To bring COVID deaths near zero, focus on the most vulnerable

The U.S. is still experiencing close to 400 daily COVID deaths and the country is enmeshed in an unresolvable debate about whether the pandemic is “over.” While this figure is about one-eighth of its peak pandemic level, it is still an unacceptable toll that would result in an estimated 113,000-188,000 annual deaths.

The White House coronavirus response coordinator, Dr. Ashish Jha, has recently stated that “we now have all of the capability to prevent … essentially all of those deaths.” This goal is within sight with the right mix of currently available tools, and especially, with a major revision to rapid testing policies to fully protect high-risk Americans.

The federal government’s end-the-pandemic optimism can be realized through five new policy pillars that do not incur grim trade-offs:

1. Focus on preventing only serious disease: With the overlay of widespread natural infection contributing to high population immunity, there has been a precipitous decline in serious or “medically significant” disease. As a critical first pillar, the national goalpost should be reset from eliminating exposure to eliminating serious disease. The national policy goal from the onset of the pandemic has been the elimination of exposure, infection and transmission. While this served to “flatten the curve” before vaccines and treatment became available, it has become an obsolete and inappropriate standard. Vaccines and natural infection produce only partial immunity which does not stop ongoing infection and transmission. Sixty-eight percent of Americans who have had COVID and are vaccinated say they had a breakthrough infection. Minimizing exposure may be a desirable goal, however, it is neither realistic nor achievable. This standard should be jettisoned.
2. Target high-risk populations: The high-risk “vulnerable” groups that suffer a hugely disproportionate burden of serious disease include those over age 65, those living in congregate settings (long-term care, prisons andhomeless shelters) and those who are immunocompromised. To minimize strain on the health care system and to achieve a radical reduction in deaths, this must be the explicit target population of our new national COVID response policy. How does this strategy impact the approximately 250 million who are not vulnerable? A September poll indicates that 46 percent of Americans have returned to their pre-COVID lives and moved on from the pandemic. This suggests that their personal risk-benefit calculus has resolved in favor of accepting exposure and the consequent risk of contracting COVID over the restriction of their routine and desired activities. In most cases, science supports this as a rational decision.
3. Deal with social trends pragmatically: Since their development, vaccines have been by far the most effective tool in blunting the pandemic disease toll. However, over a fifth of Americans are still unvaccinated and half have not received any booster. Similarly, only 37 percent of Americans ever mask outside their home and only 29 percent practice any social distancing. Also, despite extensive government efforts to provide access to free life-saving antivirals, uptake has fallen well short of projections. Rather than invoking wishful thinking or directly challenging people’s choices, these negative and frequently resistant trends must be factored in when formulating pragmatic next-generation COVID policies.
4. Realize the benefits of rapid testing: Given the evolution of the pandemic, it’s time to revisit the optimal use of rapid testing. Their favorable    performance characteristics should be applied to the new goal of preventing serious diseases in high-risk groups. The new indication for rapid testing should invoke a single criterion: “Will the test result dictate a new course of action that decreases the risk of serious disease in high-risk persons?” Testing is indicated only when the answer is “yes.” A few scenarios fulfill this criterion. When exposed asymptomatic high-risk people test positive, they should be isolated from other vulnerable people and monitored for symptoms. When symptomatic high-risk people test positive they should be provided treatment to decrease the severity of their illness, and those who have close contact with high-risk people should be candidates for self-testing or entrance testing. These use cases provide benefits that exceed individual and societal costs beyond those who are high-risk and their close contacts. 
5. Revise national testing policies: To unambiguously bring the pandemic under control, rapid testing must be deployed in innovative new ways. This calls for a significant revision to current CDC testing guidelines and related White House policy. The CDC has relaxed testing-associated isolation, quarantine, masking and international entry guidelines. But its recent recommendations and most official federal policy are still based on avoidance of exposure and infection by everyone. Diagnostic testing is still recommended for anyone with symptoms and known or suspected exposure. Similarly, screening testing strategies still apply to “all persons, irrespective of vaccination status.” New guidelines should eliminate most testing among Americans who are not high-risk. This includes most at-home symptomatic or asymptomatic diagnostic testing, school, college or workplace screenings, including test-to-stay programs, border entry testing and contact identification and tracing. At the same time, guidelines should greatly increase testing to protect high-risk groups. This will result in dramatic declines in hospitalization and deaths through the application of life-saving targeted interventions.

As the expected fall COVID and flu surges arrive, the Biden administration needs to act urgently on its promise that “when properly used, the tools we now have can prevent nearly all COVID-19 deaths.” 

The solution is a policy course correction: a strategic national rapid testing program with updated guidelines, protocols, and public education that fully protects our high-risk population. This is the key to not only ending the pandemic debate but also to fully returning the country to its dynamic, robust pre-COVID state.

Steven Phillips is a Fellow of the American College of Epidemiology and a board member of the Global Virus Network