbers</h2>
<p>In the Bayesian framework we calculate <em>p</em> as a compromise between our <em>prior</em> knowledge (or beliefs) and the new information gleaned from the data. </p>
<p>The <em>prior</em> forces us to state explicitly what we expect or believe reality to look like. And because it is a probability it also accounts for our level of certainty or ignorance. When possible we can, for example, use information from previous studies to generate the prior. </p>
<hr>
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<strong>
Read more:
<a href="https://theconversation.com/australias-coronavirus-testing-rates-are-some-of-the-best-in-the-world-compare-our-stats-using-this-interactive-142289">Australia's coronavirus testing rates are some of the best in the world – compare our stats using this interactive</a>
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<p>To be cautious, we will start with the very pessimistic assumption that an average of 1% of people in Victoria are actually infected. (We can be confident the real number is much smaller, but we are interested in a worst-case scenario.) </p>
<p>We put this 1% figure into our model as a probability distribution (called a “beta distribution”) that produces variable results with an average of 0.01 (which is another way of writing 1%).</p>
<p>If there are 0 positive tests among <em>n</em> tests then this will happen with probability (1 – <em>p</em>)<sup><em>n</em>.</sup> The bigger <em>p</em> is, the more people have the virus, and the smaller the chances we would see 0 positive results. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=130&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=130&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=130&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=163&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=163&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372429/original/file-20201202-13-1ja92oq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=163&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Just a few lines of code (here shown in the Julia programming language) can simulate the probability that there are still cases in Victoria.</span>
<span class="attribution"><span class="source">Michael Stumpf</span></span>
</figcaption>
</figure>
<p>With these two ingredients, the prior knowledge and the information from the data, we can now estimate the true frequency of infection in the Victorian population. </p>
<p>On the first day of the ongoing sequence of zero cases, October 31, 2020, there were 19,850 tests performed (thus <em>n</em>=19,850). The expected value for the true positive rate in Victoria on that day was therefore a tiny 0.0000000041 (4.1 × 10<sup>–9).</sup> We ran a million simulations of this scenario, and only in 260 instances were there any cases at all left in the population, with a maximum of 986 possible hidden cases.</p>
<p>Now after over a month of zero cases, and a total number of 438,950 tests between October 31 and December 2, the estimated probability has gone down even further to 0.00000000011 (1.1 × 10<sup>–10).</sup> The highest number of lurking infections in one million simulations is now 39 cases (and only 132 of our million simulations contained any cases at all).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372431/original/file-20201202-23-5ek7yx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Expected number of cases in Victoria per day since the 31st of October 2020. We expect there is less than 1 case in the community (about 1/10,000). If this is true it would mean that we have achieved elimination of the virus in the community.</span>
</figcaption>
</figure>
<h2>What we can learn from this</h2>
<p>Three points are worth considering, especially when applying this approach in the context of other states and territories, or Australia as a whole. </p>
<ol>
<li><p>These estimates are based on assumptions, but we can test how changes (or errors) in our assumptions affect the analysis. In this case relatively little: it is extremely unlikely there is even a single COVID case left in the Victorian community.</p></li>
<li><p>We can also ask when we would be likely to detect cases of COVID-19 if it re-enters the community. The current testing regime turns out to be remarkably sensitive. Even with only 5,000 randomly(!) administered tests we would have a better than 50-50 chance of detecting a case if only 0.0014% of Victorians – or about 91 people – were (asymptomatically) infected. If people with symptoms continue to get tested even single cases will be detected and that is what we want. </p></li>
<li><p>Testing is therefore important and the key to prolonged suppression. The simplistic statement that you get more cases if you do more testing fails to take into account just how important testing is to control the disease, especially in the early and the final suppression stages. For as long as testing is easily accessible throughout the state and used by (a large fraction of) people exhibiting COVID-like symptoms we should be able to detect and quell any resurgence, even before a vaccine becomes available. </p></li>
</ol>
<p>We were arguably lucky to get to zero cases, but we can be very confident that we have now eliminated COVID-19 in the community. The absence of evidence for coronavirus infections has slowly become evidence for the absence of the virus from Victoria.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/as-restrictions-ease-here-are-5-crucial-ways-for-australia-to-stay-safely-on-top-of-covid-19-138000">As restrictions ease, here are 5 crucial ways for Australia to stay safely on top of COVID-19</a>
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</p>
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<img src="https://counter.theconversation.com/content/151281/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Stumpf receives funding from the Volkswagen Foundation. In the past he has received funding from the Wellcome Trust, the Biotechnological and Biological Research Council (UK), the Medical Research Council (UK), the Engineering and Physical Sciences Research Council (UK), the Leverhulme Trust, and the Royal Society of London.</span></em></p>After more than a month of testing without a single positive case, the probability of coronavirus lurking in Victoria is vanishingly small.Michael P.H. Stumpf, Professor for Theoretical Systems Biology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1459602020-09-10T17:05:42Z2020-09-10T17:05:42ZBoris Johnson’s ‘moonshot’ mass testing plan is not the way out of the coronavirus pandemic<p>UK Prime Minister Boris Johnson has announced an ambitious <a href="https://www.bbc.co.uk/news/live/world-54083725">“moonshot” plan to roll out mass population testing</a> for COVID-19. Johnson said that, under the plan, the UK would process millions of tests a day, allowing those who test negative to resume their normal lives. The programme will cost around £100 billion, equivalent to two-thirds of the <a href="https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget">annual budget</a> of the National Health Service.</p>
<p>Will it work? Unfortunately, mass population testing is a flawed idea in search of science to back it up. It is unlikely to be the solution that sees us out of this pandemic. </p>
<h2>No test is perfect</h2>
<p>The <a href="https://www.bmj.com/content/370/bmj.m3262">purpose of COVID-19 mass testing</a> is to detect people who are infected so that disease control measures such as quarantine and contact tracing can be undertaken to break the chains of transmission. </p>
<p>This critically depends on how good the test is. There is no such thing as a perfect test – every type will generate false positives and false negatives. The amount of false results generated depends on the characteristics of each test, as defined by their sensitivity (how accurately they identify cases), specificity (how accurately they identify non-cases) and predictive values (how likely you are to have or not have the disease if you test positive or negative respectively).</p>
<p>Let’s look at the gold standard test: reverse transcriptase polymerase chain reaction (RT-PCR). This tells you whether the genetic material of the virus that causes COVID-19 is present, but it won’t necessarily tell you if you are currently infected or have a re-infection. It can’t tell whether it is a past infection but you are still shedding bits of virus (indeed studies have shown <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25952">some people shed viruses for many weeks</a>). And despite having viral genetic material present, the test does not tell you if you’re infectious.</p>
<p>The accuracy of RT-PCR tests are affected by <a href="https://jamanetwork.com/journals/jama/article-abstract/2762997">what samples are taken</a>, ranging from 93% for specimens taken from air passages of the lung, down to 32% for a simple throat swab. It is also affected by how the samples are taken, stored, transported and processed. Contamination at any stage can give you a false reading. Whether a test detects viral infection also depends on the stage of the disease and the person being tested. Some infected people might shed lots of virus, others less. </p>
<p>There are other types of types of test, such as, antibody tests, which are currently being used but which also have <a href="https://www.bmj.com/content/370/bmj.m2516">limitations and issues with accuracy</a>. There is the <a href="https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html">possibility of cross-reactivity with other viruses</a> with antibody tests. Antibody tests are less sensitive, especially early in the disease as there may be insufficient antibody response to be detected. Later on, antibody levels may fade and again be undetectable. And even if antibodies were detected, interpretation is tricky - is it a recent infection or past infection? We can’t tell. </p>
<p>The predictive value of the tests also <a href="https://www.bmj.com/content/353/bmj.i3139?ijkey=f575e3dc6b62a43da3b737f85e2012078378858e&keytype2=tf_ipsecsha">depends on the prevalence of disease</a> in the community. When disease prevalence is low, we are more likely to get a lot more false positives. Indeed, if you have a positive test, it may be that you don’t have disease. When disease prevalence is high, the predictive value improves and test results are more likely to be accurate. What that means in practice is that if a million people were tested, there is the real possibility that tens of thousands will get erroneous results.</p>
<h2>Why it matters</h2>
<p>Test accuracy matters – a lot of false positives can create anxiety for people affected and leads to unnecessary restrictions on them, their households, schools or workplaces. It also generates a lot of work for public health protection teams who have to investigate each case. </p>
<p><a href="https://www.mayoclinicproceedings.org/article/S0025-6196(20)30365-7/pdf">False negatives are more worrying</a>, as affected individuals who may be infectious are falsely reassured. They will continue with their lives, potentially relax their infection control behaviours, and infect others. These erroneous results are likely to undermine public trust in the testing system.</p>
<p>Another fly in the ointment is the frequency of testing required. A person could be tested negative on one day, contract an infection from an infectious person the next day, and be themselves infectious within a week. If they had an infection with no symptoms, they could unwittingly continue to spread the disease until they had their next test.</p>
<h2>Unintended consequences</h2>
<p>There are practical considerations at every step of the way for any national testing program. Who’s administering the test? What personal protective equipment and support infrastructure do they need? Who transports the specimens? Who processes the specimens? How are they safely disposed of? How are results managed? How are the results interpreted and fed back appropriately to individuals? How will positive results be notified to public health authorities? </p>
<p>Mass testing also requires a lot of infrastructure and personnel. In the UK, we have limited clinical workforce. There is an opportunity cost inherent in diverting these limited clinical resources away from other activities. Which does one consider more important – childhood vaccinations, cancer screening, diabetes management, or swabbing activity of low-risk individuals for COVID-19? The solution might be a do-it-yourself test, but a good enough version of this has not yet been developed.</p>
<p>As a system we have to ensure equitable coverage of services and care for the whole population – the sick, the people with disabilities, the elderly, children, care home residents and others. Decisions for one group may have unintended consequences for another. We have to be mindful that our actions don’t have disproportionate and harmful effects elsewhere in the system leading to sickness and death in non-COVID sectors.</p>
<p>It is worth noting that a test in itself is not an intervention. People who have been identified to be possible cases of COVID-19 through testing need to isolate and take necessary precautions. Worryingly, one study in the UK found that <a href="https://www.medrxiv.org/content/10.1101/2020.06.01.20119040v1">less than a quarter of people with COVID-19 symptoms followed isolation and lockdown advice</a>. Public support and compliance with these measures is therefore vital. Even if mass population testing is rolled out, it is unlikely to work without the buy-in of the public. </p>
<p>We know what works in fighting coronavirus – keeping our distance, using face coverings, frequent hand washing and avoiding crowds, close contact, and confined spaces. Having an effective contact tracing system as well as a support system for those who have to self-isolate is also important. The protective effect of all these measures are additive – so do it all.</p><img src="https://counter.theconversation.com/content/145960/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lee has previously received research funding from the National Institute for Health Research. He is a member of the UK Faculty of Public Health and the Royal Society for Public Health.</span></em></p>The prime minister big new plan is a flawed policy in search of the science to back it up.Andrew Lee, Reader in Global Public Health, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1452362020-08-31T12:38:28Z2020-08-31T12:38:28ZI’m a public health researcher, and I’m dismayed that the CDC’s missteps are causing people to lose trust in a great institution<figure><img src="https://images.theconversation.com/files/355397/original/file-20200829-20-1195wxl.JPG?ixlib=rb-1.1.0&rect=11%2C36%2C613%2C403&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Workers on Saturday, Aug. 29, 2020 removed the main sign to the visitors' entrance to the CDC, leaving instead a temporary one made of cardboard-like material.</span> <span class="attribution"><span class="source">Lynne Anderson</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><a href="https://www.cdc.gov/coronavirus/2019-ncov/about/steps-when-sick.html">The Centers for Disease Control and Prevention</a> has been the premier U.S. public health agency since its founding on <a href="https://www.cdc.gov/about/history/index.html">July 1, 1946</a>. </p>
<p>The CDC is responsible for assuring the health of all Americans and promoting evidence-based public health practice. It also is responsible for researching the causes of death and illness as well as working on ways to prevent them. Americans have come to trust it for <a href="https://fivethirtyeight.com/features/americans-trust-the-cdc-on-covid-19-trump-not-so-much/">accurate information</a>. </p>
<p>However, recent actions by the CDC have led many in public health to call into question the <a href="https://thehill.com/opinion/healthcare/509227-we-need-an-independent-public-health-agency">integrity</a> of the CDC’s leadership as they ignore the science and bow to <a href="https://www.cnn.com/2020/08/26/politics/cdc-coronavirus-testing-guidance/index.html">political pressure</a>. Their actions have hurt public health efforts and led to confusion and mistrust by the public at large. </p>
<p>As an <a href="https://scholar.google.com/citations?user=T8sw5R0AAAAJ&hl=en">infectious disease epidemiologist</a>, I have spent my career both in academia and in public health practice studying how viruses infect people and testing populations to determine current infection and immunity. I find the politicization of advice coming out of the CDC disturbing, to say the least. </p>
<p>The latest, most egregious non-science-based advice is a change in recommendation for who should get tested for COVID-19. Here’s what happened and why it matters so much – not just to public health experts, but to the public. </p>
<figure class="align-center ">
<img alt="A big digital sign by a road that directs people to a testing site." src="https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/355394/original/file-20200829-21-ynfi78.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A digital sign in Stony Brook, New York, directs patients to the drive-thru coronavirus test site at Stony Brook University on March 28, 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/digital-sign-on-stony-brook-road-in-stony-brook-new-york-on-news-photo/1215580919?adppopup=true">John Paraskevas/Newsday via Getty Images</a></span>
</figcaption>
</figure>
<h2>Testing is key to containing the virus</h2>
<p>Public health experts have learned a great deal about the novel coronavirus and COVID-19 since the coronavirus first appeared. </p>
<p>They have learned, for example, that an <a href="https://www.acpjournals.org/doi/10.7326/M20-3012">estimated 4 out of 10 infected people</a> will never show symptoms – but can unknowingly infect others. </p>
<p>In addition, infected persons who will go on to develop symptoms can spread the disease <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765641">one to two days</a> before those symptoms occur. These are two of the reasons the virus is so hard to contain.</p>
<p>Evidence suggests that widespread testing of people without symptoms would <a href="https://theconversation.com/rapid-screening-tests-that-prioritize-speed-over-accuracy-could-be-key-to-ending-the-coronavirus-pandemic-143882">greatly reduce the spread of the virus</a> by allowing people to know they’re infected and self-quarantine. Contacts of those asymptomatic cases can be identified and tested for the same reasons. This has been the CDC’s recommendation since studies first began to show asymptomatic transmission.</p>
<p>Then, the CDC on Aug. 24, 2020 changed course and recommended to <a href="https://www.nytimes.com/2020/08/26/us/politics/coronavirus-testing-trump-cdc.html?action=click&module=RelatedLinks&pgtype=Article">test only those people who have symptoms for COVID-19</a>. </p>
<p>Many <a href="https://www.usatoday.com/story/news/2020/08/27/cdc-walks-back-surprise-coronavirus-asymptomatic-testing-guidelines/5645630002/">public health experts were shocked</a>. Testing only those who have symptoms will miss close to half of those who are infected.</p>
<p>Two days after the revised guidelines had been quietly changed on the CDC website, <a href="https://www.statnews.com/2020/08/27/redfield-clarify-controversial-testing-guidelines/">Director Robert Redfield clarified</a> that those who come into contact with confirmed or probable COVID-19 patients could be tested even in the absence of symptoms. </p>
<p>That has always been the case, though. </p>
<p>In the meantime, the altered guidelines on the CDC website promote confusion and remain unchanged as of Aug. 31, 2020. <a href="https://www.reuters.com/article/us-health-coronavirus-usa-testing/california-florida-new-york-texas-will-not-follow-new-us-covid-19-testing-plan-idUSKBN25N31H">Arizona, California, Connecticut, Florida, Illinois, Texas, New Jersey and New York have already announced</a> they will not follow the new CDC testing guidelines, showing more understanding of the benefits of testing than our national public health institution.</p>
<figure class="align-center ">
<img alt="Dr. Anthony Fauci sits at the White House." src="https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/355426/original/file-20200830-21-1p3fhdy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, listens during a briefing on the pandemic in the press briefing room of the White House.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/national-institute-of-allergy-and-infectious-diseases-news-photo/1215224972?adppopup=true">Drew Angerer/Getty Images</a></span>
</figcaption>
</figure>
<h2>Fauci had no voice in the matter</h2>
<p>This new recommendation came from the <a href="https://www.cnn.com/2020/08/26/politics/fauci-coronavirus-cdc-testing/index.html">White House Coronavirus Task Force</a>, and the CDC fell in line. Dr. Anthony Fauci, a task force member and head of the National Institute of Allergy and Infectious Diseases, <a href="https://www.cnn.com/2020/08/26/politics/fauci-coronavirus-cdc-testing/index.html">was undergoing surgery</a> on his vocal cords when the task force met Aug. 20 and decided on the change. </p>
<p>The <a href="https://www.apha.org/news-and-media/news-releases/apha-news-releases/2020/new-covid-19-testing-guidance">American Public Health Association has pointed out</a> that the change was made without effective consultation with public health professionals working on the ground to control the pandemic. The World Health Organization continues to support testing of asymptomatic persons. Nearly every public health organization has called for a <a href="https://www.washingtonpost.com/nation/2020/08/28/coronavirus-covid-live-updates-us/?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most">reversal</a>. </p>
<p>It is a particularly confusing decision given that <a href="https://www.nytimes.com/interactive/2020/04/17/us/coronavirus-testing-states.html">lack of access to adequate testing</a> has been an ongoing issue and has led to serious barriers in getting control of the pandemic.</p>
<figure class="align-center ">
<img alt="Trump, wearing khaki pants and a MAGA hat, surrounded by health officials at the CDC." src="https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/355393/original/file-20200829-14-ka8s7a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Alex Azar, head of the Department of Health and Human Services, President Trump, CDC Director Robert Redfield and Associate Director Steve Monroe at the CDC in March 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-donald-trump-speaks-next-to-us-health-and-human-news-photo/1205520815?adppopup=true">Jim Watson/AFP via Getty Images</a></span>
</figcaption>
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<h2>See no virus, have no virus?</h2>
<p>Without test data, epidemiologists are flying blind. Not knowing who is infected, we do not have a picture of how many infected persons are in the community and how the virus is being transmitted.</p>
<p>Identifying those who may have been exposed to the virus is the whole rationale for <a href="https://www.who.int/news-room/q-a-detail/contact-tracing">contact tracing</a> – find cases, identify contacts who may have been infected, ask them to self-quarantine, and test them for the virus. Testing is at the core of controlling infectious disease spread. </p>
<p>The thinking seems to be that if you don’t test, the number of cases will go down. </p>
<p>Clearly, this is true only in the political sense. Yes, the number of reported cases will decrease, but the number of infected persons will not. By not identifying those who are infected but don’t have symptoms, spread of the virus will increase as those who don’t know they are infected, infect others. </p>
<p>Trump has said that he “likes the numbers where they are” and said at a campaign rally in Tulsa that he would tell his people to <a href="https://nymag.com/intelligencer/2020/06/trump-slow-down-coronavirus-testing-confession-joking.html">“slow the testing down.”</a></p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<h2>A series of tussles</h2>
<p>The CDC has been in the midst of a political struggle many times during this pandemic. </p>
<p>In May, it was revealed that CDC had been <a href="https://www.theatlantic.com/health/archive/2020/05/cdc-and-states-are-misreporting-covid-19-test-data-pennsylvania-georgia-texas/611935/">adding antibody tests, a marker of previous infection, to the number of PCR tests</a>, a marker of current infection, performed. This made it appear that more tests to detect current infection had been performed than actually had.</p>
<p>In July, hospitalization data, historically reported to CDC and used by health departments and researchers throughout the country to understand the pandemic, <a href="https://www.statnews.com/2020/07/16/hospital-data-reporting-covid-19/">disappeared from the CDC website</a> as reporting switched to a private contractor. It reappeared a few days later, but this raised <a href="https://www.npr.org/sections/health-shots/2020/07/15/891351706/white-house-strips-cdc-of-data-collection-role-for-covid-19-hospitalizations">concerns this would hurt the ability of CDC to gather and analyze these data</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1280857657365200902"}"></div></p>
<p>In another instance, the administration pressured CDC to rewrite its guidelines for <a href="https://www.washingtonpost.com/health/trump-sidelines-public-health-advisers-in-growing-rift-over-coronavirus-response/2020/07/09/ad803218-c12a-11ea-9fdd-b7ac6b051dc8_story.html">safely reopening schools</a>. It did this, even though once again, the guidelines did not reflect current scientific knowledge. </p>
<p>The world is now in the midst of the worst pandemic in over a century. The United States has 4.4% of the world’s population but <a href="https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6">24%</a> of COVID-19 cases. Plainly, we are not doing well, and lack of trust in CDC’s guidance as well as contantly changing messaging is hampering our efforts to control the virus. No wonder the public is confused about what they should be doing.</p>
<p>It does not bode well if we Americans can no longer trust the advice and guidelines emanating from our national public health entity, not just for control efforts in this pandemic but for future health concerns as well. </p>
<p>I answer questions about COVID-19 weekly on a <a href="https://tunein.com/podcasts/News/Houston-Matters-p517987/">radio call in</a> show. A few weeks ago a caller asked me if we could trust the information coming out of the CDC. I never thought I would be in a position where I couldn’t give an unequivocal “yes.” When politics overcomes science, public health cannot fulfill its mission, and everyone will all suffer. </p>
<p><em>Editor’s note: Any views in this article reflect the opinion of the author and not of the University of Texas Health Science Center.</em></p><img src="https://counter.theconversation.com/content/145236/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Lynne Troisi is an executive board member of the American Public Health Association. </span></em></p>The CDC has long been a trusted source of health information, keeping the public not only safe but calm in times of disease outbreaks. Public health officials fear now for its reputation.Catherine Lynne Troisi, Associate Professor of Management, Policy, and Community Health and Epidemiology, University of Texas Health Science Center at HoustonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1433402020-07-30T12:50:35Z2020-07-30T12:50:35ZTest positivity rate: How this one figure explains that the US isn’t doing enough testing yet<figure><img src="https://images.theconversation.com/files/350231/original/file-20200729-15-p7dsv5.jpg?ixlib=rb-1.1.0&rect=51%2C73%2C4853%2C3196&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As cases surge, testing needs to increase as well.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Texas/f793ee6a0f9447ba9bc0c52d70422f91/59/0">AP Photo/David J. Phillip</a></span></figcaption></figure><p>The U.S. has performed <a href="https://coronavirus.jhu.edu/testing/international-comparison">more coronavirus tests</a> than any other country in the world. Yet, at the same time, the U.S. is notably underperforming in terms of suppressing COVID-19. Confirmed cases – as well as deaths – are surging in many parts of the country. Some people have argued that the increase in cases is solely due to increased testing.</p>
