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Fast, cheap tests could enable safer reopening

Science

> Science's COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation Even as the United States ramped up coronavirus testing from about 100,000 per week in mid-March to more than 5 million per week in late July, the country fell further behind in stemming the spread of the virus. Now, diagnostics experts, public health officials, and epidemiologists are calling for a radical shift in testing strategy: away from diagnosing people who have symptoms or were exposed and toward screening whole populations using faster, cheaper, sometimes less accurate tests. By making it possible to identify and isolate infected individuals more quickly, proponents say, the shift would slow the virus' spread, key to safely reopening schools, factories, and offices. “America faces an impending disaster,” says Rajiv Shah, president of the Rockefeller Foundation. Testing, he says, needs to focus on “massively increasing availability of fast, inexpensive screening tests to identify asymptomatic Americans who carry the virus. Today, we are conducting too few of these types of tests.” Rebecca Smith, an epidemiologist at the University of Illinois, Urbana-Champaign (UIUC), agrees. To stop outbreaks from overwhelming communities, she says, “we need fast, frequent testing,” which could mean faster versions of existing RNA tests or new kinds of tests aimed at detecting viral proteins. But researchers say the federal government will need to provide major financial backing for the push. Today, COVID-19 testing relies primarily on the polymerase chain reaction (PCR), a technique to amplify the virus' genetic material, making it easy to detect. If administered properly, such tests are highly accurate, spotting positive cases nearly 100% of the time. That accuracy is vital for decisions about treating individual patients. But PCR tests cost about $100 each, require specialized machinery and reagents, and typically take at least 1 to 2 days to return results. The recent increase in coronavirus cases across the United States has added to the delay, pushing wait times to 2 weeks in some places. While they wait, people who are infected but don't yet know it may continue to interact with others and spread the virus. And if their infective period ends before they get their results, isolating them won't help. “It's like calling the fire department after your house burns to the ground,” says A. David Paltiel, an operations research expert at the Yale School of Public Health. “You can't play catch up with this virus.” A 24 July preprint on medRxiv underscored the downsides of slow tests. Shixiong Hu, a researcher with the Hunan Provincial Center for Disease Control and Prevention, and his colleagues followed 1178 people who tested positive for SARS-CoV-2 from January to April and tested their 15,648 contacts, defined as people who had been within 1 meter of a positive person between 2 days before and 14 days after the person's symptoms began. Based on which contacts were infected and when, the researchers estimated that people were most likely to spread the virus 1.8 days before the onset of symptoms. The finding suggests testing people only when they show symptoms and giving them test results days to weeks later does little to slow viral spread, says Daniel Larremore, an applied mathematician at the University of Colorado, Boulder. ![Figure][1] GRAPHIC: N. DESAI/ SCIENCE Larremore and his colleagues have modeled the benefits of more frequent tests, including ones that are less accurate than today's. Fast tests repeated every 3 days, with isolation of people who test positive, prevent 88% of viral transmission compared with no tests; a more sensitive test used every 2 weeks is less than half as effective at cutting transmission, they report in a 27 June preprint on medRxiv. Paltiel and his colleagues reached much the same conclusion when they modeled a variety of testing regimes aimed at safely reopening a 5000-student university. In a 31 July paper in JAMA Network Open , they found that, with 10 students infected at the start of the semester, a test that identified only 70% of positive cases, given to every student every 2 days, could limit the number of infections to 28 by the end of the semester. Screening every 7 days allowed greater viral spread, with the model predicting 108 infections. “A higher frequency of testing makes up for poor sensitivity,” Paltiel says. Smith says these and related studies have prompted UIUC to set up tests for all 60,000 students and faculty multiple times per week when the students return to campus this fall. The approach relies on an experimental fast PCR setup described in an 18 June preprint that bypasses some of the usual slow procedures for isolating viral RNA and tests saliva rather than nasal swabs, says Martin Burke, a UIUC chemist who was one of the test's developers. Smith says her team predicts that if the university tests everyone every 3 to 4 days, on average, it will detect positive cases half a day before those people reach peak infectivity. Antigen tests, which immobilize antibodies on a test strip, promise an even greater speedup. Those antibodies detect viral proteins in saliva or a nasal swab. Such tests cost as little as $1 to $2 each, give a yes/no readout within minutes, much like a pregnancy test, and are already used to detect influenza, HIV, and other viruses. Two companies—Quidel Corporation and Becton, Dickinson and Company (BD)—have received emergency use authorization from the U.S. Food and Drug Administration to sell antigen tests for SARS-CoV-2. Other companies have similar tests in the works. Because antigen tests don't amplify viral material but simply detect what is present in the sample, they are less accurate than PCR. Some antigen tests correctly detect only one-half to three-quarters of infections. But they could still be a valuable health tool if performed often enough; few infected people would be missed in multiple rounds of tests. And people who receive a positive antigen test could be isolated and retested with a PCR test to confirm the result. Among the hurdles facing widespread, repeat screening is the scarcity of such tests. Quidel and BD together manufacture about 3 million antigen tests per week. But a national screening strategy would likely require 25 million fast tests or more, says Jonathan Quick, who heads pandemic response for the Rockefeller Foundation. On 16 July, the foundation released a national COVID-19 testing plan calling on the federal government to spend $75 billion on providing 30 million screening and diagnostic tests per week. Quick says companies are reluctant to ramp up production dramatically if they are unsure of the market for the products. One solution, he adds, could be a promise by the federal government to buy tens of millions of tests, much as it has done with vaccine doses. In one such effort, the governors of six U.S. states announced this week they are banding together to ask Quidel and BD for a total of 3 million tests. Or the Trump administration could take over test production using the Defense Production Act, which allows the federal government to direct private companies to meet national defense needs. “I don't think it's either/or,” Quick says. “It's and/both. We don't have time to wait.” Help could also come from a National Institutes of Health test development program, which last week announced nearly $250 million in awards to seven companies for scaling up production of novel rapid SARS-CoV-2 tests, with a goal of reaching some 42 million tests per week by the end of this year. Even with federal help, broad screening programs are likely to be costly. Paltiel's study estimated that testing 5000 students every 3 days for an abbreviated 80-day semester would cost about $1.5 million, which may be beyond the reach of many universities, let alone high schools and small businesses. But if organizations won't or can't make the investment, Paltiel asserts, “they have to ask themselves if they have any business reopening.” Quick adds: “Investing will be far less costly for the nation than another economic shutdown, which will happen if we don't contain the outbreaks.” [1]: pending:yes


