By calling coronavirus testing “overrated”, Donald Trump failed to reassure those who say that the U.S. economy cannot open without strong virus countermeasures. But his lack of leadership on COVID-19 hasn’t prevented Indiana from starting to track the virus effectively.
On May 13, the IU Fairbanks School of Public Health and the Indiana State Department of Health released preliminary results from the first statewide random sample study of the prevalence of COVID-19 in Indiana. This is also the first statewide COVID-19 random sampling to take place in the U.S.
Between April 25 and May 1, Indiana University researchers tested 4,600 Hoosiers. They found that 2.8 percent tested either positive for a COVID-19 infection or for antibodies — evidence of a previous infection. Extrapolating from these results, IU researchers estimated that 11 times more Hoosiers had been infected than indicated by previous testing. At that point, 17,000 Indiana residents had tested positive (cumulative cases, minus deaths). So that put the estimated number of people of people in Indiana infected, or previously infected, with the virus between 186,000 and 187,000 as of May 1.
At the time that these preliminary results were revealed, the statewide stay-at-home orders had been in effect for six weeks.
To Nir Menachemi, lead scientist on the study and chair of the Department of Health Policy and Management at the IU Fairbanks School of Public Health, there are two big takeaways from these preliminary results.
“On the one hand, that means that we slowed the spread of the virus, because if that number was much higher you'd expect there to be a higher proportion of the population previously infected,” Menachemi said. “On the other hand, the vast majority of people haven't yet been infected.”
Researchers, he said, have not yet established whether, once infected, you're immune from being infected again.
“That's currently being investigated on an international scale,” Menachemi said. “I think there's some hope that that might be but there's some reason to believe that that might not be. And so the question becomes, once you're infected, are you immune? For many viruses that immunity can be short-lived. But for other viruses that could be indefinitely for the rest of your life. Where this particular virus fits on the level of acquired immunity after exposure is unknown.”
Roughly 45 percent of those testing positive were asymptomatic. That is, they had active infections, but no symptoms.
The researches also estimated the fatality rate from COVID-19 to be .58 percent in the state, which makes the virus six times more deadly than seasonal flu. (According to the Centers for Disease Control and prevention, the fatality rate from seasonal flu is .1 percent.)
3,600 people were randomly selected for the initial round of testing. In order to accurately mirror state demographics, organizers recruited 900 testing volunteers in Hispanic and African American communities. Three more rounds of random sampling are scheduled over the next year, with the next round of testing coming from June 3 - June 7. Ultimately 20,000 Hoosiers will be tested, with researchers using the same protocols on each round.
Random sampling delivers unbiased datasets, unlike selective testing, and this matters if you're making data-driven decisions as a policy maker.
Selective testing doesn't work as well, Menachemi said, because the people tested "are people who are either high risk, or have sufficiently high symptoms to warrant the use of one of the limited tests. And so you can almost imagine, by definition, everyone who we're going to find that way are going to be biased towards being more symptomatic and high risk and so what we're not seeing is everyone else."
The random sample study received support, Menachemi said, from the highest levels of state government.
“There was a massive amount of support for this to occur,” he said. “The Indiana State Public Health Department was tasked as one of the lead agencies on behalf of the state, but half a dozen other agencies participated in one way or another in making this happen. Some of the behind the scenes work started with just being able to pull the information needed to generate a list of all Hoosiers to select from. That involved the Department of Revenue, that involved the Bureau of Motor Vehicles [and] the Family and Social Services Administration. The Indiana State Department of Health, in conjunction with the National Guard, did a lot of the on- the-ground logistical support.”
One of the study’s preliminary findings is that there is a higher infection and sero-prevalence among racial and ethnic minorities, a result that has been seen in more conventional forms of COVID-19 testing.
“We now have the full picture and we now know that they are also disproportionately more likely to be infected,” Menachemi said. “And that can only be done through a random sample test where you get a glimpse at the folks that you are not going to ever pick up if you only do those selective / conventional / clinical testing, which the vast majority of tests in the US have been before a study like this.”
The relatively low prevalence rate of the novel coronavirus in the study’s preliminary results means that the state’s social distancing measures were effective, Menachemi said. “It gave us a little bit of breathing room in order to figure out what to do next,” he said. But he also said that it’s important, as the state opens up economically, to maintain vigilance — with mask wearing, handwashing, and social distancing — but also to realize that certain widely-implemented precautions are not entirely effective.
Noting that 45 percent of Hoosiers found in the study with active infections are asymptomatic, Menachemi said that temperature checks are problematic. “That might capture some people but it might also give us a false sense of security because if you're asymptomatic and not with a fever, measuring temperature is not going to necessarily stop the spread of the disease,” he said.