<p><a href="https://scholar.google.com/citations?hl=en&user=kWGF578AAAAJ">I am a statistician</a> who studies how mathematics and statistics can be used to track diseases. The claim that the increase in cases is only caused by increases in testing is just not true. But how do public health officials know this?</p>
<h2>Testing, confirmed cases and total cases</h2>
<p>COVID-19 testing has two purposes. The first is to confirm a diagnosis so that medical treatment can be appropriately rendered. The second is to do surveillance for tracking and disease suppression – including finding those who <a href="https://theconversation.com/can-people-spread-the-coronavirus-if-they-dont-have-symptoms-5-questions-answered-about-asymptomatic-covid-19-140531">may be asymptomatic</a> or only have mild symptoms – so that individuals and public health officials can take actions to slow the spread of the virus.</p>
<p>At a White House briefing on July 13, the president said, <a href="http://www.whitehouse.gov/briefings-statements/remarks-president-trump-roundtable-stakeholders-positively-impacted-law-enforcement">“When you test, you create cases.”</a> </p>
<p>The problem with this statement is that anyone who is infected with the coronavirus is, by definition, a case. Since taking a COVID-19 test does not cause a person to get coronavirus, just like taking a pregnancy test does not cause one to become pregnant, the president’s claim is false. Testing does not create cases. </p>
<p>However, because many COVID-19 cases are asymptomatic, many people are infected and don’t know it. What COVID-19 testing does do is identify unknown cases. And thus it does increase the number of cases that are known, or otherwise called the confirmed case count.</p>
<p>Finding unknown cases is good, not bad, because identifying those who are COVID-19-positive allows individuals and public health officials to take actions that slow the spread of the disease. When public health officials find cases, they can begin contact tracing. When a person finds out they are infected, they will know to quarantine. </p>
<p>Since the beginning of the pandemic, the U.S. has performed <a href="https://coronavirus.jhu.edu/testing/international-comparison">more total tests and more tests per capita than any other country</a>, though as of late July <a href="https://www.statista.com/statistics/1104645/covid19-testing-rate-select-countries-worldwide/">the U.K., Russia and Qatar were performing more tests per capita per day</a>. But counting the total number of tests or the tests per capita is not the right way to judge success of a testing program. </p>
<p>As it says on the <a href="https://coronavirus.jhu.edu/testing/international-comparison">Johns Hopkins testing comparison page</a>, a country’s “testing program should be scaled to the size of their epidemic, not the size of the population.” Sure, the U.S. might have a big testing program, but it has a massive epidemic. The U.S. needs an equally massive testing program if health officials want to have an accurate picture of what’s really going on. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&rect=38%2C49%2C3628%2C2187&q=45&auto=format&w=1000&fit=clip"><img alt="Two health care works standing outside preparing to perform a swab test at a drive-through testing station." src="https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&rect=38%2C49%2C3628%2C2187&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/350218/original/file-20200729-13-lzu5vp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As the need for testing has grown, so have lines at testing facilities. Results can take more than a week to be returned.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Oklahoma/c533d6aa37dd4d5e8f8f84a8d052cc37/1/0">AP Photo/Sue Ogrocki</a></span>
</figcaption>
</figure>
<h2>Test positivity rate</h2>
<p>So how do public health officials know if they are doing enough testing?</p>
<p>Better than simply counting total number of tests, the test positivity rate is a useful measure of whether enough tests are being done. The test positivity rate is simply the fraction of tests that come back positive. It is calculated by dividing the number of positive tests by the total number of tests. Generally, a lower test positivity rate is good.</p>
<p>A good way to think about test positivity is to think about fishing with a net. If you catch a fish almost every time you send the net down – high test positivity - that tells you there are probably a lot of fish around that you haven’t caught – there are a lot of undetected cases. On the other hand, if you use a huge net – more testing – and only catch a fish every once in a while – low test positivity – you can be pretty sure that you’ve caught most of the fish in the area. </p>
<p>According to the World Health Organization, before a region can relax restrictions or begin reopening, the test positivity rate from a comprehensive testing program should be <a href="http://www.who.int/publications/i/item/public-health-criteria-to-adjust-public-health-and-social-measures-in-the-context-of-covid-19">at or below 5%</a> for at least 14 days.</p>
<p>There are two ways to lower a test positivity rate: either by decreasing the number of positive tests or by increasing the total number of tests. A comprehensive testing program does both. By conducting a large number of tests, most cases in the community are detected. Then, individual and government actions can be taken that contain the virus. This results in a declining number of positive tests. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Returning to the fishing metaphor, the goal of a comprehensive testing program is to use a huge net to overfish in the coronavirus lake until there are very few COVID-19 cases left. Using the test positivity rate as a measure of success helps ensure that a testing program is appropriately scaled to the size of an epidemic.</p>
<p>As of July 27, the U.S. as a whole had a <a href="https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/testing-in-us.html">test positivity rate of 10%</a>. States where testing programs are robust and the virus is fairly well controlled have test positivity rates well below 5%, like <a href="https://coronavirus.jhu.edu/testing/testing-positivity">Massachusetts at 2.68% and New York at 1.09%</a>. In places like Mississippi and Arizona that are experiencing large outbreaks, <a href="https://coronavirus.jhu.edu/testing/testing-positivity">test positivity rates are above 20%</a>.</p>
<h2>The right amount of testing</h2>
<p>The increases in confirmed cases aren’t occurring just because there is more testing. The high test positivity rates in some locations show that the virus is in fact spreading and growing so testing needs to grow with it. I believe that if the U.S. wants to beat back this virus, one of the first things that needs to happen is to increase testing. We need to deploy larger nets to catch more fish. Yes, we’ll find more cases, but that’s the point.</p><img src="https://counter.theconversation.com/content/143340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald D. Fricker Jr. does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Test positivity rates measure the success of a testing program. Even though the US performs a huge number of tests, high test positivity rates across the country show that that it still isn’t enough.Ronald D. Fricker Jr., Professor of Statistics and Senior Associate Dean, Virginia TechLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1423662020-07-24T12:29:14Z2020-07-24T12:29:14ZMaking coronavirus testing easy, accurate and fast is critical to ending the pandemic – the US response is falling far short<figure><img src="https://images.theconversation.com/files/349199/original/file-20200723-29-15bhm4z.jpg?ixlib=rb-1.1.0&rect=22%2C66%2C2880%2C1727&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are functional tests for coronavirus, but not enough of them are being done. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Michigan/2bf9018fca3b44a7a46d6f96d48dfbde/14/0">AP Photo/Paul Sancya</a></span></figcaption></figure><p>For many people in the U.S., getting tested for COVID-19 is a struggle. In Arizona, testing sites have seen lines of hundreds of cars <a href="https://www.msn.com/en-us/weather/topstories/people-wait-in-hours-long-line-for-free-covid-19-test-in-south-phoenix/ar-BB16gAuv">stretching over a mile</a>. In Texas and Florida, some people were <a href="https://www.bloomberg.com/news/articles/2020-06-29/in-hot-spot-states-those-seeking-tests-meet-long-lines-delays">waiting for five hours</a> for free testing. </p>
<p>The inconvenience of these long waits alone <a href="https://www.washingtonpost.com/health/long-delays-in-getting-test-results-hobble-coronavirus-response/2020/07/12/d32f7fa8-c1fe-11ea-b4f6-cb39cd8940fb_story.html">discourages many people from getting tested</a>. With the surge in cases, many public testing sites have been <a href="https://www.texastribune.org/2020/06/29/coronavirus-testing-austin-dallas-houston/">reaching maximum capacity</a> within hours of opening, leaving many people unable to get tested for days. Those that do get tested often face a week-long wait to get their test results. </p>
<p>Every person who isn’t tested could be spreading COVID-19 unknowingly. These overstretched testing programs are a weak link in the U.S. pandemic response.</p>
<p>I <a href="https://publicpolicy.umbc.edu/zoe-m-mclaren/">study public health policy</a> to combat infectious disease epidemics. The key to overcoming this pandemic is to slow transmission of the virus by preventing contagious people from infecting others. A widespread quarantine would accomplish this, but is economically and socially burdensome. Testing offers a way to identify contagious people so they can be isolated to prevent the spread of the disease. This is especially important for COVID-19 because an estimated 40% or more of all people infected with SARS-CoV-2 <a href="https://theconversation.com/can-people-spread-the-coronavirus-if-they-dont-have-symptoms-5-questions-answered-about-asymptomatic-covid-19-140531">have few or no symptoms</a> so testing is the only way to identify them.</p>
<p>Some states are doing much better than others. But as a whole, the U.S. is falling far short of the amount of testing needed to control the pandemic. What are the challenges the U.S. is facing? And what is the way forward?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A lab technician using a swab to put a sample into a rapid test machine." src="https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/349203/original/file-20200723-29-112ztr1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Currently, rapid tests that take about 15 minutes to process are a quick and easy way to diagnose COVID-19 infections, but there are concerns about accuracy.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Testing-Problem/73ae28797e4845a8a138a38641821b12/1/0">AP Photo/Carlos Osorio</a></span>
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</figure>
<h2>Testing should be free, easy, fast and accurate</h2>
<p>The ultimate goal of testing is for everyone, regardless of symptoms, to know at all times whether they are infected with the coronavirus. To achieve this level of testing, tests should be free, very easy to perform and provide accurate results quickly.</p>
<p>Ideally, free COVID-19 tests would be delivered to everyone directly. The tests would be simple to perform – like a <a href="https://www.the-scientist.com/news-opinion/saliva-tests-how-they-work-and-what-they-bring-to-covid-19-67720">saliva test</a> – and would give a perfectly accurate result within minutes. Everyone could test themselves weekly or anytime they were going to be in close contact with other people.</p>
<p>In this ideal scenario, most, if not all, contagious people would be detected before they could spread the virus to others. And because of the rapid results, there would be no burden of quarantining between doing the test and getting the result.</p>
<p>Researchers are working on better-quality tests, but access is a problem of infrastructure, not science. Right now, nowhere in the U.S. comes close to meeting surging demand for testing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A line of people waiting in cars in front of a sign for COVID-19 testing." src="https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348981/original/file-20200722-24-y4f7xu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Long lines, slow turnaround times for results and shortages of testing capacity all make Texas one of the worst places to get a test in the U.S.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Texas/bf4c1e3e3ade4acb975e957da9df6fb2/7/0">AP Photo/David J. Phillip</a></span>
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<h2>One of the worst cases: Texas</h2>
<p>The difficulty of getting a COVID-19 test varies by state, but currently, people in <a href="https://coronavirus.jhu.edu/testing/individual-states/texas">Texas face some of the biggest obstacles</a>, which results in far fewer tests being done than is needed to control the pandemic.</p>
<p>First, Houston – which is <a href="https://www.nytimes.com/interactive/2020/us/texas-coronavirus-cases.html">experiencing a surge in cases</a> – and <a href="https://txdps.maps.arcgis.com/apps/webappviewer/index.html?id=8bf7c6a436a64bfe9a5ce25be580e4ff">many testing sites across the state</a> <a href="https://covcheck.hctx.net/">recommend or offer testing</a> only to people who have symptoms, were exposed to a COVID-19 case or are a member of a high-risk group.</p>
<p>Even people recommended for testing still face challenges. It is possible to request an appointment for a free COVID-19 test, but testing facilities can handle only so many patients a day and testing slots <a href="https://covcheck.hctx.net/">fill up quickly</a>. Even if someone gets an appointment, they may face an hours-long wait at the testing site.</p>
<p>Finally, public health experts recommend that people who may have been exposed to COVID-19 should <a href="https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html">quarantine at home</a> for 14 days or until they receive a negative test result. In Texas, patients are supposed to get results through an <a href="https://publichealth.harriscountytx.gov/Resources/2019-Novel-Coronavirus/COVID-19-Testing-Information">online portal in three to five days</a>, but many labs have been <a href="https://www.dallasnews.com/news/politics/2020/06/30/overwhelming-demand-for-covid-19-tests-long-waits-for-results-hamper-texas-effort-to-control-spread/">taking seven to nine days to return results</a>. These long delays mean people face a much higher burden of quarantining while waiting for results.</p>
<p>All of these challenges make it clear that Texas is <a href="https://coronavirus.jhu.edu/testing/individual-states/texas">simply not testing enough people</a> to keep the spread of COVID-19 in check.</p>
<p>To gauge the success of COVID-19 testing programs, epidemiologists use a measure called <a href="https://coronavirus.jhu.edu/testing/testing-positivity">test positivity</a>. This is simply the percentage of tests that come back positive. The lower the test positivity, the better, because that means very few cases are going undetected. A high test-positivity rate is usually a sign that only the sickest people are getting tested and many cases are being missed.</p>
<p>The <a href="https://www.who.int/publications/i/item/public-health-criteria-to-adjust-public-health-and-social-measures-in-the-context-of-covid-19">World Health Organization guidelines</a> say that if more than 1 out of 20 COVID-19 tests comes back positive – a test positivity of more than 5% – this is an indication that a lot of cases are not diagnosed and the epidemic is not under control. <a href="https://coronavirus.jhu.edu/testing/individual-states/texas">Texas currently has a test-positivity of around 16%</a>, which means that a lot of infected people are not getting tested and may be unknowingly spreading the disease.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A doctor using a nasal swab to test a state senator of New Mexico." src="https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348982/original/file-20200722-16-1syzk3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In New Mexico, it is relatively easy to get a test, so more people are getting tested.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-New-Mexico/59c51760719c4ba9b9f72e583f143427/41/0">AP Photo/Cedar Attanasio</a></span>
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<h2>One of the best cases: New Mexico</h2>
<p>In stark contrast to Texas is New Mexico, which has one of the strongest testing programs in the U.S. </p>
<p>First, public health officials there encourage everyone to get tested for COVID-19 <a href="https://cv.nmhealth.org/public-health-screening-and-testing/location-details/">regardless of symptoms or exposure</a>. The state has also prohibited health providers from charging patients for tests. People seeking a test have the option to walk in or to make an appointment ahead of time, whichever is more convenient. </p>
<p>All of this relatively good access to testing has resulted in one of the <a href="https://coronavirus.jhu.edu/testing/states-comparison">highest per capita testing rates</a> in the country, at over 20,000 tests per 100,000 people, and a <a href="https://coronavirus.jhu.edu/testing/testing-positivity">test-positivity rate of around 4%</a>. New Mexico’s testing program is diagnosing a relatively high proportion of cases despite the state experiencing a recent surge.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=experts">Expertise in your inbox. Sign up for The Conversation’s newsletter and get expert takes on today’s news, every day.</a></em>]</p>
<p>New Mexico still has room for improvement. <a href="https://www.kob.com/albuquerque-news/demand-surges-for-covid-19-testing-result-times-vary-by-location/5789494/">Long lines, wait times and limited capacity</a> are becoming more common as cases surge, but the foundation of a strong testing program has helped the state cope with the increase in cases.</p>
<h2>The big-picture problems</h2>
<p>The pre-pandemic infectious disease testing capabilities in the U.S. are clearly unable to meet the current demand. A nationwide response is needed, and there are three things that Congress, the federal government and local governments can do to help ensure COVID-19 tests will be easy to get, fast and accurate. </p>
<p>First, Congress can <a href="https://www.cnn.com/2020/07/21/politics/congress-coronavirus-testing-unspent-funds/index.html">provide funding</a> to stimulate the testing supply chain, scale up existing testing programs and promote innovation in test development. Second, governments can <a href="https://www.rockefellerfoundation.org/national-covid-19-testing-action-plan/">improve the management and coordination</a> of testing programs to <a href="https://www.statnews.com/2020/04/16/fda-changes-coronavirus-testing-swabs/">more efficiently use existing resources</a>. And third, innovative testing methods that reduce the need for lab capacity – like <a href="https://www.nytimes.com/2020/07/03/opinion/coronavirus-tests.html">paper-strip tests</a> and <a href="https://theconversation.com/group-testing-for-coronavirus-called-pooled-testing-could-be-the-fastest-and-cheapest-way-to-increase-screening-nationwide-141579">pooled testing</a> – need be approved and implemented more quickly. </p>
<p>Every little improvement in testing capabilities means more COVID-19 cases can be caught before the virus is transmitted. And slowing the spread of the virus is the key to overcoming the pandemic.</p><img src="https://counter.theconversation.com/content/142366/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zoë McLaren does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ideally everyone could get tested frequently for the coronavirus. No state is close to achieving this, but some are doing better than others. What are the challenges in meeting demand for testing?Zoë McLaren, Associate Professor of Public Policy, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1431722020-07-22T04:23:02Z2020-07-22T04:23:02ZVictoria hits bleak record of 484 new cases, NSW at a critical point — if you feel sick, get tested then stay home<p>Too many people are going out while experiencing COVID-19 symptoms or while awaiting test results, Victorian Premier Daniel Andrews said on Wednesday, after the state hit a bleak new record of 484 new cases. The state’s previous worst daily case number was 428 last Friday.</p>
<p>It’s always a shock to see a new record number, and certainly these numbers are bigger than we would have hoped. While it’s a psychological blow, it’s not cause for panic. Thankfully, we are not seeing a doubling or tripling of case numbers, which really would ring alarm bells.</p>
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Read more:
<a href="https://theconversation.com/a-200-fine-for-not-wearing-a-mask-is-fair-as-long-as-free-masks-go-to-those-in-need-142988">A $200 fine for not wearing a mask is fair, as long as free masks go to those in need</a>
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<h2>Too many people going out while sick</h2>
<p>Andrews chastised people for taking too long to get tested after first experiencing symptoms, which include fever, cough and sore throat. He <a href="https://7news.com.au/lifestyle/health-wellbeing/massive-amount-of-victorians-failed-to-self-isolate-after-feeling-sick-getting-coronavirus-test-c-1184342">said</a>:</p>
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<p>From 3,810 cases, which are the cases between July 7 and July 21, I’m very unhappy and very sad to have to report that nearly nine in ten - or 3,400 cases - did not isolate between when they first felt sick and when they went to get a test […]</p>
<p>That means people have felt unwell and just gone about their business. They have gone out shopping, they have gone to work, they have been at the height of their infectivity and they have just continued on as usual […] The one and only thing that you can and must do when you feel sick is to go and get tested. Nothing else is acceptable.“</p>
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<p>He also said 53% those 3,810 cases "did not isolate, that is, did not stay at home and have no contact with anybody else — between when they had their test taken and when they got the results of that test.”</p>
<p>Unless people stay home when unwell and isolate while awaiting test results, the case numbers will continue to climb, Andrews said.</p>
<p>The premier noted self-isolation would leave some people with no income, and urged people in that situation to call 1800 675 398 to apply for an emergency A$1500 payment.</p>
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<p>It’s good to see the premier acknowledge income as one of the major drivers for these behaviours; people may not always have the financial flexibility to do the right thing.</p>
<p>Hopefully, making more people aware of the emergency payment option will help counteract this. </p>
<p>The government may have to work harder to ensure people know to self-isolate, and that the emergency payment is available, and I suspect this will be promoted more widely.</p>
<h2>NSW at a critical point</h2>
<p>In New South Wales, Premier Gladys Berejiklian said there were 16 new cases in the 24 hours to 8pm last night, all traced to known clusters. She called on people to avoid crowded places, wash hands, stay home if unwell and get tested if they have even mild symptoms. </p>
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<p><a href="https://www.abc.net.au/news/2020-07-22/nsw-premier-gladys-berejiklian-coronavirus-warning-for-business/12478808">Berejiklian said</a> from Friday, NSW businesses breaking rules on COVID-Safe registration, and breaching caps on group bookings, would “be fined — worse than that, if you breach again you will be shut down”.</p>
<p>NSW is on especially high alert. Despite this, it’s somewhat reassuring to know the state’s new cases can be traced to known outbreaks. However NSW residents are not out of the woods yet.</p>
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<p>Speculation is rife that further lockdowns might be on the way in NSW. While nothing should be off the table, it doesn’t appear NSW is anywhere near this point yet. The state has more than enough capacity to bring things under control from where the numbers sit now.</p>
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Read more:
<a href="https://theconversation.com/vaccine-progress-report-the-projects-bidding-to-win-the-race-for-a-covid-19-vaccine-141412">Vaccine progress report: the projects bidding to win the race for a COVID-19 vaccine</a>
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<p>Today’s news serves as a grim reminder we must all follow the golden rules of pandemic management: get tested if you experience even mild symptoms, stay home if unwell or awaiting test results, wash your hands often, physically distance from others, limit social gatherings, and wear a mask if you can’t physically distance (face-coverings will be mandatory for residents of metropolitan Melbourne and Mitchell Shire as of midnight Wednesday).</p>
<p>As to where things move from here, much of that is in our hands as individuals. Each of us, by doing everything we can to prevent the spread of the virus, can make a massive contribution to saving lives and defeating COVID-19.</p>
<p>The silver lining is that we know what’s needed. What we’re being asked to do is not easy, but we do know how to bring this coronavirus pandemic under control. We’ve done it before and we can do it again.</p><img src="https://counter.theconversation.com/content/143172/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hassan Vally does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Too many people are going out with COVID-19 symptoms or while awaiting a test result, Victorian Premier Daniel Andrews has said, after the state hit a bleak new record of 484 new cases.Hassan Vally, Associate Professor, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1429822020-07-20T03:16:10Z2020-07-20T03:16:10ZDo I need a referral for a COVID-19 test? What happens if you test positive? Your coronavirus questions answered<p>As COVID-19 cases surge in Victoria and NSW, authorities have again urged anyone with symptoms, including cough, fever, or sore throat, to get tested. Most results should be available <a href="https://theconversation.com/got-a-covid-19-test-in-victoria-and-still-havent-got-your-results-heres-what-may-be-happening-and-what-to-do-142821">within a few days</a> and people should self-isolate while they’re awaiting results.</p>
<p>Victorian Premier Daniel Andrews said today Victoria recorded 275 new COVID-19 cases. Mask-wearing whenever outside the home will be mandatory for residents of metropolitan Melbourne and Mitchell Shire from Wednesday at 11:59pm. </p>
<p>NSW Premier Gladys Berejiklian said there were 20 new cases in NSW today, and urged residents to avoid crowded places, consider wearing a mask when physical distancing wasn’t possible, and minimise any non-essential travel.</p>
<p>Here are the most important things to know about testing.</p>
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Read more:
<a href="https://theconversation.com/got-a-covid-19-test-in-victoria-and-still-havent-got-your-results-heres-what-may-be-happening-and-what-to-do-142821">Got a COVID-19 test in Victoria and still haven't got your results? Here's what may be happening — and what to do</a>
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<h2>Do I need a referral to get a COVID-19 test?</h2>
<p>For the vast majority of people, no — you don’t need a referral to get tested at dedicated public COVID-19 testing clinic.</p>
<p>However, you <em>will</em> need a pathology request form if you plan to get tested at a private pathology clinic.</p>
<p>COVID-19-testing clinics in NSW are listed <a href="https://www.nsw.gov.au/covid-19/how-to-protect-yourself-and-others/clinics">here</a>, and Victorian testing sites (including pop-up clinics) are listed <a href="https://www.dhhs.vic.gov.au/where-get-tested-covid-19">here</a>. The Victorian Department of Health and Human Services says on it website: </p>
<blockquote>