Serology assays to manage COVID-19

Science

In late 2019, China reported a cluster of atypical pneumonia cases of unknown etiology in Wuhan. The causative agent was identified as a new betacoronavirus, called severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2), that causes coronavirus disease 2019 (COVID-19) (1). The virus rapidly spread across the globe and caused a pandemic. Sequencing of the viral genome allowed for the development of nucleic acid–based tests that have since been widely used for the diagnosis of acute (current) SARS-CoV-2 infections (2). Development of serological assays, which measure the antibody responses induced by SARS-CoV-2 infection (past but not current infections), took longer.


Anomalous COVID-19 tests hinder researchers

Science

Universities conduct a large proportion of the community surveillance testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ([ 1 ][1]). At the same time, they have shifted focus to SARS-CoV-2 research to address critical needs during this pandemic. There are now multiple reports of asymptomatic researchers who worked with or near non-infectious SARS-CoV-2 nucleic acids and subsequently tested positive during SARS-CoV-2 surveillance screening ([ 2 ][2], [ 3 ][3]). Such positive test results and the resulting isolation and quarantine are deleterious to the health of researchers, their research programs, and their close contacts. Universities and labs should take steps to identify and prevent misleading test results among their researchers. Because health departments cannot distinguish positive test results reflecting exposure to non-infectious nucleic acids from those revealing true active SARS-CoV-2 infections, affected U.S. researchers are removed from the testing pool for 90 days, a period during which true infections could be missed ([ 4 ][4]). Additional false positives could result when monitoring of wastewater for viral outbreaks detects DNA products that are washed down the drain as non-biohazardous waste ([ 5 ][5]). As polymerase chain reaction tests, other DNA amplification tests ([ 6 ][6], [ 7 ][7]), and the recently approved at-home nucleic acid tests ([ 8 ][8]) become more widespread, these cases will likely become more frequent among researchers. To mitigate harm from misleading results, we recommend the implementation of extra safety controls ([ 2 ][2]) in addition to standard practices for handling nucleic acids ([ 9 ][9]). Genetic loci should be chosen with care to not interfere with any available tests. Incorporation of deoxyuridine triphosphate, codon optimization, and DNA watermarks can prevent detection of a laboratory-generated nucleic acid and differentiate it from circulating pathogens ([ 10 ][10], [ 11 ][11]). DNA products should be treated with bleach or other DNA-damaging agents before disposal. The best policies and practices for preventing laboratory contamination should take place before initiating research: Once a space is contaminated with DNA, it is extremely difficult to decontaminate ([ 2 ][2]). These policies should accommodate the specific needs of the research and the institutions and not place undue burden on the essential work of studying these pathogens. For individuals who are asymptomatic, have no history of SARS-CoV-2 exposure, and are affected by anomalous surveillance test results, we propose verification with orthogonal follow-up testing. At an institutional level, administrators, environmental health and safety personnel, and departments of public health should collaborate to determine who is at risk for anomalous tests and coordinate immediate follow-up testing. Alternate providers using orthogonal tests should be established before surveillance testing and/or research initiation. Community-wide COVID-19 surveillance testing directly improves human health ([ 12 ][12]). Given the extensive development in testing infrastructure amassed during this short period, viral testing will likely extend to other pathogens, endemic or emergent. Sensible policies governing the stewardship of nucleic acids will help protect this vital asset. 1. [↵][13]Massachusetts Department of Public Health, “Massachusetts Department of Public Health COVID-19 dashboard—Dashboard of public health indicators” (2020), p. 22; [www.mass.gov/doc/covid-19-dashboard-december-20-2020/download][14]. 