Menachemi also fears a scenario where Hoosiers abandon precautions. “Elected officials, council persons, business owners, all of them need to be aligned in understanding that we can't allow for cutting corners on this,” he said. “If the person who's potentially at risk of infecting others isn't staying home, we'll be back to square one before we know it.”
In this sense, business owners like Adam Aasen are as much on the front lines of fighting COVID-19 as hospital workers. Aasen is a city councilor representing Carmel’s southeast district. He is also the co-owner of Donetello’s, a small Italian restaurant on Main Street in Carmel. After continuing with carryout-business during the two months of the shutdown, he opened the Donatello’s dining room at 50 percent capacity on May 11 per easing of stay-at-home orders in Indiana.
Aasen adjusted many of the practices in the restaurant as well as the layout of the dining room.
“Our staff are wearing masks, they are doing temperature checks,” he said. “We have hand sanitizer stations for customers; we've got disposable menus. One habit I try to break for my staff is we don't put out any plates, silverware, glasses or candles or any of those things you don't want sitting on the table ahead of time.”
The slower pace in the dining room, he said, provides a good opportunity to get his staff and customers comfortable with the new way of doing things. “We have to get comfortable because this isn't going to go away tomorrow,” he said. “A lot of the things that we're doing, we're going to have to do for quite some time so we might as well get comfortable doing it.”
For Aasen, his role as restaurateur informs his role as city councilor.
“The two biggest things I think I hear people talk about are testing employees and mask requirements,” Aasen said. “I held a roundtable of CEOs and business owners on Zoom call, and we had restaurants, barber shops, hairstylist tech companies, real estate, realtors ...They really are eager to find ways to test their employees if they have symptoms, or if the company can afford it, to maybe do testing of all employees, symptomatic or asymptomatic. But there's a lot of questions about the cost of the tests, and what kind of tests are the best, whether there are different types of tests available.”
Aside from the challenges of reopening in the middle of a pandemic, Aasen is concerned about potential closures down the road, especially if they are prolonged.
“We know that consumer habits start to change if things go on long enough,” he said. “You see this with road construction. If you close the road for a couple of weeks, 30 days, people may stop eating at a restaurant or stop going to the barber. But they don't look for a new barber if it's just 30 days. They say, well, I’ll get to them when I can. And I'll come back. If it's six months of a road closure, consumers start to develop new habits, new favorites, new routes, new places to go after two months of no dining.”
On the other hand, he realizes, there are no shortcuts to fully re-opening the economy. Towards that end, he supports the Carmel City Council’s “Wearing is Caring” campaign regarding masks on social media. It’s a campaign that has an encouraging, rather than shaming, tone, he said.
“I'm sure you've seen it on social media where people start to attack and shame each other," he said. "I just don't think that's effective ... A positive campaign is probably a better way to change hearts and minds.”
He also has a message for people who don’t like wearing masks in public. “One, I don't think it's a big inconvenience,” he said. “I wear a mask, it doesn't bother me. Two, If you want to rebuild our economy, we need to rebuild consumer confidence.”
Just because things are opening back up, he doesn’t want people to think it’s a free-for-all.
“It was not fun being in this lockdown and we don't want to have to go back to it,” he said. “We want to keep people alive, which is number one, above all. We can try to find a way to keep people safe and reopen our economy at the same time.”
Governor Holcomb's recent moves towards reopening the Indiana economy, however, might not be entirely data-driven. A recent study by the Institute for Health Metrics and Evaluation at the University of Washington outlines what is at stake. It projects that current statewide reopening measures will increase the death rate from COVID-19 in Indiana by 543 percent.
One key to reopening the economy, by means of slowing down the virus, is contact tracing, say researchers from Johns Hopkins. That is, tracing the contacts of everyone who tests positive with the goal of notifying those contacts that they need to self-quarantine. Neither testing nor tracing, according to researchers at the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, should be left just to the states. “A national effort to scale up and expand local, state, and territorial case investigation and management is necessary before US communities can begin to return to ‘normal’” they wrote in an April 10 report.
The Trump administration, however, wants to merely play a backup, support role for the states, according to a May 25 article in The New York Times. (The article’s title “‘This is Not the Hunger Games’: National Testing Strategy Draws Concerns” sort of telegraphs the punch.) It’s hard, therefore, to see the Trump administration taking contact tracing any more seriously than testing.
With the Trump administration declining to be fully-engaged, the way forward seems to have been left to states, local governments, and research institutions.
“We ourselves as a team are talking with several other states about the potential to assist them in replicating our protocol in their states,” Dr. Menachemi said, regarding the potential use of the Indiana random sample study as a model.
But he believes that more federal guidance could be helpful.
“I think the federal role should be doing something like [random sampling] at the federal level,” he said. “We need the US population estimates for federal policy in the same way that we need state estimates for state policy, and counties, county policy. This is not a one time thing. You need to keep monitoring how the population is doing at any level. That matters to us from a policy perspective.”