<p>Please call ahead before visiting a testing site, unless you choose to be tested at a pop-up testing site.</p>
</blockquote>
<p>Testing locations are listed on each state or territory’s health departments, including for <a href="https://www.qld.gov.au/health/conditions/health-alerts/coronavirus-covid-19/stay-informed/testing-and-fever-clinics">Queensland</a>, <a href="https://www.healthywa.wa.gov.au/Articles/A_E/COVID-clinics">Western Australia</a>, <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/conditions/infectious+diseases/covid+2019/covid-19+response/covid-19+clinics+and+testing+centres">South Australia</a>, <a href="https://coronavirus.nt.gov.au/stay-safe/testing">Northern Territory</a> and the <a href="https://www.covid19.act.gov.au/stay-safe-and-healthy/symptoms-and-getting-tested">Australian Capital Territory</a>.</p>
<p>Start by seeing if there is a pop-up drive-through or walk-through clinic near you. Some public sector fever clinics have a booking system to reduce wait times but many of the pop-up testing drive-through sites will allow you just to show up in your car.</p>
<p>Do <em>not</em> walk unannounced into a private pathology clinic, hospital emergency department or into your GP’s surgery. </p>
<p>If you can’t get to a dedicated public COVID-19 testing clinic, call your GP and ask for a telehealth consult. The GP can organise a pathology request form to be sent electronically to a private pathology clinic and will advise you on how to get tested there.</p>
<p>While you’re waiting for your test results, it’s important to stay at home in case you are infectious.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-whats-the-new-coronavirus-saliva-test-and-how-does-it-work-141877">Explainer: what's the new coronavirus saliva test, and how does it work?</a>
</strong>
</em>
</p>
<hr>
<h2>What happens if I test positive?</h2>
<p>You will be notified if you’ve tested positive to COVID-19. If you were tested at a private clinic, you may receive a call from your GP who ordered the test, or from the public health team.</p>
<p>If you were tested at a public testing site like a drive-through clinic, a state government public health official will contact you. They will usually do the contact tracing at the same time.</p>
<p>Their job is to find out about anyone else you may have given the virus to while you’ve been infectious. They will usually ask where you’ve been and who you’ve seen in the last few days before you became ill.</p>
<p>There are <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm">national guidelines</a> for management of coronavirus, but how they are implement is usually a state decision. Generally, the facility where you got the test will tell you how long you need to isolate for.</p>
<p>It’s important to ask as many questions as possible when you’re informed of your result.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>How can I get tested? Is there a blood test?</h2>
<p>Most tests will usually be done by a swab around the back of the throat and the nose. Some sites will either just swab your throat, or just your nose, but the gold standard at the moment is to swab both.</p>
<p>There’s also a new <a href="https://theconversation.com/explainer-whats-the-new-coronavirus-saliva-test-and-how-does-it-work-141877">saliva test</a>, which tests a sample you spit into a small container. It’s used in limited circumstances where it’s not possible to take a nasal swab, such as with young children resisting a swab.</p>
<p>The problem is saliva seems to have less of the virus in it than sputum (which is collected from the back of the nose and throat), so a saliva test result may not be as reliable.</p>
<p>There are currently two types of blood tests. One is an antibody test, which can measure whether you’ve already had the virus and recovered. But it’s not very useful because health authorities are more concerned about finding out who has the virus now, so they can do contact tracing.</p>
<p>Researchers from Monash University <a href="https://www.monash.edu/news/articles/breakthrough-blood-test-detects-positive-covid-19-result-in-20-minutes">announced</a> recently they’ve able to detect positive COVID-19 cases using blood samples in about 20 minutes, and identify whether someone has contracted the virus. </p>
<p>However, it’s very new research and likely won’t be rolled out on a large scale very soon. The researchers <a href="https://www.monash.edu/news/articles/breakthrough-blood-test-detects-positive-covid-19-result-in-20-minutes">said</a> last week they’re seeking commercial and government support to upscale production.</p>
<p>Despite problems with new types of tests, in a pandemic it’s important to research and trial novel testing methods that can help us fight the virus.</p>
<p>The most important thing you can do to help stop the spread is to try to maintain physical distancing as much as you can. Wash your hands frequently, and if you develop any symptoms — even very minor ones — err on the side of getting tested.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/which-face-mask-should-i-wear-142373">Which face mask should I wear?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/142982/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Trent Yarwood has no relevant funding disclosures or conflicts of interests. These represent his personal opinions and not those of his employer(s).</span></em></p>For the vast majority of people, no — you don’t need a referral to get tested at dedicated public COVID-19 testing clinic. It’s different if you plan to get tested at a private pathology clinic.Trent Yarwood, Infectious Diseases Physician, Senior Lecturer, James Cook University and, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1428212020-07-16T06:09:59Z2020-07-16T06:09:59ZGot a COVID-19 test in Victoria and still haven’t got your results? Here’s what may be happening — and what to do<p>Stories are emerging of Victorians who have followed advice and sought a COVID-19 test, only to find they’re still waiting to hear results more than five days later. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1282960011727998981"}"></div></p>
<p>The scale of testing underway in Victoria — and Australia’s testing rates are among the <a href="https://theconversation.com/australias-coronavirus-testing-rates-are-some-of-the-best-in-the-world-compare-our-stats-using-this-interactive-142289">highest in the world</a> — means it’s likely this will happen from time to time. It’s unclear if this is happening to many people or to just a handful. </p>
<p>Nevertheless, it’s evidently happening to <em>some</em> people and we can piece together some information about what may be contributing to this problem, and what you can do if it happens to you.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/eradication-elimination-suppression-lets-understand-what-they-mean-before-debating-australias-course-142495">Eradication, elimination, suppression: let's understand what they mean before debating Australia's course</a>
</strong>
</em>
</p>
<hr>
<h2>What to do if it happens to you in Victoria</h2>
<p>Firstly, if you are showing symptoms and still waiting on results of a test, it’s important you do not go out. Of course, that will grow increasingly difficult the longer you wait for a test result but self-isolating while awaiting test results is a crucial part of the pandemic management strategy.</p>
<p>Victorian health minister Jenny Mikakos said on Twitter results are usually available within 1-3 days or “sometimes longer” and referred people to a <a href="https://www.dhhs.vic.gov.au/getting-tested-coronavirus-covid-19#after-the-test">health department fact sheet</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1282140153092247552"}"></div></p>
<p>The factsheet says:</p>
<blockquote>
<p>Victorian and interstate labs are working around the clock to process all the tests, but with so many coming in every day, sometimes it takes a little longer to confirm the results.</p>
</blockquote>
<p>It lists phone numbers to try if you haven’t got your result within the expected time frame.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=735&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=735&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=735&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=923&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=923&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347830/original/file-20200716-19-1lu44i9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=923&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Information from a Victorian health department factsheet.</span>
<span class="attribution"><a class="source" href="https://www.dhhs.vic.gov.au/getting-tested-coronavirus-covid-19#after-the-test">DHHS</a></span>
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</figure>
<p>The factsheet doesn’t say what to do if you did the test using a home testing kit but the Victorian Department of Health and Human Services later tweeted to say:</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1281858092846780416"}"></div></p>
<p>Of course, if all else fails it might be simplest just to go and get another test.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-coronavirus-testing-rates-are-some-of-the-best-in-the-world-compare-our-stats-using-this-interactive-142289">Australia's coronavirus testing rates are some of the best in the world – compare our stats using this interactive</a>
</strong>
</em>
</p>
<hr>
<h2>Why might this be happening?</h2>
<p>Again, we must acknowledge the enormous scale of the testing program underway in Victoria. </p>
<p>On Wednesday alone, <a href="https://www.sbs.com.au/news/victoria-records-317-new-coronavirus-cases-in-biggest-daily-increase-of-any-state-or-territory">28,607</a> tests were undertaken in Victoria, and the total number of tests undertaken since January 1 is now at <a href="https://www.theaustralian.com.au/nation/coronavirus-australia-live-news-contact-tracing-teams-swamped-as-count-surges/news-story/63af63b35f5b71148d06ff20bf54e174">1,225,999</a>, Victorian Premier Daniel Andrews said in his Thursday press briefing. </p>
<p>Widespread testing is one of the best things we can do to control the spread of coronavirus, and these numbers are very impressive.</p>
<p>Many of these tests will be processed at laboratories in other states, as it is not possible for Victorian labs to test so many samples on their own.</p>
<p>A health department <a href="https://www.dhhs.vic.gov.au/sites/default/files/documents/202006/2001628_COVID-19_COVID-19%20suburban%20testing%20blitz.pdf">factsheet</a> dated June 25, 2020 said:</p>
<blockquote>
<p>Laboratories in Victoria, with surge staff capacity, can process 18,000 tests a day, noting that turn-around times are adversely affected when there is sustained testing above 14,000 tests per day. </p>
<p>New South Wales, South Australia, Queensland and Tasmania have agreed to provide surge lab capacity of over 4,000 tests a day. Private laboratories can also provide surge capacity of around 13,500 tests a day through their interstate operations. This will allow for at least 25,000 Victorian tests to be processed a day. There are currently sufficient test kits to meet this level of demand. </p>
<p>In addition, private pathology providers can draw on interstate supply chains. Safeguards, including repeat testing, will manage the risk of false positive tests.</p>
</blockquote>
<p>So if you’ve got a test but haven’t heard back, it’s possible the delay is caused by test samples needing to be taken to interstate labs (which adds time) and the huge scale of testing underway.</p>
<p>It’s also possible there may have been some other problem with the test, so make sure you double check at the testing centre.</p>
<h2>Who should get tested and why testing is important?</h2>
<p>The Victorian health department says on its website:</p>
<blockquote>
<p>Testing is currently available for people with the following symptoms, however mild: fever, chills or sweats, cough, sore throat, shortness of breath, runny nose, and loss of sense of smell or taste. The test takes around a minute and involves a swab from the back of your throat and nose.</p>
</blockquote>
<p>The less invasive saliva test may also be available for some people in certain places and circumstances, the department has <a href="https://www.dhhs.vic.gov.au/coronavirus-covid-19-english">said</a>.</p>
<p>Despite any difficulties you may be experiencing in getting tested or in getting your results, it’s vital to understand how critical getting tested is to protecting the community from this coronavirus. By being tested you are helping limit the spread of COVID-19. You are potentially helping save lives. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1282103092377341952"}"></div></p><img src="https://counter.theconversation.com/content/142821/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hassan Vally does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you’ve got a test but haven’t heard back, it’s possible the delay is caused by test samples needing to be taken to interstate labs and the huge scale of testing underway.Hassan Vally, Associate Professor, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1422552020-07-09T20:00:12Z2020-07-09T20:00:12ZVital Signs: We’re testing 50,000 Australians a day for COVID-19. Should it be 6.5 million?<p>As Victoria grapples with a second-wave outbreak of COVID-19, the importance of large-scale testing has again been highlighted.</p>
<p>Without its “<a href="https://www.abc.net.au/news/2020-06-26/coronavirus-melbourne-testing-blitz-underway-in-hotspot-suburbs/12393984">testing blitz</a>” aiming at 10,000 tests a day, the extent of the outbreak would have been invisible for much longer. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-coronavirus-testing-rates-are-some-of-the-best-in-the-world-compare-our-stats-using-this-interactive-142289">Australia's coronavirus testing rates are some of the best in the world – compare our stats using this interactive</a>
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</p>
<hr>
<p>Australia-wide, we’ve so far achieved a seven-day rolling average of a little more than <a href="https://www.covid19data.com.au/testing">50,000 tests a day</a>.</p>
<hr>
<p><iframe id="tc-infographic-496" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/496/0598668018a5666e15da133b092ce9a6dc3b6534/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<p>Since the beginning of the pandemic, proponents of mass testing having been arguing the need to test dramatically larger numbers.</p>
<p>One is US economist Paul Romer, who shared the <a href="https://www.nobelprize.org/prizes/economic-sciences/2018/romer/facts/">2018 Nobel Prize for economics</a> for his work on the importance of knowledge and ideas in the economy. In late March <a href="https://paulromer.net/covid-sim-part2/">he modelled</a> a “frequent testing policy” in which:</p>
<blockquote>
<p>7% of the population is randomly selected for testing each day. Over the 500 days illustrated in the plots and the animation, this means that the average person is tested about 30 times in 500 days – roughly once very two weeks.</p>
</blockquote>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/fx2SGGwAhRQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>This rate of testing would mean testing close to 2 million Australians a day. But even that is probably not enough.</p>
<h2>The mathematics of mass testing</h2>
<p>To appreciate why an even large number of tests is needed, imagine purely random testing is being used. That is, testing not focused on “hot spots” as has been the case in Melbourne. </p>
<p>Testing, tracing and isolating will only be effective if, on average, the process identifies cases before those people transmit the virus. Epidemiologists call the number of infections caused by a single case the “reproduction” (R) number. If it’s less than 1, the pandemic will die out. If it’s more than 1, the virus spreads.</p>
<p>When uncontrolled, COVID-19 spreads roughly <a href="https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article">once every six days</a>. This corresponds to a reproduction number of 2.5 over the 15 days a person with COVID-19 is generally infectious.</p>
<p>Moreover, <a href="https://paulromer.net/covid-sim-part2/">as Romer notes</a>, current tests are far from perfect. He assumes a 20% false negative rate (tests results saying someone doesn’t have COVID-19 when they do) and a 1% false positive rate (results saying someone has it when they don’t). </p>
<p>The mathematics says to control the disease we need to test the entire population roughly every four days.</p>
<p>In a paper published by Harvard University’s <a href="https://ethics.harvard.edu/files/center-for-ethics/files/white_paper_6_testing_millions_final.pdf">Edmond J. Safra Center for Ethics</a>, Divya Siddarth and Glen Weyl] calculate the 20% who are false negatives will, on average, pass the virus to 2.5 people. The other 80% of cases are caught on average halfway through the testing cycle. </p>
<p>To put it in basic maths terms, if we test people every “x” days, we catch those infections on average after half that time (x/2 days). To keep the effective reproduction rate at, say, 0.75 we need “x” to be 3.75. That means testing everyone roughly once every four days. </p>
<p>And that would mean testing more than 6.5 million Australians a day. Yikes!</p>
<h2>Asymptomatic cases</h2>
<p>Given the scale needed to make random testing a success, it is perhaps not surprising authorities have opted for targeted testing – focusing on transmission hot spots.</p>
<p>But Siddarth and Weyl explain the fatal flaw with any testing strategy reacting only to symptomatic cases:</p>
<blockquote>
<p>By the time symptomatic patients show up, they will already have infected .833 people. Furthermore, 20% of those infected will be asymptomatic throughout the time they have the disease, and 20% of those tested will yield false negatives. This means that a policy of only testing those who present with symptoms and only quarantining those who test positive will lead an average infected individual to infect others at a rate of 1.4.</p>
</blockquote>
<p>Being above 1, this means the virus still grows exponentially.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-asymptomatic-people-can-still-develop-lung-damage-141154">Coronavirus: asymptomatic people can still develop lung damage</a>
</strong>
</em>
</p>
<hr>
<h2>Testing with contact tracing</h2>
<p>A better solution is to test based on rigorous contact tracing of known infections. This is why governments pinned such great hopes on the technology of tracing apps such as Australia’s COVIDSafe.</p>
<p>Siddarth and Weyl consider a kind of best-case scenario that traces everyone an infectious person has come into contact with, and everyone those people have come into contact with as well. They calculate this could lead to tracking down 75% of cases. Other transmission would be pursued through prompt testing of everyone with symptoms. </p>
<p>In the US this would require about 2 million tests a day. In Australia it would need about 150,000 tests a day – three times as many tests as are being done now.</p>
<h2>Group testing</h2>
<p>An intriguing solution is “group testing”. This idea has been around since the 1940s and involves pooling patient specimens for testing. If the pooled test is negative, the whole group is cleared. If the test is positive, more focused testing is done to identify individual cases.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/group-testing-for-coronavirus-called-pooled-testing-could-be-the-fastest-and-cheapest-way-to-increase-screening-nationwide-141579">Group testing for coronavirus – called pooled testing – could be the fastest and cheapest way to increase screening nationwide</a>
</strong>
</em>
</p>
<hr>
<p>The question, then, is what is the optimal group-testing strategy? For instance, what is the best group size to choose? Should some people be placed in multiple groups? Should there be multiple stages of group testing?</p>
<p>In a US National Bureau of Economic Research <a href="https://www.nber.org/papers/w27457.pdf">working paper</a> published this month, four scholars from the University of California Berkeley show how machine learning can help to determine the optimal strategy.</p>
<p>For example, optimal group test size depends on the prevalence of the virus in the population. By estimating individual risk profiles – a person’s age, pre-existing health problems, where they live, if they work in a job that exposes them to risks, and so on – it is possible to target tests more efficiently than if treating everyone as equally at risk.</p>
<p>The goal is to improve predictive accuracy by incorporating as many observable characteristics that may influence risk as possible. This is a classic problem for “supervised machine learning”. Using machine learning could make group testing perhaps four to five times more efficient, the Berkeley researchers suggest.</p>
<p>Done this way, we might be able to achieve an effective strategy by testing as few as 30,000 to 40,000 Australians a day.</p>
<p>But the approach will need to be very different from now.</p>
<h2>Our pre-vaccine future</h2>
<p>Until an effective vaccine is found and widely deployed, testing is crucial to control COVID-19.</p>
<p>As the Berkeley authors emphasise, modern analytic techniques can make “high-frequency, intelligent group testing a powerful new tool in the fight against COVID-19, and potentially other infectious diseases”.</p>
<p>We need all the tools we can find.</p><img src="https://counter.theconversation.com/content/142255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Holden does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To control the COVID-19 pandemic through random testing would require about 6.5 million test a day. Using group testing and machine learning could get that number down to fewer than 40,000 day.Richard Holden, Professor of Economics, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1422762020-07-08T19:50:36Z2020-07-08T19:50:36ZWhy children and teens with symptoms should get a COVID-19 test, even if you think it’s ‘just a cough’<p>A Victorian teenager holidaying on the NSW South Coast has been diagnosed with COVID-19, NSW chief health officer Kerry Chant <a href="https://www.abc.net.au/news/2020-07-08/victorian-teen-on-holiday-in-nsw-tests-positive-for-coronavirus/12433710">said</a> on Wednesday. </p>
<p>The revelation follows <a href="https://www.theage.com.au/national/victoria/senior-students-behind-runaway-covid-19-cluster-at-al-taqwa-college-20200707-p559wd.html">reports</a> senior students at Al-Taqwa College in Melbourne are now considered the main source of Victoria’s second-biggest COVID-19 cluster.</p>
<p>These cases serve as a reminder that although children and teens are considered less likely than adults to catch and spread COVID-19, everyone with symptoms should get a test — including children and teens.</p>
<p><iframe id="518wu" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/518wu/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Children, teens and COVID-19 risk: what we know so far</h2>
<p>In my field, paediatric infectious disease, new research is emerging all the time about how SARS-CoV-2 (the virus that causes COVID-19) affects children and teens. In short, the evidence so far says:</p>
<ul>
<li><p>children and teens <em>can</em> contract and spread the disease — but compared to adults, several studies suggest that they are less likely to.</p></li>
<li><p>children and teens are much less likely to get severely unwell, be hospitalised or die compared to adults and older people. </p></li>
<li><p>tragically, <a href="https://www.abc.net.au/news/2020-06-18/why-are-so-many-indonesian-children-dying-from-coronavirus/12356444">children</a> and <a href="https://www.bbc.com/news/uk-england-south-yorkshire-53097646">babies</a> overseas have died of COVID-19, but compared with adults, this is much less common. Thankfully, it has not yet occurred in <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers">Australia</a>.</p></li>
</ul>
<p>The current thinking is that for most of Australia, the benefit of keeping schools open outweighs the risk. (In metropolitan Melbourne and Mitchell Shire, however, school holidays have been extended for all students except for those in year 11 and 12 or specialist schools.) </p>
<p>In Australia, the youngest COVID-19 death has been a <a href="https://www.sbs.com.au/news/death-of-42-year-old-in-australia-shows-coronavirus-is-not-an-old-person-s-disease-say-health-authorities">person in their 40s</a>. Less than <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers">7%</a> of all cases in Australia have so far have been recorded in children and teenagers. This proportion may rise, depending on the demographics in areas where community transmission is occurring.</p>
<h2>What about older teens?</h2>
<p>The risk of becoming unwell with COVID-19 increases with age. We know older teens are very different to young teens, both in growth and development but also in their activities - many of these activities put older teens at greater risk. </p>
<p>As Victoria’s Chief Health Officer Brett Sutton has <a href="https://www.theage.com.au/national/victoria/senior-students-behind-runaway-covid-19-cluster-at-al-taqwa-college-20200707-p559wd.html">said</a></p>
<blockquote>
<p>They are older kids, they tend to have more transmission that is akin to adults if they’re not doing the physical distancing appropriately.</p>
</blockquote>
<p>And if teens do develop COVID-19, the disease can move incredibly quickly from person to person and may soon reach populations with much greater risk, such as older people. </p>
<p>That’s why the very best strategy we have is to get tested. </p>
<p>Most children or teens with COVID-19, and indeed most people, will experience a mild illness that improves by itself. However, a small proportion of the community will become severely unwell. I’d be encouraging parents to remember that having a test is not just about the child; it’s about the community, children, parents and grandparents.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346265/original/file-20200708-19-1vl9hc7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Most children or teens, and indeed most people, who get COVID-19 will experience a mild illness that improves by itself.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Younger kids and the constant runny nose or cough</h2>
<p>As we head into winter time, we’re starting see more children and adults with common cough and cold viruses. For many parents of younger children, runny noses and coughs are a constant part of life during this time. </p>
<p>To these parents I would say: if it is a new cough, a new fever or sore throat, consider getting the child tested. This is particularly important for those living in places where community transmission is occurring, such as Victoria.</p>
<p>Some children, particularly through winter, will have an ongoing sniffle or cough and one infection will roll into the next. In this situation, the thing to watch for is a worsening of a fever or cough. If this happens, do not hesitate to get tested. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344726/original/file-20200630-103653-tfep86.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Testing is a key strategy</h2>
<p>To sum it up, testing is one of the key strategies to contain the spread of COVID-19 in Australia. One needs only look to Victoria to see what can happen when flare-ups occur. Although some of the public health interventions may appear draconian, we have to make sure people who are infectious are separated from those who are susceptible.</p>
<p>If your child is showing symptoms, you might be tempted to think “it’s just a cough” — and most of the time it <em>will</em> be just a cough. It’s not that we think every child with a cough has got coronavirus, but early detection — along with other measures such as physical distancing, staying home if unwell and hand hygiene — is absolutely crucial in our response.</p><img src="https://counter.theconversation.com/content/142276/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Blyth receives funding from the National Health and Medical Research Council. He is affiliated with the Australasian Society of Infectious Diseases, and is a member of government advisory committees including Australian Technical Advisory Group on Immunisation.