2. [↵][15]1. L. R. Robinson-McCarthy et al ., OSF Preprints, 10.31219/osf.io/9svjq (2020). 3. [↵][16]1. K. J. Wu , “These researchers tested positive. But the virus wasn't the cause,” The New York Times (2020). 4. [↵][17]Centers for Disease Control and Prevention, “Duration of isolation and precautions for adults with COVID-19,” (2020); [www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html][18]. 5. [↵][19]“Status of environmental surveillance for SARS-CoV-2 virus” (World Health Organization, 2020). 6. [↵][20]1. B. A. Rabe, 2. C. Cepko , Proc. Natl. Acad. Sci. U.S.A. 117, 24450 (2020). [OpenUrl][21][Abstract/FREE Full Text][22] 7. [↵][23]1. J. Joung et al ., N. Engl. J. Med. 383, 1492 (2020). [OpenUrl][24] 8. [↵][25]U.S. Food and Drug Administration, “Lucira COVID-19 all-in-one test kit” letter of authorization (2020); [www.fda.gov/media/143810/download][26]. 9. [↵][27]“Dos and Don'ts for molecular testing” (World Health Organization, 2018). 10. [↵][28]1. D. C. Jupiter et al ., PLOS Pathog. 6, e1000950 (2010). [OpenUrl][29][PubMed][30] 11. [↵][31]1. M. C. Longo, 2. M. S. Berninger, 3. J. L. Hartley , Gene 93, 125 (1990). [OpenUrl][32][CrossRef][33][PubMed][34][Web of Science][35] 12. [↵][36]1. A. M. Neilan et al ., Clin. Infect. Dis. 10.1093/cid/ciaa1418 (2020). L.R.R.-M., A.J.M., G.T.F., R.F., O.D., D.T.-O., G.M.C., and J.M.T. are co-inventors of MAP-Dx, a COVID diagnostic platform. J.J.C. is a co-founder and director of Sherlock Biosciences. G.M.C.'s tech transfer, advisory roles, and funding sources can be found at . [1]: #ref-1 [2]: #ref-2 [3]: #ref-3 [4]: #ref-4 [5]: #ref-5 [6]: #ref-6 [7]: #ref-7 [8]: #ref-8 [9]: #ref-9 [10]: #ref-10 [11]: #ref-11 [12]: #ref-12 [13]: #xref-ref-1-1 "View reference 1 in text" [14]: http://www.mass.gov/doc/covid-19-dashboard-december-20-2020/download [15]: #xref-ref-2-1 "View reference 2 in text" [16]: #xref-ref-3-1 "View reference 3 in text" [17]: #xref-ref-4-1 "View reference 4 in text" [18]: http://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html [19]: #xref-ref-5-1 "View reference 5 in text" [20]: #xref-ref-6-1 "View reference 6 in text" [21]: {openurl}?query=rft.jtitle%253DProc.%2BNatl.%2BAcad.%2BSci.%2BU.S.A.%26rft_id%253Dinfo%253Adoi%252F10.1073%252Fpnas.2011221117%26rft_id%253Dinfo%253Apmid%252F32900935%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [22]: /lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoicG5hcyI7czo1OiJyZXNpZCI7czoxMjoiMTE3LzM5LzI0NDUwIjtzOjQ6ImF0b20iO3M6MjI6Ii9zY2kvMzcxLzY1MjYvMjQ0LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ== [23]: #xref-ref-7-1 "View reference 7 in text" [24]: {openurl}?query=rft.jtitle%253DN.%2BEngl.%2BJ.%2BMed.%26rft.volume%253D383%26rft.spage%253D1492%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [25]: #xref-ref-8-1 "View reference 8 in text" [26]: http://www.fda.gov/media/143810/download [27]: #xref-ref-9-1 "View reference 9 in text" [28]: #xref-ref-10-1 "View reference 10 in text" [29]: {openurl}?query=rft.stitle%253DPLoS%2BPathog%26rft.aulast%253DJupiter%26rft.auinit1%253DD.%2BC.%26rft.volume%253D6%26rft.issue%253D6%26rft.spage%253De1000950%26rft.epage%253De1000950%26rft.atitle%253DDNA%2Bwatermarking%2Bof%2Binfectious%2Bagents%253A%2Bprogress%2Band%2Bprospects.%26rft_id%253Dinfo%253Apmid%252F20585560%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [30]: /lookup/external-ref?access_num=20585560&link_type=MED&atom=%2Fsci%2F371%2F6526%2F244.atom [31]: #xref-ref-11-1 "View reference 11 in text" [32]: {openurl}?query=rft.jtitle%253DGene%26rft.stitle%253DGene%26rft.aulast%253DLongo%26rft.auinit1%253DM.%2BC.%26rft.volume%253D93%26rft.issue%253D1%26rft.spage%253D125%26rft.epage%253D128%26rft.atitle%253DUse%2Bof%2Buracil%2BDNA%2Bglycosylase%2Bto%2Bcontrol%2Bcarry-over%2Bcontamination%2Bin%2Bpolymerase%2Bchain%2Breactions.%26rft_id%253Dinfo%253Adoi%252F10.1016%252F0378-1119%252890%252990145-H%26rft_id%253Dinfo%253Apmid%252F2227421%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [33]: /lookup/external-ref?access_num=10.1016/0378-1119(90)90145-H&link_type=DOI [34]: /lookup/external-ref?access_num=2227421&link_type=MED&atom=%2Fsci%2F371%2F6526%2F244.atom [35]: /lookup/external-ref?access_num=A1990EC87400018&link_type=ISI [36]: #xref-ref-12-1 "View reference 12 in text"


