Too Much to Lose: Lives and Livelihoods
Eve Higginbotham SM, MD
There has been a continuous outcry for increased testing during this pandemic and unfortunately, the absence of a nationally coordinated system of testing has not emerged. In the state of Pennsylvania, the number of tests per million is reported to be 15,029 which is less than half than other states such as New York, Massachusetts, and Louisiana and 33% less than New Jersey.[1] As a country, the United States ranks well below other countries such as South Korea, Italy, Austria, and the United Kingdom.[2] The states cannot accomplish the goal of widespread testing on their own, considering the multiple private companies, research institutions, and medical centers which share this space, the number of required supplies to conduct the testing, and the absence of a robust national public health infrastructure to strategize and implement interventions. Clearly, conducting 1.2 million tests as was performed last week in the United States, is not enough, given the millions of individuals at risk.[3] Thus, the current mantra for increased testing is justified, which could be facilitated with a well-coordinated federal effort.
The initial focus on the personal protective equipment and ventilators is another lost opportunity to launch a coordinated effort to use the Defense Production Act to order private companies to manufacture critical supplies during a state of emergency.[4] States are left to secure these necessary supplies on their own; testing is being subjected to the same fragmented approach. Moreover, as this commentary is written, there are over 40 molecular diagnostic tests available for active infection with SARS CoV-2 and over 130 serological tests to determine if there has been a prior immune response to this pathogen. All of these entries are listed on the FDA website, with additional entries occurring weekly.[5] Most of these tests have not gone through an extensive FDA review and have only been validated by the specific vendor or the institution. The validity of these individual tests is critically important to keep in mind, specifically the sensitivity and specificity. The risk of a high false negative rate is concerning in this current pandemic considering the risk of such a patient infecting others. When there is a scarcity in resources, the most vulnerable populations are at the greatest risk, exposing further challenges to the health of communities. Testing is a vital component of public health surveillance, providing the path forward to contact tracing and ultimate containment. The new norm when businesses can open will not safely unfold without this critical step. So, what is at stake here in the state of Pennsylvania? This commentary will consider the current state of health in Pennsylvania, recent data related to COVID-19, and offer considerations for the implementation of testing in vulnerable communities.
Pennsylvania has its health challenges, ranking 28th in the country overall according to the United Health Foundation. Its strengths as listed by the Foundation include a low percentage of uninsured, a respectable number of primary care physicians compared to other states, and a high number of adolescents who have undergone immunization. The challenges include a high number of deaths related to drug overdosing, notably a 25% increase from 2018 to 2019 (an increase from 28.1 to 35.1 death per 100,000 population), a high prevalence of mental distress (an increase from 26%, from 11.4% to 14.4% of adults), and high levels of air pollution. Moreover, since 2012 there has been an increase in diabetes by a factor of 19% since 2012.[6] Considering the risks associated with COVID-19 among diabetics and those with asthma, which can be exacerbated by air pollution, these data are particularly worrisome. Superimpose on these data, the onslaught of the pandemic, and the unfortunate recognition that as a state, the disparities in health care access, are being exposed and exacerbated. African Americans are disproportionately impacted by COVID-19, making up at least a third of the 26% of cases for which the state Department of Health has data related to ancestry. It should be noted that African Americans make up only 12% of the state population. Also noted, individuals of European ancestry make up 63% of that cohort and comprise 80% of the state’s population. These trends are consistent with other states reporting ancestry-specific data. It is notable that within the zip code, 19104 (West Philadelphia) the reported percent positive for SARS-COV-2 is 33%, number 68.1 per 100,000.[7] In a state that ranks 44th in the country in public health funding,3 it is vital to be strategic in deploying these precious invested dollars to test in those areas throughout the state such as West Philadelphia where there are the high proportions of at-risk individuals.
So, what should be considered when launching strategies in vulnerable communities? First of all, testing volume has been significantly increased in order to begin to better contain the virus with identification of actively infected individuals. In the absence of national efforts to coordinate testing, at least regional testing should be considered, shifting resources as needs evolve. Once these two requirements are in place, the additional recommendations are the following, using an equity lens as a filter: 1. Facilitated access to testing, considering individuals with high-risk jobs and chronic conditions as an initial focus and associated resources for contact tracing; 2. Implementation of culturally appropriate messaging regarding the need for testing; 3. Engaging trusted community partners to amplify efforts; 4. Ensuring, for those who are negative, there is follow up with primary care providers for continuous care for chronic conditions. These recommendations should be targeted initially on communities at risk. If the businesses reopen before these recommendations are in process, more new cases will be likely. Lives and livelihoods are at stake.
[1] . https://www.worldometers.info/coronavirus/country/us/. Accessed, 4/26/20
[2] . https://www.worldometers.info/coronavirus/covid-19-testing/ . Accessed 4/26/20
[3] . Trump Suggests Daily Briefings No Longer Worth His Time as White House Considers Replacing Health Secretary, April 25, 2020, New York Times. https://www.nytimes.com/2020/04/25/us/coronavirus-news.html?referringSource=articleShare. Accessed, 4/26/20
[4] . Arnsdorf, I. The Defense Production Act Gives the President Power—but Not Much Funding. March 25, 2020. https://www.propublica.org/article/the-defense-production-act-gives-the-president-power-but-not-much-funding Accessed, April 25, 2020
[5] . https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations#covid19ivd. Accessed, 4/25/20
[6] . Pennsylvania Annual Report- 2019, American’s Health Rankings. https://www.americashealthrankings.org/explore/annual/measure/Overall/state/PA . Accessed, 4/26, 20
[7] .Orso, A., and Fernandez, C. Pa. released figures on the coronavirus and race, but not specific geographic data. Experts say that is a problem. April 17, 2020. https://www.inquirer.com/health/coronavirus/spl/coronavirus-covid-19-demographic-data-pennsylvania-geographic-race-20200417.html. Accessed 4/26/20