</span></em></p>Recent cases remind us that although children and teens are considered less likely than adults to catch and spread COVID-19, everyone with symptoms should get a test — including children and teens.Christopher Blyth, Paediatrician, Infectious Diseases Physician and Clinical Microbiologist, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1422892020-07-08T07:00:55Z2020-07-08T07:00:55ZAustralia’s coronavirus testing rates are some of the best in the world – compare our stats using this interactive<p>Data on COVID-19 testing rates per thousand people show that Australia is doing extremely well compared to many other countries. </p>
<p>This gives us a reasonable level of confidence that we are detecting most of the COVID-19 cases across the country. </p>
<p>The prospects of elimination remain elusive but even with the current outbreak in Victoria, Australia is continuing to maintain a high level of surveillance. </p>
<p>In terms of the broader consequences, including deaths per 1,000 people, Australia is among the best in the world when it comes to responding to the pandemic. </p>
<p>That doesn’t mean we can afford to be complacent. To retain this current status, we need to maintain a high level of testing. We also need every person in Australia to take the coronavirus threat seriously and stick to the basics: physical distancing, staying home if unwell, washing hands, and getting tested if you have any symptoms at all. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cases-deaths-and-coronavirus-tests-how-australia-compares-to-the-rest-of-the-world-139753">Cases, deaths and coronavirus tests: how Australia compares to the rest of the world</a>
</strong>
</em>
</p>
<hr>
<p>Use the tool below, which uses data from <a href="https://ourworldindata.org/">Our World in Data</a>, to explore how each country compares on:</p>
<ul>
<li>the total number of COVID-19 cases</li>
<li>the total number of cases per million people</li>
<li>the number of daily new confirmed cases</li>
<li>the number of daily new confirmed cases per million people. </li>
</ul>
<p>On COVID-19 fatalities for each country, you can see:</p>
<ul>
<li>the total number of deaths</li>
<li>the total number of deaths per million people</li>
<li>the number of daily new deaths</li>
<li>the number of daily new deaths per million people.</li>
</ul>
<p>And for tests performed by each country (except China, which Our World in Data says has <a href="https://ourworldindata.org/coronavirus-testing">limited</a> publicly available data on testing rates nationwide), you can see: </p>
<ul>
<li>the total number of tests performed</li>
<li>the total tests per thousand people</li>
<li>the number of daily new tests</li>
<li>the number of daily new tests per 1,000 people.</li>
</ul>
<p><iframe id="tc-infographic-502" class="tc-infographic" height="900" src="https://cdn.theconversation.com/infographics/502/0e9a333540d47da10de93a3e16deacd6ceb7270f/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<figure>
<figcaption>Data visualisation: Kaho Cheung https://observablehq.com/@unkleho/covid-19-bubble-chart-with-d3-render. Data source: Our World in Data https://ourworldindata.org. New deaths, cases and tests refers to new daily confirmed deaths, cases and tests. Countries with a population under 1 million not shown.</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-pandemic-shows-its-time-for-an-australian-centre-for-disease-control-in-darwin-138724">Coronavirus pandemic shows it's time for an Australian Centre for Disease Control – in Darwin</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/142289/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Kamradt-Scott receives funding from the Australian Research Council to examine the role of militaries in health emergencies, and the Canadian Government on examining compliance with the International Health Regulations (2015) during COVID-19. Adam is a director of the Global Health Security Network, and co-convenor of the Global Health Security conferences.</span></em></p>The prospects of elimination remain elusive but even with the current Victoria outbreak, Australia is maintaining a high number of tests per thousand people.Adam Kamradt-Scott, Associate professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1417942020-07-03T04:58:42Z2020-07-03T04:58:42ZWhy some people don’t want to take a COVID-19 test<p>Last week, outgoing chief medical officer Brendan Murphy <a href="https://www.sbs.com.au/news/all-travellers-returning-to-australia-will-be-tested-for-coronavirus-before-and-after-quarantine">announced</a> all returned travellers would be tested for COVID-19 before and after quarantine.</p>
<p>Some were <a href="https://thenewdaily.com.au/news/coronavirus/2020/06/28/coronavirus-test-refuse-hotel-quarantine/">surprised</a> testing was not already required. Others were outraged <a href="https://www.smh.com.au/politics/federal/states-divided-on-compulsory-testing-of-international-travellers-20200626-p556pa.html">some 30%</a> of returned travellers in hotel quarantine in Victoria had declined to be tested.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1276505296857227266"}"></div></p>
<p>This week, Victorian premier Daniel Andrews <a href="https://www.theage.com.au/national/victoria/please-say-yes-premier-s-plea-on-covid-19-testing-20200630-p557rt.html">said</a> <a href="https://www.news.com.au/world/coronavirus/australia/coronavirus-victoria-massive-number-of-people-refusing-tests-in-broadmeadows-and-keilor-downs/news-story/9b0499388dd2ec2dd0f6e9b0efde24cd">more than 900 people</a> in two Melbourne “hotspots” had declined door-to-door testing.</p>
<p>Again, there was outrage. People refusing COVID-19 tests were labelled <a href="https://7news.com.au/lifestyle/health-wellbeing/virus-cases-expected-as-australians-return-c-1128727">selfish</a> and <a href="https://twitter.com/natashamitchell/status/1277848580020002817">rude</a>. </p>
<p>A positive test result, together with contact tracing, gives public health authorities important information about the spread of SARS-CoV-2, the coronavirus that causes COVID-19, in a community.</p>
<p>So why might people at higher risk of a positive result be reluctant testers? And what can we do to improve testing rates?</p>
<h2>The many reasons why</h2>
<p>Reluctance to be tested for COVID-19 is not unique to returned travellers in hotel quarantine or people living in “hotspot” suburbs.</p>
<p>In the week ending June 28, <a href="https://info.flutracking.net/">FluTracking</a>, a voluntary online surveillance system, reported only <a href="https://info.flutracking.net/reports-2/australia-reports/">46% of people</a> with a fever and cough had gone for a COVID-19 test.</p>
<p>That can be for a variety of reasons.</p>
<p>A medical test result is not a neutral piece of information. People may refuse medical testing (if they have symptoms) or screening (if no symptoms) of any type because they want to <a href="https://journals.sagepub.com/doi/full/10.1177/1757975916635079?casa_token=vwjZykWFtRkAAAAA%3A83DZ5jBY2qnKc5CkKiqCMNkRfHGaFcrFYJNhSGcnU5-1P6gvVN36CfpqXGrDSqxb_WIoRVFuKSirKA">avoid</a> the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0022103116303249">consequences</a> of a <a href="https://link.springer.com/article/10.1186/s12885-019-5787-x">positive result</a>. </p>
<p>Alternatively, they might want <a href="https://academic.oup.com/jpubhealth/article/40/2/315/3807259">to avoid</a> the <a href="https://www.pressrepublican.com/news/coronavirus/dont-fear-the-swab-p-r-reporters-gets-coronavirus-test/article_bb3ed147-366c-5cd3-980f-48c7bcb4036a.html">perceived burden</a> of the test procedure itself.</p>
<p><strong>Reasons may relate to potentially losing money or work</strong></p>
<p>Many reasons for avoiding testing are likely to be structural: a casualised workforce means <a href="https://theconversation.com/if-we-want-workers-to-stay-home-when-sick-we-need-paid-leave-for-casuals-138431">fewer workers with sick leave</a> and a higher burden associated with having to isolate while waiting for test results. After a COVID-19 test in NSW, for instance, this can take <a href="https://www.health.nsw.gov.au/Infectious/covid-19/Pages/advice-for-professionals.aspx">24-72 hours</a>.</p>
<p>Then there’s the issue of <a href="https://theconversation.com/precarious-employment-is-rising-rapidly-among-men-new-research-94821">precarious work</a>. If people can’t attend work, either waiting at home for test results or recovering from sickness, they may lose their job altogether.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/if-we-want-workers-to-stay-home-when-sick-we-need-paid-leave-for-casuals-138431">If we want workers to stay home when sick, we need paid leave for casuals</a>
</strong>
</em>
</p>
<hr>
<p>In the case of hotel quarantine, a positive result on day ten will mean a longer stay in isolation. Hotel quarantine is <a href="https://twitter.com/7NewsSydney/status/1249453719957078016">not an easy experience</a> for many, particularly if quarantining alone. </p>
<p>An extension of time at a point where the end is in sight may be a very difficult proposition to stomach, such that avoiding testing is a preferable option.</p>
<p>Another structural issue is whether governments have done enough to reach linguistically diverse communities with public health advice, which Victoria’s chief health officer Brett Sutton <a href="https://www.abc.net.au/news/2020-06-27/victorias-horror-coronavirus-week-testing-blitz-and-restrictions/12396324">recently admitted</a> may be an issue.</p>
<p>Through no fault of their own, may people who don’t speak English as a first language, in Victoria or elsewhere, may not be getting COVID-19 health advice about symptoms, isolation or testing many of us take for granted.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/multilingual-australia-is-missing-out-on-vital-covid-19-information-no-wonder-local-councils-and-businesses-are-stepping-in-141362">Multilingual Australia is missing out on vital COVID-19 information. No wonder local councils and businesses are stepping in</a>
</strong>
</em>
</p>
<hr>
<p><strong>People might fear the procedure or live with past traumas</strong></p>
<p>Reasons may be personal and include <a href="https://www.pressrepublican.com/news/coronavirus/dont-fear-the-swab-p-r-reporters-gets-coronavirus-test/article_bb3ed147-366c-5cd3-980f-48c7bcb4036a.html">fear</a> of the test procedure itself (or fear it will hurt their children), <a href="https://academic.oup.com/jpubhealth/article/40/2/315/3807259">distrust</a> in government or public health systems, and worry about the extent of public health department <a href="https://www.hhrjournal.org/2020/04/contact-tracing-apps-extra-risks-for-women-and-marginalized-groups/">scrutiny</a> a positive result will bring. </p>
<p>People may also feel unprepared and cautious in the case of door-knocking testing campaigns.</p>
<p>We can’t dismiss these concerns as paranoid. Fears of invasive procedures are associated with past trauma, <a href="https://journals.lww.com/gastroenterologynursing/Abstract/2006/05000/The_Endoscopy_Patient_With_a_History_of_Sexual.3.aspx">such as</a> <a href="https://srh.bmj.com/content/38/4/214.short">sexual abuse</a>.</p>
<p>People who have experienced discrimination and marginalisation may also be less likely to <a href="https://psycnet.apa.org/record/2013-34232-001">trust</a> governments and <a href="https://www.mja.com.au/journal/2004/180/10/institutional-racism-australian-healthcare-plea-decency">health systems</a>.</p>
<p>COVID-19 can also lead to <a href="https://www.who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf">social stigma</a>, including blame and ostracism, even after recovery.</p>
<p>As with any health-related decision, people usually consider, consciously or not, whether benefits outweigh harms. If the benefit of a test is assumed to be low, particularly if symptoms are light or absent, the balance may tip to harms related to discomfort, lost income or diminished freedoms.</p>
<h2>Should we force people to get tested?</h2>
<p>Although <a href="https://theconversation.com/lockdown-returns-how-far-can-coronavirus-measures-go-before-they-infringe-on-human-rights-141782">federal and state laws</a> can compel certain people to undergo testing under limited circumstances, acting chief medical officer Paul Kelly <a href="https://www.abc.net.au/news/2020-07-01/can-the-government-force-you-to-take-a-coronavirus-test/12410118">said</a> it was “a last resort”.</p>
<p>Forcing a person to undergo a test contravenes that person’s right to <a href="https://www.cambridge.org/core/journals/cambridge-law-journal/article/nature-and-significance-of-the-right-to-bodily-integrity/79703F3BE9C5C21BB76338C050E951BC/core-reader">bodily integrity</a>. This is the right to make decisions about what happens to your own body, without outside coercion.</p>
<p>It also involves medical personnel having to override their professional responsibility to obtain voluntary and informed consent.</p>
<p>Some states have indicated they will introduce punishments for refusing testing. They include an extension of hotel quarantine and the <a href="https://www.abc.net.au/news/2020-07-01/can-the-government-force-you-to-take-a-coronavirus-test/12410118">potential for fines</a> for people not willing to participate in community testing.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lockdown-returns-how-far-can-coronavirus-measures-go-before-they-infringe-on-human-rights-141782">Lockdown returns: how far can coronavirus measures go before they infringe on human rights?</a>
</strong>
</em>
</p>
<hr>
<h2>Forced testing will backfire</h2>
<p>We don’t think forced testing is the way to go. A heavy-handed approach can create an antagonistic and mistrustful relationship with public health institutions. </p>
<p>The current situation is not the only infectious disease emergency we will face. Removing barriers to participating in public health activities, in the immediate and long term, will enable people to comply with and help build trusted institutions. This is likely to create an enduring public good.</p>
<p>Victoria is trying to make testing easier. It is offering a test that takes a saliva sample rather than a nasal swab, which is widely perceived to be unpleasant.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-whats-the-new-coronavirus-saliva-test-and-how-does-it-work-141877">Explainer: what's the new coronavirus saliva test, and how does it work?</a>
</strong>
</em>
</p>
<hr>
<p>This may encourage parents to have their children tested. The test is less sensitive, however, so the gains in increased uptake may be lost in a larger number of <a href="https://theconversation.com/the-positives-and-negatives-of-mass-testing-for-coronavirus-137792">false negatives</a> (people who have the virus but test negative).</p>
<p>Ultimately, we need to understand why people refuse testing, and to refine public health approaches to testing that support individuals to make decisions in the public interest.</p><img src="https://counter.theconversation.com/content/141794/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Williams receives funding from the APPRISE Centre for Research Excellence</span></em></p><p class="fine-print"><em><span>Bridget Haire receives funding from the National Health and Medical Research Council. and NSW Health.</span></em></p>There are some very good reasons why some people decline coronavirus testing, which we need to address before jumping to conclusions.Jane Williams, Researcher at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of SydneyBridget Haire, Postdoctoral Research Fellow, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1418772020-07-02T20:10:01Z2020-07-02T20:10:01ZExplainer: what’s the new coronavirus saliva test, and how does it work?<p>A cornerstone of containing the COVID-19 pandemic is widespread testing to identify cases and prevent new outbreaks emerging. This strategy is known as “test, trace and isolate”.</p>
<p>The standard test so far has been the swab test, in which a swab goes up your nose and to the back of your throat.</p>
<p>But an alternative method of specimen collection, using saliva, is being evaluated in Victoria and other parts of the world. It may have some benefits, even though it’s not as accurate.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/victoria-is-on-the-precipice-of-an-uncontrolled-coronavirus-outbreak-will-the-new-measures-work-141706">Victoria is on the precipice of an uncontrolled coronavirus outbreak. Will the new measures work?</a>
</strong>
</em>
</p>
<hr>
<h2>Saliva testing can reduce risks for health workers</h2>
<p>The gold standard for detecting SARS-CoV-2 (the coronavirus that causes COVID-19) is a polymerase chain reaction (PCR). This tests for the genetic material of the virus, and is performed most commonly on a swab taken from the nose and throat, or from sputum (mucus from the lungs) in unwell patients.</p>
<p>In Australia, more than 2.5 million of these tests have been carried out since the start of the pandemic, contributing significantly to the control of the virus.</p>
<p>Although a nasal and throat swab is the preferred specimen for detecting the virus, PCR testing on saliva has recently been <a href="https://theconversation.com/keep-your-nose-out-of-it-why-saliva-tests-could-offer-a-better-alternative-to-nasal-covid-19-swabs-138816">suggested</a> as an alternative method. Several studies demonstrate the feasibility of this approach, including one conducted at the <a href="https://jcm.asm.org/content/jcm/early/2020/04/17/JCM.00776-20.full.pdf">Doherty Institute</a> (where the lead author of this article works). It used the existing PCR test, but examined saliva instead of nasal samples.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/keep-your-nose-out-of-it-why-saliva-tests-could-offer-a-better-alternative-to-nasal-covid-19-swabs-138816">Keep your nose out of it: why saliva tests could offer a better alternative to nasal COVID-19 swabs</a>
</strong>
</em>
</p>
<hr>
<p>The use of saliva has several advantages:</p>
<ul>
<li><p>it is easier and less uncomfortable to take saliva than a swab</p></li>
<li><p>it may reduce the risk to health-care workers if they do not need to collect the sample</p></li>
<li><p>it reduces the consumption of personal protective equipment (PPE) and swabs. This is particularly important in settings where these might be in short supply.</p></li>
</ul>
<h2>But it’s not as sensitive</h2>
<p>However, a recent <a href="https://www.medrxiv.org/content/10.1101/2020.05.26.20112565v1">meta-analysis</a> (not yet peer-reviewed) has shown detection from saliva is less sensitive than a nasal swab, with a lower concentration of virus in saliva compared to swabs. It’s important to remember, though, this data is preliminary and must be treated with caution.</p>
<p>Nonetheless, this means saliva testing is likely to miss some cases of COVID-19. This was also shown in our <a href="https://jcm.asm.org/content/jcm/early/2020/04/17/JCM.00776-20.full.pdf">recent study</a>, which compared saliva and nasal swabs in more than 600 adults presenting to a COVID-19 screening clinic.</p>
<p>Of 39 people who tested positive via nasal swab, 87% were positive on saliva. The amount of virus was less in saliva than in the nasal swab. This most likely explains why testing saliva missed the virus in the other 13% of cases. </p>
<p>The laboratory test itself is the same as the PCR tests conducted on nasal swabs, just using saliva as an alternative specimen type. However, Australian laboratories operate under strict quality frameworks. To use saliva as a diagnostic specimen, each laboratory must verify saliva specimens are acceptably accurate when compared to swabs. This is done by testing a bank of known positive and negative saliva specimens and comparing the results with swabs taken from the same patients. </p>
<h2>When could saliva testing be used?</h2>
<p>In theory, there are several settings where saliva testing could play a role in the diagnosis of COVID-19. These may include:</p>
<ul>
<li><p>places with limited staff to collect swabs or where high numbers of tests are required</p></li>
<li><p>settings where swabs and PPE may be in critically short supply</p></li>
<li><p>some children and other people for whom a nasal swab is difficult. </p></li>
</ul>
<p>The use of saliva testing at a population level has not been done anywhere in the world. However, a pilot study is <a href="https://www.gov.uk/government/news/new-saliva-test-for-coronavirus-piloted-in-southampton">under way</a> in the United Kingdom to test 14,000 health workers. The US Food and Drug Administration recently issued an emergency approval <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-diagnostic-test-using-home-collection-saliva">for a diagnostic test</a> that involves home-collected saliva samples.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1276137829597396992"}"></div></p>
<p>In Australia, the Victorian government is also piloting the collection of saliva in <a href="https://www.dhhs.vic.gov.au/coronavirus-covid-19-daily-update">limited circumstances</a>, alongside traditional swabbing approaches. This is to evaluate whether saliva collection is a useful approach to further expanding the considerable swab-based community testing occurring in response to the current <a href="https://theconversation.com/victoria-locks-down-36-melbourne-suburbs-to-try-to-control-covid-19-spike-141707">outbreaks in Melbourne</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/these-10-postcodes-are-back-in-stage-3-coronavirus-lockdown-heres-what-that-means-141705">These 10 postcodes are back in Stage 3 coronavirus lockdown. Here's what that means</a>
</strong>
</em>
</p>
<hr>
<h2>A saliva test may be better than no test at all</h2>
<p>Undoubtedly, saliva testing is less sensitive than a nasal swab for COVID-19 detection. But in the midst of a public health crisis, there is a strong argument that, in some instances, a test with moderately reduced sensitivity is better than no test at all.</p>
<p>The use of laboratory testing in these huge volumes as a public health strategy has not been tried for previous infectious diseases outbreaks. This has required a scaling up of laboratory capacity far beyond its usual purpose of diagnosing infection for clinical care. In the current absence of a vaccine, widespread testing for COVID-19 is likely to occur for the foreseeable future, with periods of intense testing required to respond to local outbreaks that will inevitably arise. </p>
<p>In addition to swab-free specimens like saliva, testing innovations include self-collected swabs (which has <a href="https://www.medrxiv.org/content/10.1101/2020.04.09.20057901v1">also been tested in Australia</a>), and the use of <a href="https://www.livescience.com/pooled-testing-us-coronavirus.html">batch testing</a> of specimens. These approaches could complement established testing methods and may provide additional back-up for population-level screening to ensure testing is readily available to all who need it.</p>
<hr>
<p><em>This article is supported by the <a href="https://theconversation.com/au/partners/judith-neilson-institute">Judith Neilson Institute for Journalism and Ideas</a>.</em></p><img src="https://counter.theconversation.com/content/141877/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Williamson receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Allen Cheng receives funding from the National Health and Medical Research Council. He is a member of government advisory committees, including those involved in COVID-19 responses. </span></em></p><p class="fine-print"><em><span>Sharon Lewin receives funding from the National Health and Medical Research Council of Australia, the Medical Research Future Fund, the National Institutes of Health, the Wellcome Trust and the American Foundation for AIDS Research</span></em></p>Saliva testing is less sensitive than a nasal swab. But in the midst of a public health crisis, in some cases a test with slightly reduced sensitivity may be better than no test at all.Deborah Williamson, Professor of Microbiology, The Peter Doherty Institute for Infection and ImmunityAllen Cheng, Professor in Infectious Diseases Epidemiology, Monash UniversitySharon Lewin, Director, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital and Consultant Physician, Department of Infectious Diseases, Alfred Hospital and Monash University, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1417822020-07-02T02:33:17Z2020-07-02T02:33:17ZLockdown returns: how far can coronavirus measures go before they infringe on human rights?<figure><img src="https://images.theconversation.com/files/345171/original/file-20200702-2649-1d4ahoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">DANIEL POCKETT/AAP</span></span></figcaption></figure><p>As of this morning, <a href="https://theconversation.com/these-10-postcodes-are-back-in-stage-3-coronavirus-lockdown-heres-what-that-means-141705">ten “hot spot” postcodes</a> in Melbourne’s suburbs have gone back into Stage 3 coronavirus lockdown.</p>