COVID-19 affects HIV and tuberculosis care

Science

Shortly after instituting coronavirus disease 2019 (COVID-19) mitigation measures, such as banning air travel and closing schools, the South African government implemented a national lockdown on 27 March 2020 when there were 402 cases and the number of cases was doubling every 2 days ([ 1 ][1]). This drastic step, which set out to curb viral transmission by restricting the movement of people and their interactions, has had several unintended consequences for the provision of health care services for other prevalent conditions, in particular the prevention and treatment of tuberculosis (TB) and HIV. Key resources that had been extensively built up over decades for the control of HIV and TB are now being redirected to control COVID-19 in various countries in Africa, particularly South Africa. These include diagnostic platforms, community outreach programs, medical care access, and research infrastructure. However, the COVID-19 response also provides potential opportunities to enhance HIV and TB control. In Africa, the COVID-19 epidemic is unfolding against a backdrop of the longstanding TB and HIV epidemics. South Africa ranks among the worst-affected countries in the world for both diseases. Despite having just 0.7% of the world's population, South Africa is home to ∼20% (7.7 to 7.9 million people) of the global burden of HIV infection ([ 2 ][2]) and ranks among the worst affected countries in the world for TB, with the fourth highest rate of HIV-TB co-infection (59%) ([ 3 ][3]). South Africa has made steady progress since 2010 in controlling both diseases. Increased access to antiretroviral drugs for treatment and for prevention of mother-to-child transmission of HIV has resulted in a 33% reduction in AIDS-related deaths between 2010 and 2018 ([ 2 ][2]). Similarly, the death rate among TB cases has declined from 224 per 100,000 population in 2010 to 110 per 100,000 population in 2018 ([ 3 ][3]). Have the strategies implemented for COVID-19 mitigation, particularly the lockdown, inadvertently threatened these gains in HIV and TB? HIV and TB polymerase chain reaction (PCR) tests are key to treatment initiation and monitoring to achieve the United Nations goals for the control of HIV and TB. Disturbingly, these diagnostic tests declined during the lockdown. The 59% drop in the median number of daily GeneXpert TB tests—a cartridge-based PCR test capable of diagnosing TB within 2 hours while simultaneously testing for drug resistance—was accompanied by a 33% reduction in new TB diagnoses ([ 4 ][4]). The restriction of people's movement and curtailment of public transport has led to substantial declines in patient attendance at health care facilities. A survey of 339 individuals in South Africa revealed that 57% were apprehensive about visiting a clinic or hospital during the lockdown, in part because of concerns that they may be exposed to infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from COVID-19 patients attending these facilities ([ 5 ][5]). Delayed HIV and TB testing impedes initiation of appropriate treatment, which increases the risk of new infections and drug resistance ([ 6 ][6]). Both TB and HIV diagnostic platforms are important contributors to COVID-19 testing. The GeneXpert point-of-care testing platform, which is widely used in South Africa to diagnose TB, with more than 2 million individuals tested annually ([ 7 ][7]), is also being used to diagnose COVID-19. Until now, the limited availability of the GeneXpert COVID-19 cartridges has meant that spare capacity is mostly being used with little, if any, displacement of TB testing. Because there was also a decline in CD4+ assays (to test for immune status in HIV patients), it indicates decreased demand rather than displacement because this assay is not used for COVID-19. This may change as the demand for COVID-19 point-of-care testing rises and GeneXpert cartridges for COVID-19 become more readily available. South African clinical laboratories have