<p>In these suburbs, stay-at-home restrictions will be enforced by police patrols, “booze bus”-style barriers and random checks in transport corridors. In what Premier Daniel Andrews described as “<a href="https://www.abc.net.au/news/2020-06-30/daniel-andrews-coronavirus-press-conference-key-moments/12407560">extraordinary steps</a>”, people moving in and out of these suburbs will be asked by police to identify themselves and provide one of four valid reasons for being out. Otherwise, they could face fines.</p>
<p>It seems likely that ever-more restrictive public health measures will be adopted should the coronavirus outbreak continue to worsen. With measures to protect public health competing with individual rights in what appears to be a zero-sum game, there are legitimate questions about how far the government can go before it reaches the outer limits of the law.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-spike-why-getting-people-to-follow-restrictions-is-harder-the-second-time-around-141287">Coronavirus spike: why getting people to follow restrictions is harder the second time around</a>
</strong>
</em>
</p>
<hr>
<h2>Compulsory testing</h2>
<p>In two suburbs of Melbourne, <a href="https://www.theage.com.au/national/victoria/please-say-yes-premier-s-plea-on-covid-19-testing-20200630-p557rt.html">over 900 people have refused to be tested for coronavirus</a>. The reasons vary, but include people being <a href="https://www.abc.net.au/news/2020-07-01/can-the-government-force-you-to-take-a-coronavirus-test/12410118">concerned about having to self-isolate</a> and <a href="https://www.theage.com.au/national/victoria/please-say-yes-premier-s-plea-on-covid-19-testing-20200630-p557rt.html">not understanding the dangers of the virus</a>, as well as privacy reasons.</p>
<p>These refusals aren’t explicitly linked to increased transmission rates, but some disgruntled residents in locked-down suburbs and others have called for compulsory testing.</p>
<p>Existing laws already enable compulsory testing, but they have not yet been used. <a href="https://www.news.com.au/national/politics/coronavirus-australia-human-biosecurity-emergency-declared/news-story/cd7fbff78297c076c8bb774595459c59">The March declaration</a> of a human biosecurity emergency under the Biosecurity Act empowers the health minister to issue directions considered necessary to prevent or control the spread of coronavirus.</p>
<p><a href="https://www.legislation.gov.au/Details/C2020C00127">Under the act</a>, these powers must not be used in a manner that is more restrictive and intrusive than necessary. However, there are few other obvious limits on these powers. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345176/original/file-20200702-2640-1joivc7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Door-to-door testing is now under way in parts of suburban Melbourne.</span>
<span class="attribution"><span class="source">James Ross/AAP</span></span>
</figcaption>
</figure>
<p>The <a href="http://classic.austlii.edu.au/au/legis/vic/consol_act/phawa2008222/">Victoria Public Health and Wellbeing Act 2008</a> gives the chief health officer the power to compel a person to take a test. To use this power, the officer must believe the person either </p>
<blockquote>
<p>is infected with the infectious disease or has been exposed to the infectious disease in circumstances where a person is likely to contract the infectious disease.</p>
</blockquote>
<p>Unlike the Commonwealth Biosecurity Act, this power seems constrained to being used as a measure of last resort. The Victorian act refers to the consideration of alternatives and a <a href="http://classic.austlii.edu.au/au/legis/vic/consol_act/phawa2008222/s112.html">preference</a> for the </p>
<blockquote>
<p>measure which is the least restrictive of the rights of the person.</p>
</blockquote>
<p>Such orders could be reviewed or challenged in the courts, but more practical challenges, including the need to have <a href="https://www.sbs.com.au/news/people-refusing-to-get-tested-in-melbourne-s-hotspot-suburbs-could-face-fines-scott-morrison-warns">police present when conducting compulsory testing</a>, may explain why this measure has not yet been used.</p>
<h2>Quarantine restrictions</h2>
<p>In the state of emergency currently in force in Victoria, the chief health officer also has the <a href="http://classic.austlii.edu.au/au/legis/vic/consol_act/phawa2008222/">power to detain or restrict the movement of any person</a> for as long as necessary to eliminate or reduce a serious risk to public health.</p>
<p>The hotel quarantine program relies on this power. While the chief health officer must review the need for the continued detention of people at least once every 24 hours, there are no other obvious limits on this power. </p>
<p>In practice, international travellers entering Victoria receive notices imposing a 14-day quarantine with permission to leave their hotel rooms only for medical care, where it is reasonably necessary for physical or mental health, on compassionate grounds, or if there is an emergency.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-the-australian-governments-powers-to-quarantine-people-in-a-coronavirus-outbreak-132877">Explainer: what are the Australian government's powers to quarantine people in a coronavirus outbreak?</a>
</strong>
</em>
</p>
<hr>
<p>The quarantine program in Victoria <a href="https://www.9news.com.au/national/victoria-coronavirus-hotel-quarantine-breaches-health-minister-greg-hunt-response/24386887-c396-4b84-8b14-3aadaba4688f">has been a clear failure</a>, due to the alleged breaches of public health protocols. </p>
<p>An <a href="https://www.sbs.com.au/news/77-new-coronavirus-cases-in-victoria">independent inquiry</a> into the program is being conducted by retired judge Jennifer Coate, and Corrections Victoria <a href="https://www.abc.net.au/news/2020-07-01/victoria-coronavirus-hotel-quarantine-how-did-we-get-here/12408256">will take over supervision</a> of the program from the private security contractors who had been running it.</p>
<p>It is possible the newly appointed authorities - with prior experience managing prisoners - may adopt a more restrictive approach. </p>
<p>People detained under the new regime may find it more difficult, for example, to get permission to leave their rooms for supervised outdoor exercise. If this approach is disproportionate to the health risk, and causes or contributes to a person’s ill health, court action may ensue.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1278452331303047170"}"></div></p>
<h2>Possible infringements on human rights</h2>
<p>Public authorities responsible for the management of people in quarantine must balance their role mitigating public health risks with their duty to protect the human rights of those in their care and custody. </p>
<p>In a civil society, fundamental freedoms and individual liberties are highly valued, and intrusive powers should be used only where necessary. In a state of emergency, some limitations of rights may be necessary, but any such limitation must be <a href="https://www.humanrights.vic.gov.au/legal-and-policy/covid-19-and-human-rights/embedding-human-rights-during-covid-19/">necessary, justifiable, proportionate and time-bound</a>. </p>
<p>Unless it is overridden by parliament, the Victorian <a href="http://classic.austlii.edu.au/au/legis/vic/consol_act/cohrara2006433/">Charter of Human Rights and Responsibilities Act 2006</a> continues to apply during a state of emergency. Although no charter rights are absolute, this act has been used <a href="https://www.supremecourt.vic.gov.au/detention-of-children-in-youth-justice-facility-within-barwon-prison-found-to-be-unlawful">successfully</a> by people challenging the conditions of their detention. </p>
<p>Governments across Australia have extraordinary emergency powers at their disposal, and have been prepared to use many of them in response to the pandemic. Although the courts have considered the impact of coronavirus on existing laws and procedures – such as <a href="https://www.afr.com/politics/federal/nsw-appeal-court-authorises-sydney-rally-20200606-p55059">the right to protest in the face of social-distancing measures</a> and <a href="https://jade.io/article/727740">increased risks to the health of prisoners</a> – they have yet to scrutinise some of the key public health measures adopted. </p>
<p>Despite the deference of courts to public health measures in the face of a deadly infectious disease, there are limits, and it seems inevitable that some limits will eventually be reached.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345177/original/file-20200702-2679-1228bt7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Returning overseas travellers have been forced to quarantine in hotels since early in the pandemic.</span>
<span class="attribution"><span class="source">Scott Barbour/AAP</span></span>
</figcaption>
</figure>
<h2>Questions over legitimacy</h2>
<p>There are also limits to the effectiveness of these measures when people perceive them as unfair.</p>
<p>People obey laws and comply with rules when they <a href="https://www.oxfordbibliographies.com/view/document/obo-9780195396607/obo-9780195396607-0241.xml">see them as legitimate, not because they fear punishment</a>. If the rules are unclear, or the process of developing them poorly explained, they may feel like postcode lottery to residents. This, in turn, could bring more dissatisfaction with lockdown measures and fail to effect behaviour change.</p>
<p>During times of emergency, it is critical powers with the potential to limit human rights and deprive people of liberty are properly communicated to the community and used with restraint. </p>
<p>This is not only important for the protection of individual rights, but also to prevent lasting damage to the rule of law. Ensuring that respect for human rights remains a central concern of government responses to the pandemic will build confidence and resilience in our communities and our institutions as we emerge from the crisis.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-drones-used-to-enforce-lockdown-pose-a-real-threat-to-our-civil-liberties-138058">Coronavirus: drones used to enforce lockdown pose a real threat to our civil liberties</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/141782/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stan Winford does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As compulsory testing and more restrictive quarantine rules are being considered, it is critical these measures are properly communicated and used with restraint.Stan Winford, Associate Director, Centre for Innovative Justice, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1397532020-06-03T20:10:51Z2020-06-03T20:10:51ZCases, deaths and coronavirus tests: how Australia compares to the rest of the world<figure><img src="https://images.theconversation.com/files/338741/original/file-20200601-78849-l59kmj.png?ixlib=rb-1.1.0&rect=0%2C3%2C2560%2C1272&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Molly Glassey/Pexels</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>When it comes to coronavirus cases, deaths and tests, Australia is performing better than many other countries with comparable populations and geographies, a new COVID-19 data visualisation reveals.</p>
<p>Use the tool below, which uses data drawn from <a href="https://ourworldindata.org/">Our World in Data</a>, to explore how each country compares on:</p>
<ul>
<li>the total number of COVID-19 cases</li>
<li>the total number of cases per million people</li>
<li>the number of daily new confirmed cases</li>
<li>the number of daily new confirmed cases per million people. </li>
</ul>
<p>On COVID-19 fatalities for each country, you can see:</p>
<ul>
<li>the total number of deaths</li>
<li>the total number of deaths per million people</li>
<li>the number of daily new deaths</li>
<li>the number of daily new deaths per million people</li>
</ul>
<p>And for tests performed by each country (except China, which Our World in Data says has <a href="https://ourworldindata.org/coronavirus-testing">limited</a> publicly available data on testing rates nationwide), you can see: </p>
<ul>
<li>the total number of tests performed</li>
<li>the total tests per thousand people</li>
<li>the number of daily new tests</li>
<li>the number of daily new tests per thousand people.</li>
</ul>
<p><iframe id="tc-infographic-488" class="tc-infographic" height="900" src="https://cdn.theconversation.com/infographics/488/450697708ba9c055e2555057d8ca0294a2fa73e6/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<figure>
<figcaption>Data visualisation: Kaho Cheung https://observablehq.com/@unkleho/covid-19-bubble-chart-with-d3-render. Data source: Our World in Data https://ourworldindata.org. New deaths, cases and tests refers to new daily confirmed deaths, cases and tests. Countries with a population under 1 million not shown.</figcaption>
</figure>
<p>Hit the “play” button to show how the situation for each metric developed over time (noting the long period at the beginning for which COVID-19 cases appeared to be confined to China, and the lack of publicly available data for nationwide testing rates in China). You can read more <a href="https://ourworldindata.org/coronavirus">here</a> about the limitations of the data.</p>
<p>The Conversation asked Adam Kamradt-Scott, an expert on health security and pandemic preparedness, to reflect on what the data reveal at date of this article’s publication. Here’s what he told us:</p>
<hr>
<h2>Australia is doing well</h2>
<p>Overall, the data show Australia is doing pretty well. It has conducted a high number of tests (currently about 58 total tests per thousand people), which is more than the US, Canada or South Korea have done per thousand. The comparison with South Korea, which has been widely praised for its handling of the pandemic, is especially notable and reflects well on Australia. </p>
<p>In Australia, the number of total cases, new cases and cases per million is low. </p>
<p>I hold some reservations about the speed with which social distancing measures are being relaxed around Australia, as there’s a risk we could see a surge of new infections if there are undetected cases.</p>
<p>But as long as we are able to maintain a high level of testing and people follow the guidance after testing, we might be OK.</p>
<p>It’s interesting to see Australia compares favourably with Canada, which is broadly comparable to Australia in population size and geographical spread, given Canada also went through the 2003 SARS outbreak and so has more experience in handling a pandemic.</p>
<h2>Total tests and tests per thousands</h2>
<p>You’d have to say one of the standouts is Bahrain. Based on this data, it has done an average of about 190 total tests per thousand. That is pretty high, which can provide a measure of reassurance you are capturing the majority of cases.</p>
<p>So when we look at the <em>overall</em> number of tests, the US, Russia and Italy appear to be best but when you look at tests per thousand, Bahrain leaps ahead. (It’s worth noting, however, it’s a small and densely populated country, which puts it at an advantage when it comes to tests per head of population).</p>
<p>US president Donald Trump has <a href="https://www.politico.com/news/2020/05/19/trump-high-number-coronavirus-cases-testing-progress-268646">said</a> America has “more testing than anybody else”. This data currently show that while the US has the highest number of tests overall, it is bested by Australia, New Zealand, Russia, Bahrain, Italy and many other countries if you measure tests per thousand people (a better indication of how widespread testing is).</p>
<h2>Deaths and deaths per million</h2>
<p>Belgium is unfortunately a bit of a surprise, appearing in this data set to be suffering the highest rate of fatalities per million people. Quite a lot has been made of the UK and the number of fatalities there compared to other parts of Europe. But compared to others, Belgium is hardest hit when it comes to deaths per million, but this may have to do with the way they <a href="https://www.smh.com.au/world/europe/is-belgium-the-world-s-deadliest-covid-19-country-or-just-the-most-honest-20200522-p54voq.html">report</a> data. </p>
<p>It’s worth remembering that in some countries, though, we’ll never really know how many people have really died of COVID-19. That’s because, in some cases, countries didn’t test people who died.</p>
<p>That’s a limitation of the data, which relies on what countries report. If some countries are simply burying people who have died without investigating the cause of death, then the picture can be skewed.</p>
<p>We will never know the full number of deaths in all countries from COVID-19, principally because it is very difficult to verify the cause of death in many parts of the world. You need the lab capacity and affordable access to testing, which many countries lack. In those circumstances, they can only make an educated guess.</p>
<p>Sweden, which has reportedly pursued a “herd immunity” strategy and eschewed many of the lockdown measures other countries have in place, is an interesting one. It is not as bad as Belgium, but it’s certainly up there with about 440 deaths per million. And if we look at <em>new</em> deaths per million, it also looks grim for Sweden (as well as the UK, Brazil and Peru).</p>
<p>The argument the Swedish government is reportedly making is that, in the long run, Sweden is going to be better off. But the Swedish strategy is an inherently risky one.</p>
<p>For example, if there’s a slight mutation or a new strain emerges the question would then be: to what extent does exposure to the previous strain confer immunity? If the answer is “not much” then Sweden could get hit with a second round of infections. That hasn’t happened and may not happen, but it highlights one of the risks.</p>
<p>At the same time, if we see a vaccine successfully developed, then one of the questions the Swedish government will have to answer is whether more lives could have been saved if they’d implemented lockdowns like many other countries did. </p>
<p>Unfortunately, only time will tell.</p><img src="https://counter.theconversation.com/content/139753/count.gif" alt="The Conversation" width="1" height="1" />
Australia is performing better than many other countries with comparable populations and geographies, a new COVID-19 data visualisation reveals.Sunanda Creagh, Senior EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1386922020-05-27T12:21:51Z2020-05-27T12:21:51ZHow leadership in various countries has affected COVID-19 response effectiveness<figure><img src="https://images.theconversation.com/files/336512/original/file-20200520-152327-4a89vf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5457%2C3633&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Germany led the way with its early response to the coronavirus crisis.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-wearing-face-masks-who-said-they-did-not-mind-being-news-photo/1221330962?adppopup=true">Getty Images / Sean Gallup</a></span></figcaption></figure><p>COVID-19 has put political leaders and health care systems worldwide to the test. Although lockdowns are the common approach, some countries have opted for less stringent measures. </p>
<p><a href="https://bush.tamu.edu/scowcroft/programs/team/">As scientists</a> and <a href="https://scholar.google.com/citations?user=o-pB1IMAAAAJ&hl=en">public policy experts</a>, we have spent years analyzing how countries prepare and respond to pandemics. We believe this is certain: The policy and communication choices that national leaders make has a measurable impact on the effectiveness of pandemic response.</p>
<h2>Some countries respond with science</h2>
<p>In particular, Germany and New Zealand have handled the crisis effectively. Both countries have not wavered from a science-based approach and strong, centralized messaging.</p>
<p>Germany discovered its <a href="https://www.businessinsider.com/why-germany-has-a-low-covid-19-mortality-rate-2020-4">first cases on Jan. 27</a>. At the time, the country’s health minister considered COVID-19 a low threat; still, Charité University Hospital in Berlin began developing a test. Within a month, new test kits were available – and Germany’s labs had already <a href="https://www.nytimes.com/2020/04/04/world/europe/germany-coronavirus-death-rate.html">stocked up</a>. </p>
<p>By mid-March, the country had <a href="https://www.bmj.com/content/369/bmj.m1395">closed schools and retail businesses</a>. Testing was swiftly rolled out, and within approximately two weeks, Germany was processing more than <a href="https://www.ncbi.nlm.nih.gov/pubmed/32193299">100,000 tests per week</a>. Around this same time period, the United States had tested approximately <a href="https://www.theatlantic.com/health/archive/2020/03/coronavirus-testing-numbers/607714/">5,000 people</a> and did not reach numbers similar to Germany until <a href="https://ourworldindata.org/covid-testing-us-uk-korea-italy">several weeks later</a>. Chancellor Angela Merkel led Germany’s coordinated response, which included social distancing policies along with the early and wide-scale testing. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336526/original/file-20200520-152302-1rwn5b5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In Hamm, Germany, a boy stands in front of a graffiti featuring a nurse as Superwoman. Germany is widely credited for its rapid response to COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/boy-stands-in-front-of-a-graffiti-painted-by-artist-kai-news-photo/1209475434?adppopup=true">Getty Images / Ina Fassbender</a></span>
</figcaption>
</figure>
<p>Not everything went smoothly. In many instances, <a href="https://www.theguardian.com/world/2020/apr/05/germanys-devolved-logic-is-helping-it-win-the-coronavirus-race">lower-level health services</a> still had autonomy; this led to a degree of discontinuity in policy implementation across states. Yet most Germans <a href="https://www.bmj.com/content/369/bmj.m1395">voluntarily adhered</a> to the policies set forth by the national government. Now Germany is moving to lift restrictions.</p>
<p>New Zealand, led by Prime Minister Jacinda Ardern, responded with a slogan: “<a href="https://www.newsroom.co.nz/2020/03/14/1083045/we-must-go-hard-and-we-must-go-early">We must go hard and we must go early</a>.” In mid-February, <a href="https://www.reuters.com/article/us-china-health-newzealand/new-zealand-extends-ban-on-china-arrivals-no-curbs-yet-for-other-nations-idUSKCN20I046">travelers from China</a> were banned. </p>
<p>On March 23 – a month after its first case – New Zealand committed to a total elimination strategy and implemented a strict national lockdown despite having only <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31097-7.pdf">102 COVID-19 cases and no recorded deaths</a>. Schools were closed. So were nonessential businesses. Social gatherings were banned. A 14-day self-isolation period was required for <a href="https://www.newsroom.co.nz/2020/03/14/1083045/we-must-go-hard-and-we-must-go-early">anyone entering the country</a>, with a few Pacific Island exceptions. </p>
<p>With a population of just under 5 million, New Zealand has already tested more than <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases/covid-19-testing-rates-ethnicity-and-dhb">175,000 potentially infected</a> people – approximately 4% of its population. It is now expanding the program. </p>
<p>Like Germany, the country has emphasized science, leadership and consistent messaging. Prime Minister Ardern builds public trust through regular appearances on social media, including posts <a href="https://www.bbc.com/news/av/world-asia-52189013/jacinda-ardern-tooth-fairy-and-easter-bunny-are-essential-workers">aimed at children</a>. As of May 9, the country had <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31097-7.pdf">fewer than 1,500 confirmed cases and 20 deaths</a> from COVID-19.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336530/original/file-20200520-152284-w39cy0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A burial takes place at a cemetery in Manaus, Brazil. The grave area hosts suspected and confirmed victims of the pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/aerial-picture-showing-a-burial-taking-place-at-an-area-news-photo/1210677694?adppopup=true">Getty Images / Michael Dantas</a></span>
</figcaption>
</figure>
<h2>Instead of hand-washing, a hands-off approach</h2>
<p>Brazil and Nicaragua have taken a decidedly different approach. Leaders of both countries have adopted a “hands-off” policy – in some cases, even discouraging citizens from following public health measures taken in other countries.</p>
<p><a href="https://doi.org/10.1016/S0140-6736(20)31095-3">On Feb. 25</a>, Brazil recorded its first case. Since then, the country has reported more than 300,000 cases and 20,000 deaths – the third largest outbreak in the world, behind only the U.S. and Russia. </p>
<p>Over these months, President Jair Bolsonaro has said the virus is not a threat, calling it a “<a href="https://www.aljazeera.com/news/2020/05/bolsonaro-called-biggest-threat-brazil-coronavirus-response-200509054352022.html">little flu</a>.” He has also <a href="https://www.aljazeera.com/news/2020/05/bolsonaro-called-biggest-threat-brazil-coronavirus-response-200509054352022.html">encouraged defiance of</a> social distancing measures put in place by governors. </p>
<p>Brazil has many advantages over its neighbors for an effective pandemic response: <a href="https://www.medrxiv.org/content/10.1101/2020.03.30.20047662v1.full.pdf">universal health coverage</a>, a large community-based primary care delivery system, and experience responding to the Zika health crisis in 2015. </p>
<p>But the lack of leadership from Bolsonaro have led some to label him as the “<a href="https://doi.org/10.1016/S0140-6736(20)31095-3">biggest threat</a>” to the country’s ability to fight the SARS-CoV-2. His continued attacks on <a href="https://theconversation.com/brazil-jair-bolsonaros-strategy-of-chaos-hinders-coronavirus-response-136590">scientists, universities and experts</a>, along with the <a href="https://theconversation.com/activist-farmers-in-brazil-feed-the-hungry-and-aid-the-sick-as-president-downplays-coronavirus-crisis-136914">lack of organized federal response</a>, have disrupted efforts to control the pandemic. An Imperial College of London <a href="https://mrc-ide.github.io/covid19-short-term-forecasts/index.html">study</a> showed Brazil with the highest rate of transmission of the 48 countries examined. </p>
<p>Nicaragua has also failed to acknowledge the dangers of this virus. President Daniel Ortega, an <a href="https://theconversation.com/one-year-after-nicaraguan-uprising-ortega-is-back-in-control-113991">authoritarian leader who has remained in office despite term limits and sustained popular protests</a> demanding his resignation, is resisting travel restrictions while <a href="https://www.hrw.org/news/2020/04/10/nicaragua-reckless-covid-19-response">encouraging schools and businesses</a> to stay open. He discourages the <a href="https://www.miamiherald.com/news/nation-world/world/americas/article241706736.html">use of masks</a>, even by health care workers. </p>
<p>With his wife and vice president, Rosario Murillo, Ortega has suggested that citizens attend church and go to the beach; they even organized a huge parade <a href="https://confidencial.com.ni/rosario-murillo-convoca-caminata-amor-en-tiempos-del-covid-19/">called “Love Against COVID-19”</a> on March 14. The ruling couple, however, are noticeably absent for many of these activities, at which social distancing is impossible. </p>
<p>In a country of more than 6 million, Nicaragua reported <a href="https://coronavirus.jhu.edu/map.html">25 confirmed cases and eight deaths</a> from COVID-19 as of May 15. But many experts suspect the true number of infections is much higher, both because of minimal testing – the government only allows <a href="https://confidencial.com.ni/nueva-orden-del-minsa-hacer-solo-50-pruebas-diarias-de-covid-19/">50 tests per day</a> – and because many COVID-19 deaths are classified as “pneumonia.” Since January 2020, pneumonia deaths in Nicaragua have reportedly been <a href="https://www.reuters.com/article/us-health-coronavirus-nicaragua/nicaragua-reports-more-pneumonia-deaths-some-tied-to-covid-19-idUSKBN22V0CZ">increasing</a>. But there is little government transparency in Nicaragua, so the data is difficult to confirm. </p>
<h2>Lessons for the US</h2>
<p>Reliance on science and centralized messaging help countries move faster to safely lift restrictions. Confusing and mixed messages, coupled with distrust of scientific experts, lets the virus spread. In the U.S., messaging is confusing and <a href="https://jamanetwork.com/channels/health-forum/fullarticle/2766033">decentralized</a> and defers to state governments for the majority of policy development. This decentralization has led to vastly different actions by governors. Georgia and <a href="https://www.nytimes.com/interactive/2020/us/texas-coronavirus-cases.html">Texas reopened as cases continued to increase</a>, while Washington and <a href="https://www.kdrv.com/content/news/Governor-Brown-extends-coronavirus-state-of-emergency-through-July-570145731.html">Oregon extend lockdowns</a> well into the summer. </p>
<p>A coordinated, science-driven, national-level strategy is vital to an effective response. But at the moment, the U.S. federal government has communicated more like Brazil and Nicaragua, rather than Germany and New Zealand. The examples we highlight here are a warning to all of us. </p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/138692/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Countries across the globe responded differently to the pandemic, and results show a difference in effectiveness as well.Christine Crudo Blackburn, Deputy Director, Pandemic & Biosecurity Policy Program, Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M UniversityLeslie Ruyle, Associate Research Scientist and Assistant Director Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1388162020-05-19T20:01:42Z2020-05-19T20:01:42ZKeep your nose out of it: why saliva tests could offer a better alternative to nasal COVID-19 swabs<figure><img src="https://images.theconversation.com/files/335961/original/file-20200519-83363-hns6p8.jpg?ixlib=rb-1.1.0&rect=21%2C0%2C7160%2C4780&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Saliva is one of our biggest foes in the COVID-19 pandemic, because of its role in spreading the virus. But it could be our friend too, because it potentially offers a way to diagnose the disease without using invasive nasal swabs.</p>
<p>Our research review, <a href="https://www.mdpi.com/2075-4418/10/5/290">published in the journal Diagnostics</a>, suggests saliva could offer a readily accessible diagnostic tool for detecting the presence of SARS-CoV-2, the virus that causes COVID-19, and might even be able to reveal whether someone’s immune system has already encountered it.</p>
<p>COVID-19 testing is a crucial part of the pandemic response, especially now countries are gradually lifting social distancing restrictions. This requires widespread, early, accurate and sensitive diagnosis of infected people, both with and without symptoms.</p>
<p>Our review looked at the results of three different studies, in Hong Kong, the nearby Chinese mainland city of Shenzhen, and Italy. All three studies found SARS-CoV-2 is indeed present in the saliva of COVID-19 patients (at rates of 87%, 91.6%, and 100% of patients, respectively). This suggests saliva is a potentially very useful source of specimens for detecting the virus.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-positives-and-negatives-of-mass-testing-for-coronavirus-137792">The positives and negatives of mass testing for coronavirus</a>
</strong>
</em>
</p>
<hr>
<p>Saliva <a href="https://www.sciencedirect.com/science/article/pii/S016041202031254X">spreads the SARS-CoV-2 virus</a> via breathing, coughing, sneezing, and <a href="https://www.nap.edu/catalog/25769/rapid-expert-consultation-on-the-possibility-of-bioaerosol-spread-of-sars-cov-2-for-the-covid-19-pandemic-april-1-2020">conversation</a>, which is why guidelines suggest we maintain a distance of at least 1.5 metres from one another. We also know <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7094991/">SARS-CoV-2 can survive in tiny droplets of saliva</a> in an experimental setting.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=242&fit=crop&dpr=1 600w, https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=242&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=242&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=305&fit=crop&dpr=1 754w, https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=305&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/335968/original/file-20200519-83388-16ad0ui.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=305&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>Saliva is an attractive option for detecting SARS-CoV-2, compared with the <a href="https://www.healthdirect.gov.au/coronavirus-covid-19-seeing-a-doctor-getting-tested-faqs#diagnosis">current tests</a> which involve taking swabs of mucus from the upper respiratory tract. Saliva is easy to access, which potentially makes the tests cheaper and less invasive. Saliva can hold up a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19726214">mirror to our health</a>, not just of our mouth but our whole body. </p>
<p>For this reason, saliva has already been widely investigated as a diagnostic tool for chronic systemic diseases, as well as for oral ailments such as periodontal disease and oral cancers. But less attention has been given to its potential usefulness in acute infectious diseases such as COVID-19, perhaps because researchers and clinicians don’t yet appreciate its full potential. </p>
<h2>What a mouthful</h2>
<p>When we get sick, much of the evidence is present in our saliva – from the germs themselves, to the antibodies and immune system proteins we use to fight them off. Saliva also contains genetic material and other cellular components of pathogens after we have broken them down (for the full biochemical breakdown of the weird and wonderful things in our saliva, see pages 51-61 of our <a href="https://www.mdpi.com/2075-4418/10/5/290">review</a>).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=545&fit=crop&dpr=1 600w, https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=545&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=545&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=685&fit=crop&dpr=1 754w, https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=685&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/335967/original/file-20200519-83397-65o81d.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=685&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>Saliva is also hardy. It can be <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=High-yield+RNA-extraction+method+for+saliva">stored at –80°C for several years with little degradation</a>.</p>
<p>This means it would be relatively straightforward to track the progression of COVID-19 in individual patients, by collecting saliva at various times during the disease and recovery. Saliva tests from recovered patients could also tell us if they have encountered the disease for a second time, and how strong their immune response is.</p>
<p>However, there is no research yet available on using saliva to monitor immune responses. This will be well worth investigating, given the pressing need for a reliable and cost-effective way to monitor the population for immunity to COVID-19 as the outbreak continues.</p>
<h2>Could saliva testing replace nasal swabs?</h2>
<p>An ideal saliva test would be a disposable, off-the-shelf device that could be used at home by individuals, without exposing them or others to the risk of visiting a clinic.</p>
<p>One drawback with the research so far is that it has involved small numbers of patients (each of the three studies we reviewed involved no more than 25 people), and there is little published detail on exactly how these studies collected the saliva – whether from the mouth or throat, whether by spitting, drooling or swabbing, and whether collected by the patient or by a clinician.</p>
<p>Nevertheless, based on the modest amount of research done so far, saliva looks like a promising candidate for COVID-19 testing. More research is now needed, in larger groups of people, to learn more about how to confidently test for SARS-CoV-2 in the saliva of both symptomatic and non-symptomatic people.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-why-do-we-make-saliva-130288">Curious Kids: why do we make saliva?</a>
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</em>
</p>
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<p>Earlier this month the US Food and Drug Administration <a href="https://www.nytimes.com/2020/05/08/health/fda-coronavirus-spit-test.html">approved the sale</a> of saliva-based COVID-19 test kits that will allow people to collect their own samples and send them to a lab for analysis.</p>
<p>A reliable test would offer a cheaper, less invasive and potentially even more accurate way to detect the virus, which would also reduce the risk posed by routine COVID-19 checks to both patients and front-line medical professionals.</p><img src="https://counter.theconversation.com/content/138816/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pingping Han works on salivary diagnostic research at the University of Queensland. She is affiliated with the School of Dentistry, at The University of Queensland</span></em></p>The SARS-CoV-2 coronavirus is currently detected using invasive nasal swabs. But the virus is also present in saliva, potentially paving the way for cheaper, safer tests that people could do at home.Pingping Han, Postdoctoral Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1377922020-05-15T06:19:45Z2020-05-15T06:19:45ZThe positives and negatives of mass testing for coronavirus<figure><img src="https://images.theconversation.com/files/334904/original/file-20200514-167748-1ut4hzs.jpg?ixlib=rb-1.1.0&rect=18%2C0%2C4071%2C2152&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><a href="https://www.nejm.org/doi/10.1056/NEJMoa2006100">Many</a> <a href="https://www.bmj.com/content/368/bmj.m1165">jurisdictions</a> around the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31100-4/fulltext">world</a> are now testing people without symptoms as part of efforts to manage COVID-19. In Victoria, asymptomatic health-care workers have been part of the recent “<a href="https://www.premier.vic.gov.au/major-coronavirus-testing-blitz-targets-100000/">testing blitz</a>”.</p>
<p>We tend to take for granted that the results of medical tests are accurate – but no test is perfect and all carry a risk of harm of some kind. Although there has been a drive to increase testing, we must recognise this is also true for coronavirus.</p>
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<strong>
Read more:
<a href="https://theconversation.com/what-is-sentinel-surveillance-and-how-might-it-help-in-the-fight-against-coronavirus-136845">What is sentinel surveillance and how might it help in the fight against coronavirus?</a>
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<h2>All tests have limitations</h2>
<p>Among the shortfalls of diagnostic testing is the possibility of false negatives (failing to detect a condition when it’s present) and false positives (detecting a condition when it’s absent).</p>
<p>It’s easy to see why false negatives can be a problem – we lose the benefits of early intervention. </p>
<p>But false positives can also cause harm, including unnecessary treatment. This is why positive screening tests are often followed up with a second, different test to confirm a diagnosis. </p>
<p>Examples include further imaging and possibly biopsy following a positive mammogram for <a href="https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/red-book/early-detection-of-cancers/breast-cancer">breast cancer</a>, or colonoscopy following positive screening for <a href="https://www.cancervic.org.au/bowel/bowel-cancer-screening-program">colon cancer</a>.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/as-restrictions-ease-here-are-5-crucial-ways-for-australia-to-stay-safely-on-top-of-covid-19-138000">As restrictions ease, here are 5 crucial ways for Australia to stay safely on top of COVID-19</a>
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<h2>Why do we get false positives?</h2>
<p>False positives can occur for many reasons, including normal human and system errors (for example mislabelling, data entry errors or sample mishandling). </p>
<p>Sometimes false positive test results could be due to a cross-reaction with something else in the sample, such as a different virus. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334913/original/file-20200514-167762-qb060.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Data entry errors can lead to false positives or false negatives.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>For COVID-19, the only routinely available option to confirm a positive result is to retest using the same method. This can address the false positives generated through sample contamination or human error. </p>
<p>Even so, <a href="https://www.dhhs.vic.gov.au/coronavirus-disease-2019-covid-19-guidelines-health-services-and-general-practitioners">some authorities</a> recommend isolation for any person who returns a positive test, regardless of subsequent results.</p>
<h2>Testing more widely could mean more false positives</h2>
<p>The proportion of false positives among all positive results depends not just on the characteristics of the test, but on how common the condition being tested for is among those being tested. </p>
<p>This is because even a highly specific test – one that generates hardly any false positives – may still generate more false positive results than there are actual cases of the condition in those being tested (true positives).</p>
<p>Let’s work through an example.</p>
<p>Say we have a very good test which is 99.9% specific – that is, only one in 1,000 tests give a false positive. And imagine we’re testing 20,000 people for condition X. Condition X has a very low prevalence – we estimate it affects 0.01%, or one in 10,000 people in the population. </p>
<p>At this level we could expect two people in our sample to have condition X, so we might get two true positive results. But we would also expect around 20 false positive results, given the error rate of our test. </p>
<p>So the proportion of people testing positive who actually have condition X would be only two out of 22, or 9.1%. </p>
<p>This is called the <a href="https://geekymedics.com/sensitivity-specificity-ppv-and-npv/">positive predictive value</a> of a test. The lower the prevalence of a condition in the population, the lower the positive predictive value. </p>
<h2>What about COVID-19?</h2>
<p>In Australia, control measures have been <a href="https://theconversation.com/we-may-well-be-able-to-eliminate-coronavirus-but-well-probably-never-eradicate-it-heres-the-difference-137991">very successful</a> in reducing the number of people currently infected with COVID-19. We estimate the likelihood of a positive test to be very low right now (although of course this may change as restrictions ease).</p>
<p>The current reported number of active COVID-19 cases in Australia is <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers">about 600</a>. And even if we’ve only diagnosed one in every ten people currently infected, this still represents less than 0.03% of the population.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/can-you-get-the-covid-19-coronavirus-twice-137309">Can you get the COVID-19 coronavirus twice?</a>
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<p>While we’re still establishing the specificity of tests for SARS-CoV-2 (the coronavirus that causes COVID-19), early evidence suggests an estimate of <a href="https://www.finddx.org/covid-19/sarscov2-eval-molecular/molecular-eval-results/">99% or greater</a> is reasonable. </p>
<p>However, following the same calculations as in the example above, at a prevalence of 0.03%, even a test with 99.9% specificity would mean only 30% of people who test positive actually have the condition. This means more than two-thirds of positive results would actually be false positives if we were testing asymptomatic people with no increased risk. </p>
<p>This is why testing criteria are often applied. If testing is offered only to those with symptoms consistent with COVID-19, the condition is almost certainly more common in those being tested than in the general (asymptomatic) population, and therefore the rate of true positives is going to be higher.</p>
<p>But if we start testing more broadly, the likelihood of false positives becomes a greater concern.</p>
<h2>Why are false positives a problem?</h2>
<p>Clearly we need tests to be as sensitive as possible – it’s easy to see why a false negative COVID-19 result could be a serious issue. But it’s important to recognise a false positive result can also cause significant problems for an individual and the community.</p>
<p>Consider, for example, the impact of asymptomatic health worker screening if a false positive test result leads to isolation of the person falsely diagnosed, and quarantining of their clinical co-workers identified (incorrectly) as close contacts of a case of COVID-19.</p>
<p>Further, a person who has had a false positive result may feel they are not at risk of future infection as they believe they are immune, leading to potential consequences for the individual and their contacts. </p>
<p>Even from an epidemiologicial perspective, a high proportion of false positives could distort our understanding of the spread of COVID-19 in the community. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/more-testing-will-give-us-a-better-picture-of-the-coronavirus-spread-and-its-slowdown-135698">More testing will give us a better picture of the coronavirus spread and its slowdown</a>
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<p>Testing for COVID-19 in Australia is highly regulated and uses the best possible tests and highly qualified staff.</p>
<p>But asymptomatic screening when the prevalence of a condition is as low as that of COVID-19 in Australia currently must carefully weigh the benefits of such testing against the potential harms.</p><img src="https://counter.theconversation.com/content/137792/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer MacLachlan receives funding from governments and other funding bodies for research unrelated to the subject of this article. She is Vice-President of the Board of Hepatitis Victoria. </span></em></p><p class="fine-print"><em><span>Benjamin Cowie receives funding from governments and other funding bodies for research unrelated to the subject of this article. </span></em></p>As we start to test people without symptoms for COVID-19, the likelihood of generating false positive tests goes up. Here’s why that’s a problem.Jennifer MacLachlan, Epidemiologist, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityBenjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1380002020-05-12T19:49:17Z2020-05-12T19:49:17ZAs restrictions ease, here are 5 crucial ways for Australia to stay safely on top of COVID-19<p>As Australia’s coronavirus restrictions are <a href="https://theconversation.com/australia-starts-to-re-open-but-the-premiers-have-the-whip-hand-on-timing-138218">gradually lifted</a>, we may well see an upswing in cases of COVID-19. The World Health Organisation has <a href="https://www.sbs.com.au/news/who-urges-extreme-vigilance-as-countries-start-to-ease-lockdowns">warned</a> of the need for “extreme vigilance” in countries that are now emerging from lockdown.</p>
<p>A vaccine remains the best possible tool to guard against the virus. But with a vaccine still months or even years away, we will have to rely on other epidemic control measures, of which there are five key pillars.</p>
<p><a href="https://theconversation.com/newsletter"><img src="https://images.theconversation.com/files/320030/original/file-20200312-116261-a6ugi0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=90&fit=crop&dpr=2" alt="Sign up to The Conversation" width="100%"></a></p>
<h2>1. Finding every new case</h2>
<p>We need to find and isolate every new case of COVID-19, to prevent transmission. Testing is the way we identify cases. Because even <a href="https://www.scripps.edu/science-and-medicine/translational-institute/about/news/sarc-cov-2-infection/index.html">people without symptoms can transmit the virus</a>, the testing regime should include <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e1.htm?s_cid=mm6913e1_w">high-risk, asymptomatic people</a>. </p>
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Read more:
<a href="https://theconversation.com/to-get-on-top-of-the-coronavirus-we-also-need-to-test-people-without-symptoms-134381">To get on top of the coronavirus, we also need to test people without symptoms</a>
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<p>Expanded testing criteria in some states allow any doctor to order a test if they suspect COVID-19, but <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/what-you-need-to-know-about-coronavirus-covid-19#testing">national criteria</a> still do not recommend testing of high-risk people (such as family contacts) who do not have symptoms.</p>
<p>In closed settings where COVID-19 cases have been identified – such as an aged care facility, <a href="https://academic.oup.com/jtm/advance-article/doi/10.1093/jtm/taaa030/5766334">cruise ship</a> or household – everyone exposed should be tested, as there is a high rate of asymptomatic and pre-symptomatic infection that would otherwise be missed.</p>
<p>This was not done aboard the Ruby Princess cruise ship, where only those with symptoms were tested. This may have resulted in <a href="https://www.9news.com.au/national/ruby-princess-coronavirus-cruise-ship-ground-zero-tasmania-cluster-northwest/c7cd45b2-8244-4a8a-8429-a9b04ed8180b">missed infections and further outbreaks</a>. It is vital to avoid further incidents like this as we move out of lockdown.</p>
<h2>2. Rigorous contact tracing</h2>
<p>Every person who has come into contact with a known COVID-19 case needs to be traced and <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30074-7/fulltext#%20">quarantined for two weeks</a>. Ideally, they should be tested. Using the COVIDSafe app will help identify all contacts more thoroughly.</p>
<h2>3. Continued social distancing</h2>
<p>Extreme social distancing measures such as home lockdowns are now coming to an end in Australia. But we should keep practising lesser measures, such as maintaining a distance of <a href="https://www.nytimes.com/interactive/2020/03/20/us/coronavirus-model-us-outbreak.html">1.5 metres from other people</a>.</p>
<h2>4. Ongoing travel bans</h2>
<p>Travel bans prevent infections being imported from <a href="https://www.medrxiv.org/content/10.1101/2020.03.09.20032045v1">countries with severe epidemics</a>. In Australia, <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers">more than 60%</a> of cases up to May 12 were imported through travel. Keeping the borders closed will allow further lifting of restrictions within Australia.</p>
<p>It is also important to <a href="https://www.news.com.au/world/coronavirus/australia/coronavirus-quarantine-hotel-rules-for-returning-travellers-to-australia/news-story/0e13698bd804b2505bc6205de8dc04ba">continue quarantining return travellers</a>, and testing Australians arriving home from high-risk countries. The Emirates airline has gone further, announcing <a href="https://www.travelweekly.com.au/article/emirates-becomes-worlds-first-airline-to-conduct-covid-19-tests-for-passengers/">COVID-19 testing for all passengers</a>.</p>
<h2>5. Face masks</h2>
<p>Everyone in the United States has been advised to wear a face mask, because peak transmission occurs in the <a href="https://www.nature.com/articles/s41591-020-0869-5#Fig1">two days before symptom onset or on the first day</a>. This can help flatten the curve, even if mask use is only modestly effective, especially if <a href="https://www.sciencedirect.com/science/article/pii/S0025556420300560?via%3Dihub">combined with social distancing</a>. </p>
<p>It is not a recommendation at this stage in Australia, but masks can also help ease restrictions safely, and may be something to consider in the coming months in crowded public places. </p>
<h2>Know your enemy</h2>
<p>Besides on-the-ground tactics such as widespread testing and contact tracing, we also need a clear understanding of infectious disease epidemiology, and defined criteria to alert us when we may be heading into an epidemic period. </p>
<p>In countries that have flattened the curve and achieved low incidence of COVID-19, such as Australia and New Zealand, there has been talk of “elimination” of the disease. </p>
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<strong>
Read more:
<a href="https://theconversation.com/we-may-well-be-able-to-eliminate-coronavirus-but-well-probably-never-eradicate-it-heres-the-difference-137991">We may well be able to eliminate coronavirus, but we'll probably never eradicate it. Here's the difference</a>
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<p>But because of the low total infection numbers in these countries, most people remain susceptible to COVID-19. This means fresh outbreaks are possible in the 12-24 months or longer until we have a vaccine. </p>
<p>The concepts of “elimination”, “eradication” and “control” arose from vaccination programs. Eradication is global, whereas elimination is national or regional, and “control” is a goal when elimination is <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/su48a7.htm">not possible</a>. For measles, outbreaks may still occur during elimination, usually imported through travel, but do not lead to <a href="https://www.who.int/bulletin/volumes/87/1/07-046375.pdf">sustained transmission</a>. </p>
<p>The World Health Organisation <a href="https://www.who.int/immunization/diseases/measles/en/">criteria</a> for the elimination of measles include: </p>
<ul>
<li><p>low incidence with an R0 below 1 (meaning each person with the disease infects less than one other)</p></li>
<li><p>high-quality surveillance </p></li>
<li><p>high population immunity.</p></li>
</ul>
<p>But with no vaccine for COVID-19, low incidence and high population immunity are mutually exclusive propositions. For a novel disease with no vaccine, it is premature to talk about eradication. </p>
<p>Ideal infections for elimination and eradication have no presymptomatic transmission and no animal host - for these reasons, eradication of COVID-19 is unlikely.</p>
<p>This means for the time being at least, we need to aim for “control” of COVID-19 – keeping the disease at a manageable level. For this, we need to differentiate between sustained community transmission and sporadic, non-sustaining outbreaks. </p>
<p>Widespread testing is the key to this. It will tell us how much infection is present, and if it is increasing. A stark reminder of the consequences of failure to test is the case of the United States, where the growth of the epidemic was not detected until it was <a href="https://www.theatlantic.com/health/archive/2020/03/how-many-americans-are-sick-lost-february/608521/">too late</a>.</p>
<p>How do we distinguish between sustained and non-sustained outbreaks? One possible definition of a sustained outbreak would be a certain number of generations of transmission from an original case. Another would be demonstrating ongoing community transmission over a defined period of time (such as three months), or a <a href="https://www.nytimes.com/2020/04/23/world/europe/coronavirus-R0-explainer.html">rise in the R0 value</a>, a measure of how strongly the outbreak is growing. Contact tracing will clearly be vital to assessing this. </p>
<p>Detection of a sustained outbreak would be a warning sign that we are potentially heading into another epidemic period. This might therefore signal the need for increased testing, stronger social distancing, and other measures. </p>
<p>It is likely we will face alternating epidemic and non-epidemic periods, and will need to continue to manage COVID-19 with <a href="https://science.sciencemag.org/content/early/2020/04/24/science.abb5793">intermittent returns to stronger restrictions</a>. That is, until we have a vaccine, at which point we can begin working towards bringing the COVID-19 crisis to a genuine close.</p><img src="https://counter.theconversation.com/content/138000/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and Sanofi (for influenza research).</span></em></p>Test, trace, maintain social distance, and keep travel bans and quarantines in place. These measures will help Australia keep the coronavirus in check as we gradually emerge from lockdown hibernation.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1372122020-04-27T12:11:33Z2020-04-27T12:11:33ZFailure to count COVID-19 nursing home deaths could dramatically skew US numbers<figure><img src="https://images.theconversation.com/files/330600/original/file-20200427-145508-18uj5n.jpg?ixlib=rb-1.1.0&rect=3%2C0%2C2087%2C1398&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Life Care Center in Kirkland, Washington, had the first known COVID-19 outbreak in a U.S. nursing home. In Massachusetts, one-third of nursing homes now have more than 30 COVID-19 cases.</span> <span class="attribution"><a class="source" href="http://gettyimages.com">Jason Redmond/AFP/Getty Images</a></span></figcaption></figure><p>In New York state, 19 nursing homes have each reported <a href="https://apnews.com/cc22e7c9d6af5080983b454644cdc113">20 or more deaths</a> from COVID-19. A nursing home in New Jersey reported <a href="https://www.nytimes.com/2020/04/19/nyregion/coronavirus-nj-andover-nursing-home-deaths.html">70 deaths</a> out of its 500 residents. In the words of New York <a href="https://www.axios.com/coronavirus-nursing-home-cuomo-new-york-a814f291-d0c8-4aa5-8465-9e13fa39409a.html">Gov. Andrew Cuomo</a>, these homes have become a “feeding frenzy” for the virus and “the single biggest fear.” </p>
<p>With the clustering of people who are frail and have multiple other illnesses like heart disease, stroke, chronic lung disease and diabetes, the <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html">risk of severe illness and death</a> from COVID-19 is much higher in nursing homes.</p>
<p>Yet, the United States does not know how many people are dying from COVID-19 in part because the government is <a href="https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/upcoming-requirements-notification-confirmed-covid-19-or-covid-19-persons-under-investigation-among">only just now requiring nursing homes</a> to start reporting numbers of presumed and confirmed cases and deaths to the federal Centers for Disease Control and Prevention. </p>
<p>The missing cases could dramatically skew the national death count. When France started reporting death data from some of its nursing homes, the daily COVID-19 <a href="https://www.bloomberg.com/news/articles/2020-04-02/france-virus-deaths-jump-to-5-387-with-nursing-homes-included">fatality numbers almost doubled</a>. </p>
<p><a href="https://apnews.com/e34b42d996968cf9fa0ef85697418b01">The Associated Press</a> conducted its own survey in the U.S. and found there had been nearly 11,000 COVID-related nursing home deaths across the country as of April 24. However, <a href="https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/">just 23 states</a> have been publicly reporting nursing home deaths. States also vary in how and where they are <a href="https://www.arkansasonline.com/news/2020/apr/24/most-nursing-homes-still-in-dark-about-/">performing tests</a>, and some count only proven cases and not also presumptive ones, leading to significant underestimates of the death toll.</p>
<p>As a geriatrician at <a href="http://www.bmc.org">Boston Medical Center</a> and <a href="https://www.bumc.bu.edu/centenarian/">researcher</a> at <a href="https://www.bumc.bu.edu/busm/">Boston University School of Medicine</a>, I have watched in dismay as COVID-19 has become a deadly flash flood among the very old people I care for and study. I would not be surprised if the deaths in nursing homes at least double the U.S. COVID-19 death count. </p>
<h2>In Massachusetts, 77% of nursing homes affected</h2>
<p>Hints of what <a href="https://skillednursingnews.com/2020/04/mass-gov-covid-19s-impact-on-top-nursing-homes-requires-heavy-duty-analytics-to-explain/">nursing homes</a> and their residents and staff are going through have emerged from the states that have started publicly sharing data about them. </p>
<p>With Massachusetts <a href="https://www.newyorker.com/science/medical-dispatch/its-not-too-late-to-go-on-offense-against-the-coronavirus">Gov. Charlie Baker</a> leading the charge, <a href="https://www.mass.gov/doc/covid-19-dashboard-april-25-2020/download">the Massachusetts Department of Public Health</a> is providing a daily update on nursing homes where residents or staff have either tested positive or are presumed to be infected with COVID-19.</p>
<p>As of April 25, <a href="https://www.mass.gov/doc/covid-19-dashboard-april-25-2020/download">about 77% of Massachusetts nursing homes</a> – 299 of 389 – had at least one case of COVID-19. That percentage will no doubt climb as the state carries out its mandated testing at nursing homes. About one-third of Massachusetts nursing homes reported more than 30 COVID-19 cases each among residents and staff. </p>
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<p>Nursing homes are required to maintain <a href="https://theconversation.com/preventing-covid-19-from-decimating-nursing-home-residents-requires-spending-money-and-improving-infection-control-134220">infection prevention protocols</a> to prevent the spread of infectious diseases into and within their facilities. But COVID-19, which is <a href="https://theconversation.com/r0-how-scientists-quantify-the-intensity-of-an-outbreak-like-coronavirus-and-predict-the-pandemics-spread-130777">much more contagious than the flu</a>, has punched holes in even the most careful and diligent facilities. Some nursing homes have also been <a href="https://www.washingtonpost.com/business/2020/04/17/nursing-home-coronavirus-deaths/">in trouble</a> for past problems with infection control. </p>
<p>It was initially estimated that on average, a person infected with COVID-19 led to an additional 2.5 people becoming infected. This basic <a href="https://theconversation.com/r0-how-scientists-quantify-the-intensity-of-an-outbreak-like-coronavirus-and-predict-the-pandemics-spread-130777">reproductive number</a> is called R0. A <a href="https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article">Los Alamos National Laboratory study</a> released April 7 indicates that this earlier estimate is woefully low and that the R0 is more like 5.7. For comparison, the R0 for flu is around 2. </p>
<p>Among nursing home residents, the reproductive number is likely even higher than the average of 5.7. Many of the brave and caring <a href="https://www.theguardian.com/us-news/2020/apr/15/nurses-surgeons-janitors-first-us-health-workers-to-die-covid-19">staff</a> in these nursing homes become infected, likely because of the intensity of this higher R0 and their exposure time with residents. By one <a href="https://www.mcknights.com/news/cms-waives-nurse-aide-training-certification-requirements/">report</a>, nearly half of surveyed nursing homes reported staff staying home and not working because they had signs of or were proven to have COVID-19. The exposure to COVID-19 underscores how critical it is for <a href="https://skillednursingnews.com/2020/04/even-strictest-nursing-home-guidance-meaningless-without-two-things-covid-19-tests-and-ppe/">nursing homes</a> to get the adequate supplies of <a href="https://www.maseniorcare.org/ppe-donations-massachusetts-nursing-homes">personal protective equipment</a> they have been crying out for.</p>
<p>I believe it is likely that the majority of nursing homes throughout the U.S. and beyond have or will soon have multiple residents and staff who are COVID-19 positive. One large nursing home operator in Britain estimates that <a href="https://www.bbc.com/news/health-52284281">two-thirds of its homes have outbreaks</a>. </p>
<h2>We haven’t heard about most deaths yet</h2>
<p>By the Centers for Disease Control and Prevention’s latest estimate, the U.S. has about <a href="https://www.cdc.gov/nchs/fastats/nursing-home-care.htm">15,600 nursing homes</a> with some 1.3 million residents. One quarter of those residents, about 425,000, are over the age of 80. In Massachusetts, the <a href="https://www.mass.gov/doc/covid-19-dashboard-april-25-2020/download">average age of death</a> in confirmed COVID-19 cases is 82.</p>
<p>As of April 26, <a href="https://www.mass.gov/doc/covid-19-dashboard-april-26-2020/download">56% of Massachusetts’ COVID-19 deaths</a> occurred in nursing homes. The <a href="https://www.voanews.com/covid-19-pandemic/who-europe-half-deaths-care-homes">World Health Organization</a> similarly estimates that half of COVID-19 deaths in Europe and the Baltics are among their <a href="https://gateway.euro.who.int/en/indicators/hfa_491-5101-number-of-nursing-and-elderly-home-beds/">4.1 million</a> nursing home residents. A minimum of 50% of the COVID-19 deaths occurring in nursing homes also agrees with the <a href="https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/">Kaiser Family Foundation’s</a> review of data from the 23 states that are publicly reporting nursing home deaths.</p>
<p>The limited scope of counting people who have died from COVID-19 is not just a U.S. problem. A representative of British nursing homes, <a href="https://www.theguardian.com/world/2020/apr/18/uk-care-home-covid-19-deaths-may-be-five-times-government-estimate">Care England</a>, says that 7,500 people in nursing homes there have died due to COVID-19 – five times the U.K. government’s estimate of 1,600.</p>
<p>One indication of the high death toll from nursing homes comes from <a href="https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases">Belgium</a>. The country <a href="https://www.bloomberg.com/news/articles/2020-04-25/why-the-world-s-highest-virus-death-rate-is-in-europe-s-capital">has the highest per capita rate</a> of COVID-19 deaths in the world – 57 per 100,000 people – primarily because <a href="https://www.reuters.com/article/uk-health-coronavirus-belgium-tally/belgium-says-white-house-reading-of-its-covid-19-deaths-unfair-idUKKCN2242QC">officials there include nursing homes’ COVID-19 deaths</a> in the national count and they are including both presumed and proven cases. Like Massachusetts, more than half of COVID-19 deaths in Belgium occur <a href="https://www.bloomberg.com/news/articles/2020-04-25/why-the-world-s-highest-virus-death-rate-is-in-europe-s-capital?sref=Hjm5biAW">outside of hospitals</a>.</p>
<p>The current U.S. rate, according to <a href="https://coronavirus.jhu.edu/data/mortality">Johns Hopkins University</a>, is 16 per 100,000, but its reports are only as reliable as its <a href="https://coronavirus.jhu.edu/map-faq">data sources</a>, which include the CDC and state departments of health. <a href="https://www.usatoday.com/story/news/politics/2020/04/22/coronavirus-trump-says-us-mortality-rate-one-worlds-lowest/3002516001/">This rate is likely lower</a> than Belgium and 11 other countries because of the great variation across the U.S. in which data are not included, such as people who die outside of hospitals, and the data missing due to limited testing.</p>
<p>On April 19, the <a href="https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/upcoming-requirements-notification-confirmed-covid-19-or-covid-19-persons-under-investigation-among">Centers for Medicare Services</a> announced it would begin requiring U.S. nursing homes to report all confirmed or presumed COVID-19 cases to the CDC. I hope this will include past cases and deaths.</p>
<p>To get an accurate count, veterans’ homes, assisted living centers, group homes and other senior housing facilities must be required to report their past and current COVID-19 cases and deaths, as well. </p>
<p>There is plenty we still do not know about for why nursing home residents have borne the brunt of this pandemic. As <a href="https://skillednursingnews.com/2020/04/mass-gov-covid-19s-impact-on-top-nursing-homes-requires-heavy-duty-analytics-to-explain/">Gov. Baker</a> has indicated, “This is a topic that will get a lot of appropriate analysis after the fact.”</p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/137212/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Perls does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The government doesn’t know how many people have died of COVID-19, in part because it didn’t require nursing homes to report cases to the CDC. In some states, over half of deaths are in nursing homes.Thomas Perls, Professor of Medicine, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1368442020-04-24T02:07:04Z2020-04-24T02:07:04ZFlushing is our next weapon against COVID-19, if you’re happy to have your sewage scrutinised<figure><img src="https://images.theconversation.com/files/330003/original/file-20200423-47784-7dsgnu.jpg?ixlib=rb-1.1.0&rect=7%2C118%2C4913%2C3135&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>We may have a surprising new ally in the bid to contain the COVID-19 outbreak: <a href="https://www.nature.com/articles/d41586-020-00973-x?utm_source=fbk_nnc&utm_medium=social&utm_campaign=naturenews&fbclid=IwAR1GAguCEORMq3czVF_WjCBRCKOxTUtzBjVweKKgkdPqropiNhyk0UwfSB4">your sewage</a>. </p>
<p>Australia’s government <a href="https://www.abc.net.au/news/2020-04-17/australia-to-test-sewage-for-coronairus-as-testing-net-widens/12156858">recently announced</a> that sewage is to be tested for SARS-CoV-2, the coronavirus that causes COVID-19. Federal health minister Greg Hunt explained this will be a key part of the monitoring program that will need to be in place to guard against future local outbreaks of the virus.</p>
<p>Researchers in <a href="https://www.medrxiv.org/content/10.1101/2020.03.29.20045880v1">the Netherlands</a>, <a href="https://www.medrxiv.org/content/10.1101/2020.04.12.20062679v1">France</a>, <a href="https://www.medrxiv.org/content/10.1101/2020.04.05.20051540v1">the United States</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0048969720322816">Australia</a> have been testing sewage for SARS-CoV-2 for more than a month, and have generally reported that the rise and fall of their results reflect the officially reported local rates of infection with COVID-19. </p>
<p>This suggests sewage can indeed be used to monitor the future spread of the virus. And with many infections thought to be symptomless, this means we can potentially detect cases that might evade other monitoring programs.</p>
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Read more:
<a href="https://theconversation.com/we-dont-know-for-sure-if-coronavirus-can-spread-through-poo-but-its-possible-135305">We don't know for sure if coronavirus can spread through poo, but it's possible</a>
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<p>The testing for SARS-CoV-2 in sewage doesn’t detect the virus itself, but just a very small fragment (about 0.1%) of the virus’s genetic material, called RNA. This means it cannot tell whether the water contains infectious virus particles or just a few pieces of leftover RNA from inactivated or decomposed viruses.</p>
<p>This type of waste tracking is not new. It has already been used in Australia to <a href="https://www.sciencedirect.com/science/article/pii/S0048969719316912?via%3Dihub">track viruses such as norovirus</a>. And since 2017, sewage testing has been used to uncover <a href="https://www.acic.gov.au/publications/reports/national-wastewater-drug-monitoring-program-reports">evidence of illicit drug use</a> at the population level. Drug-testing sewage has helped police and other authorities discover <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610511/">what drugs are used</a> in particular cities, and even to track down illicit drug labs. </p>
<p>The newer aspect is the proposal to use sewage monitoring in the context of a major pandemic, and potentially to rely on the data to inform some very high-stakes decisions. This introduces a high burden of responsibility to ensure that the data are collected by reliable means, with well understood rates of false results, both positive and negative. </p>
<p>If major decisions are to be based on measured concentrations, it will be essential to understand all the factors behind these measurements. </p>
<h2>If sewage tests positive, what next?</h2>
<p>While technically possible, sewage testing from individual properties is unlikely to be cost-effective. But it might potentially be used to sample wastewater from large buildings, hospitals or even ships or aircraft. </p>
<p>It will be important to understand how we would respond to positive results for SARS-CoV-2. Locking down a building or cruise ship might require isolation for everyone involved. Alternatively, a positive result could be used as a trigger for individual testing of those people who may have contributed to the positive sewage sample. In any case, the impacts to individuals will be sufficient to warrant a high reliability for sewage testing. </p>
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Read more:
<a href="https://theconversation.com/we-dont-know-for-sure-if-coronavirus-can-spread-through-poo-but-its-possible-135305">We don't know for sure if coronavirus can spread through poo, but it's possible</a>
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<p>Meanwhile, how confident can we be about sewage that tests negative for SARS-CoV-2? Do we properly understand the likelihood of missing what could have been a positive result? Would there be liability placed on the testing authorities, governments, or others in the case of false negatives leading to missed opportunities for virus containment? </p>
<p>We will also need to understand the trends that may be observed in terms of increasing and decreasing concentrations of SARS-CoV-2 in sewage. While we may assume these accurately reflect changing patterns of infection, other factors such as rainfall and sampling variability could significantly influence the measured concentrations. </p>
<p>Of course, direct clinical testing of patients is also subject to many types of errors, and there are protocols in place for how we respond. But sewage testing would likely have higher degrees of uncertainty and greater numbers of people directly affected by the responses.</p>
<p>The issue is thus far less straightforward than it might appear on first reflection. That means it deserves a similar level of scrutiny as the government’s planned contact tracing mobile phone app, which has prompted <a href="https://www.theguardian.com/world/2020/apr/20/privacy-concerns-persist-over-australias-coronavirus-tracing-app">significant privacy concerns</a>.</p>
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Read more:
<a href="https://theconversation.com/coronavirus-contact-tracing-apps-most-of-us-wont-cooperate-unless-everyone-does-135959">Coronavirus contact-tracing apps: most of us won’t cooperate unless everyone does</a>
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<h2>A human right to flush without self-incrimination?</h2>
<p>If coronavirus testing is to be used to dictate specific actions or responses from public health officials under emergency orders, it raises questions that have not yet been addressed in Australia’s drug testing. </p>
<p>A testing regime that delivers information on the scale that would be most useful for public health would create challenges for human rights. The human right to water is recognised under international law, and includes <a href="https://www.un.org/waterforlifedecade/human_right_to_water.shtml">the right to safe and accessible sanitation</a>. If sewage testing is used to support sanctions in the form of lockdowns, this may erode our basic right to access sanitation. </p>
<p>This kind of testing also poses challenges for public water authorities, which must comply with the <a href="https://www.oaic.gov.au/privacy/australian-privacy-principles/">Information Privacy Principles</a>. </p>
<p>We may also wonder where our own “rights” to our waste end. In Australia, household garbage remains the legal property of the householder while on their private property, but belongs to the garbage collection agency (usually a local government) once collected. Is this an appropriate model for bodily waste? </p>
<p>Australia’s legal frameworks around sewage collection, treatment and management have struggled to <a href="https://www.waterquality.gov.au/guidelines/recycled-water">keep pace</a> with developments in sewer mining, stormwater reuse and water recycling. </p>
<p>It might seem strange to ponder the ethics of what people flush down the toilet. But given the personal details that sewage can reveal – everything from diseases and pollutants to drug and alcohol use – we need a national framework to ensure the technology does not go unchecked.</p><img src="https://counter.theconversation.com/content/136844/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Kosovac has previously received funding from Yarra Valley Water. </span></em></p><p class="fine-print"><em><span>Erin O'Donnell has previously consulted for Melbourne Water and is currently receiving funding from the Victorian Department of Environment, Land, Water and Planning. Erin is a member of the Birrarung Council, the voice of the Yarra River/Birrarung. </span></em></p><p class="fine-print"><em><span>Stuart Khan receives funding from many Australian water utilities including Sydney Water and others. </span></em></p>The government plans to monitor sewage for the SARS-CoV-2 coronavirus. And while this holds promise to tracking future local outbreaks, there are also some sticky ethical questions to consider.Anna Kosovac, Research Fellow in International Urban Politics, The University of MelbourneErin O'Donnell, Early Career Academic Fellow, Centre for Resources, Energy and Environment Law, The University of MelbourneStuart Khan, Professor of Civil & Environmental Engineering, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1369422020-04-23T08:04:55Z2020-04-23T08:04:55ZWhy coronavirus emerges in clusters, and how New Zealand plans to eliminate outbreaks after lockdown<figure><img src="https://images.theconversation.com/files/329981/original/file-20200423-47784-23k0ih.jpg?ixlib=rb-1.1.0&rect=19%2C118%2C6567%2C3170&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>After four weeks of some of the <a href="https://covidtracker.bsg.ox.ac.uk/">world’s strictest lockdown conditions</a>, New Zealand now records much higher numbers of people who have recovered from COVID-19 than new infections.</p>
<p>In its <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases">April 23 update</a>, the Ministry of Health <a href="https://www.rnz.co.nz/news/national/414950/covid-19-three-new-cases-in-nz-two-further-deaths-reported">reported</a> only three new cases – though another two people died, taking the death toll to 16. The <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases">total number of cases is 1451</a>, with more than a thousand people having now recovered from the illness.</p>
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<a href="https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=325&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=325&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=325&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=408&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=408&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329993/original/file-20200423-47841-1lovqdt.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=408&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases">April 23 update, New Zealand's Ministry of Health</a></span>
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</figure>
<p>As New Zealand prepares to <a href="https://www.beehive.govt.nz/release/alert-level-3-restrictions-announced">ease lockdown</a> conditions <a href="https://theconversation.com/delight-relief-and-caution-six-experts-on-new-zealands-move-to-ease-its-coronavirus-lockdown-136715">from April 28</a>, it can expect new clusters of infections to emerge, as has been happening in <a href="https://www.nst.com.my/world/world/2020/04/586759/covid-19-resurges-northeast-china">northeast parts of China</a>.</p>
<p>But it plans to continue using a combination of testing and contact tracing to stamp out the spread of COVID-19.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-weekly-as-virus-numbers-peak-governments-are-charting-the-path-out-of-lockdown-136712">Coronavirus weekly: as virus numbers peak, governments are charting the path out of lockdown</a>
</strong>
</em>
</p>
<hr>
<h2>How new clusters can emerge – even with closed borders</h2>
<p>New Zealand moves on to <a href="https://covid19.govt.nz/latest-updates/new-zealand-be-at-alert-level-3-from-tuesday-28-april/">two weeks of level 3 lockdown</a> from Tuesday, and people who cannot work from home will start returning to their workplaces, if they can maintain social distancing measures.</p>
<p><a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-border-controls">Border controls</a> will remain in place indefinitely to avoid new introductions of coronavirus.</p>
<p>Prime Minister Jacinda Ardern has said New Zealand will continue to pursue its goal of elimination with a strategy that differs from most other countries.</p>
<blockquote>
<p>Success doesn’t mean zero COVID-19 cases. It means zero tolerance, which means that as soon as we know we have a case, we go in straight away, we’re testing around that person, we’re isolating them […] we do our interviews and contact trace to find all the people who have been in contact with them while they may have passed it on, and we ask them to isolate. That’s how we keep stamping out COVID cases. </p>
</blockquote>
<p>New Zealand now has <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases/covid-19-significant-clusters">16 significant clusters</a>, with more than 90 people associated with the two largest of them. People in each cluster are from different households, but they are connected through transmission. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=579&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=579&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=579&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=728&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=728&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329994/original/file-20200423-47784-1s9tqrp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=728&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The location of identified COVID-19 cases across New Zealand, shown by district health board area, as of April 23.</span>
</figcaption>
</figure>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=566&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=566&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=566&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=711&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=711&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329995/original/file-20200423-47847-lspcj1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=711&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As of April 23, 1,065 of New Zealand’s 1,451 COVID-19 cases had recovered, while 16 people had died. This shows total cases by district health board area.</span>
</figcaption>
</figure>
<p>Clusters are the starting points of epidemics or local outbreaks. Epidemiologists think of clusters like networks through which an infection can propagate. If different networks are connected by one or more common members who can travel from one network to another, clusters can join and grow. </p>
<p>Likewise, if networks are kept isolated from each other, the chain of transmission is broken. This is how lockdowns work. Each of our household bubbles is a small network, and as long as we can maintain that bubble without connecting with others outside of our own, we prevent new clusters. </p>
<p>But new cases have continued to emerge because:</p>
<ol>
<li><p>even under stringent lockdown conditions and self-isolation, people still need to access public places such as supermarkets where they are at risk of exposure</p></li>
<li><p>COVID-19 has a variable <a href="https://www.who.int/news-room/q-a-detail/q-a-coronaviruses">infectious period</a> and many people don’t show symptoms but can still infect others </p></li>
<li><p>some people within clusters were infected before lockdown started, and continued to infect others within small networks. </p></li>
</ol>
<h2>Why contact tracing is crucial beyond lockdown</h2>
<p>When lockdown conditions ease, people who return to work and children who go back to school will move between networks. This will increase the risk of new infections, but testing has ramped up significantly during the weeks under level 4 conditions and will continue to increase to capture new infections. In some regions, <a href="https://www.countiesmanukau.health.nz/news/covid-19-sentinel-community-testing-undertaken-in-auckland/">sentinel community testing</a> was carried out to identify any symptom-free cases.</p>
<p>Testing laboratories now process <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases#lab">thousands of COVID-10 tests</a> every day, with a record 6480 tests carried out on April 22. The total number of tests is now 101,277.</p>
<p>At the same time, contact tracing has also increased to identify different network structures and clusters. Contact tracers start with an “index” person and track everyone who was connected to that individual to interrupt any forward transmission as the contacts are isolated. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-contact-tracing-apps-most-of-us-wont-cooperate-unless-everyone-does-135959">Coronavirus contact-tracing apps: most of us won’t cooperate unless everyone does</a>
</strong>
</em>
</p>
<hr>
<p>When the COVID-19 outbreak began in New Zealand, the capacity for <a href="https://yournz.org/2020/04/21/audit-of-contact-tracing-for-covid-19-in-new-zealand/">contact tracing was limited</a>, but rapid case detection, contact tracing and isolation now has over <a href="https://www.health.govt.nz/publication/rapid-audit-contact-tracing-covid-19-new-zealand">90% efficacy against COVID-19 at the population level</a>.</p>
<p>Contact tracing is important for mapping the networks of infected people. “Super spreaders” – individuals who move between clusters – can be identified quickly and their movements tracked. This will help to contain any new clusters. </p>
<p>Manual contact tracing for an outbreak on the scale of COVID-19 needs to be supplemented with digital tools such as <a href="https://info.flutracking.net/">Flutracker</a>. The Ministry of Health is also considering a contact tracing app like Singapore’s <a href="https://www.tracetogether.gov.sg/">TraceTogether</a> to prevent large clusters. </p>
<p>With continued contact tracing, we expect the number of new cases to remain low and with border controls preventing imported cases, any emerging new clusters should be able to be detected and contained rapidly. This intervention is central to COVID-19 elimination in New Zealand.</p><img src="https://counter.theconversation.com/content/136942/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arindam Basu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As New Zealand prepares to ease its lockdown from April 28, new COVID-19 clusters are likely to emerge – but a combination of testing and contact tracing should be able to stamp out major outbreaks.Arindam Basu, Associate Professor, Epidemiology and Environmental Health, University of CanterburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1356982020-04-16T23:05:12Z2020-04-16T23:05:12ZMore testing will give us a better picture of the coronavirus spread and its slowdown<p><a href="https://7news.com.au/lifestyle/health-wellbeing/coronavirus-australia-infection-rate-continues-to-decline-as-australia-ponders-exit-strategy-c-979164">Many states</a> are <a href="https://www.abc.net.au/news/2020-04-15/sa-broadens-coronavirus-testing-with-two-week-covid-blitz/12150524">now</a> <a href="https://www.abc.net.au/news/2020-04-14/victoria-expands-coronavirus-testing-criteria/12146166">ramping up the number of tests</a> by relaxing the criteria for who can get tested for COVID-19. This should give us a better idea of whether the spread is easing or getting worse.</p>
<p>We get regular updates about COVID-19 with lots of data, figures and graphs with some interpretations to see if we are flattening the curve on the number of new cases.</p>
<p>But most of these are based on using only the total or the daily number of confirmed new cases. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-much-has-australia-really-flattened-the-curve-of-coronavirus-until-we-keep-better-records-we-dont-know-136252">How much has Australia really flattened the curve of coronavirus? Until we keep better records, we don't know</a>
</strong>
</em>
</p>
<hr>
<p>This does not provide enough information about whether the situation is improving, stabilising or getting worse. That is why we also need to consider the number of people tested daily for COVID-19.</p>
<p>For example, in percentage terms there is no actual difference between getting 20 positive cases out of 1,000 tests one day and 100 positive cases out of 5,000 tests the next. Both lead to the conclusion we have 2% reported infected people of those tested.</p>
<p>If we are only given the number of new cases, getting 100 in a day sounds a lot worse than getting 20. The 2% percentage figure here tells us things are pretty much the same over the two days.</p>
<h2>Curves and trends</h2>
<p>Take Victoria, if we look at the total number of confirmed cases we see it followed an exponential trend for a while – one that was increasingly rising – and then started to divert on April 3.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=558&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=558&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=558&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=701&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=701&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328279/original/file-20200416-140745-urr91b.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=701&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>In the daily number of confirmed cases we see high jumps and large fluctuations going back and forth.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=527&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=527&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=527&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=662&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=662&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328281/original/file-20200416-140719-npy0fk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=662&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>When the daily number of applied tests is considered, we can calculate the actual percentage of new cases each day. Now we have a way flatter curve (below) with different fluctuations.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=838&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=838&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=838&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1054&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1054&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328284/original/file-20200416-140729-sfncn1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1054&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>The peak is now on March 24 when the number of tests is included. If we just look at the daily count, the highest number of confirmed cases was on March 27. When we look at the percentage, it shows a decrease rather than an increase with more than 2,300 tests.</p>
<p>From the daily new cases data it looks like there is a strongly decreasing trend in the number of confirmed cases between April 2 and 6. </p>
<p>But we do not see the same strong downward movement in the percentage data on the number of tests. Although both figures go down, then up slightly, the percentage trend downward is not as strong as the daily trend.</p>
<p>This is a good example of the discrepancy between the inferences from the raw and percentage data. When we consider the number of tested people, we get a different view on the progress of the pandemic.</p>
<h2>More tests needed</h2>
<p>In using the number of tests to get a more reliable picture of the situation, there is an important point to consider. That’s were the purple error bars in the graph (above) come in.</p>
<p>They show the margin of error where each percentage estimate swings for the daily number of applied tests, so the actual number could be higher or lower but within those purple bars.</p>
<p>When we have a larger number of applied tests, we get a reduced margin of error, and that gives us a clearer picture of what is happening. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/even-in-a-pandemic-continue-with-routine-health-care-and-dont-ignore-a-medical-emergency-136246">Even in a pandemic, continue with routine health care and don't ignore a medical emergency</a>
</strong>
</em>
</p>
<hr>
<p>Since the peak on March 24 is backed up by only 500 tests, it has the largest margin of error. The figure on March 28 is based on 8,900 tests with a very small amount of error. </p>
<p>To get a more reliable picture of the situation, the number of applied tests has to be expanded, which it is what is happening in some states. This should reduce the margin of error.</p>
<h2>Out in the community</h2>
<p>After getting some signals of flattening the curve in <a href="https://www.theage.com.au/national/victoria/wonderful-success-optimism-that-victoria-has-started-to-flatten-the-curve-20200405-p54h9v.html">Victoria</a> and <a href="https://www.theguardian.com/world/2020/apr/05/health-officials-hopeful-australia-is-flattening-coronavirus-curve-but-warn-against-complacency">Australia</a> as well, do we see an exponential increase in just the community transmission? </p>
<p>Community transmission is where someone has caught the virus locally, not an infected traveller who’s returned from a cruise or overseas. At the moment they are <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers">the minority of cases</a> and authorities would like it to stay that way to <a href="https://www.abc.net.au/news/2020-04-11/what-is-community-transmission-of-coronavirus-covid-19/12142638">contain the spread of the virus</a>.</p>
<p>Again, we need to consider the number of tests to answer this question clearly. The raw numbers of community transmission in Victoria looked like they were increasing exponentially.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=569&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=569&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328296/original/file-20200416-140741-12r4ldn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=569&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>But the numbers as a percentage of the number tested tell a different story. Although there is some increase in the rate of community transmissions recently, it still shows a way flatter behaviour far from the exponential curve.</p>
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<p>That is why it is important to understand the impact of the number of tests on the figures displaying the progress of the pandemic. Understanding this relationship could reassure people about new numbers.</p><img src="https://counter.theconversation.com/content/135698/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Haydar Demirhan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Don’t just tell us how many new cases of COVID-19 have been confirmed, tell us how many people you tested as well. That helps us to know if things are getting better or worse.Haydar Demirhan, Senior Lecturer in Analytics, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.