substantial capacity to perform high-throughput PCR assays for HIV viral load (more than 50,000 tests per day). However, the lack of COVID-19 test kits in South Africa, stemming from the global shortage, has meant that the available spare capacity on these platforms has sufficed for COVID-19 testing. The full potential of this PCR capacity is likely to be called upon when the country needs to expand COVID-19 PCR testing for the expected surge in cases, estimated to exceed 1 million at peak ([ 8 ][8]). Laboratory capacity for PCR testing developed for HIV and TB is now an essential resource for COVID-19 testing. The use of this capacity for COVID-19 needs to be monitored to identify and address any potential displacement of HIV and TB testing. South Africa's experience in dealing with substantial HIV and TB epidemics has laid the foundations for the country's rapid, early community-based response. Both TB and COVID-19 are respiratory infections and can present with similar symptoms. They therefore present substantial infection control challenges, requiring timely and rapid diagnosis. Both diseases can spread more easily in conditions associated with poverty where social distancing is difficult to implement. Well-established community outreach capabilities for contact tracing, established for TB, were deployed to undertake contact tracing and quarantine monitoring for COVID-19. With the highest HIV burden in the world, South Africa has a highly developed network of health care providers that includes tens of thousands of community health care workers who are trained to interact safely with infectious individuals and have experience in undertaking door-to-door visits in South Africa's most socially vulnerable communities. About 28,000 HIV community health care workers were deployed for COVID-19 symptom screening and testing referral (HIV outreach was put on hold) in 993 vulnerable, high-density communities, many lacking running water, to identify cases and thus reduce time to diagnosis and hence limit transmission. As clinical cases increased, there were insufficient tests for community-based screening, creating testing backlogs that delayed hospital patient results and led to curtailment of the community program with proposed adjustment to screening and quarantine without testing. The established community engagement and outreach for HIV, TB, and noncommunicable diseases (such as hypertension and diabetes) provide an opportunity for integrating screening and testing in the long-term COVID-19 response. This approach will play an important role in reaching at-risk populations who do not readily make use of health services to establish a broader program of health promotion, prevention, and early detection. Such integration can be facilitated by the expansion of mobile onsite rapid testing approaches, using newly developed COVID-19 tests ([ 9 ][9]) and existing tests for HIV and other conditions on readily accessible samples such as saliva and blood from finger pricks. Combining health promotion programs for these diseases will reduce duplication and provide synergistic messaging because social distancing affects not only COVID-19 transmission but also that of TB and other respiratory infections. After the COVID-19 surge, integrated services could potentially provide an important approach to balancing ongoing vigilance for COVID-19 with early community-based detection of individuals with HIV and/or TB. Access to medical care for non–COVID-19 conditions was limited during the lockdown, with health facilities experiencing declines in the number of TB and HIV patients collecting their medication on schedule. The World Health Organization estimates that a 6-month disruption of antiretroviral therapy could lead to more than 500,000 additional deaths from AIDS-related illness in 2021 and a reversal of gains made in the prevention of mother-to-child transmission ([ 10 ][10]). In South Africa, 1090 TB patients and 10,950 HIV patients in one province have not collected their medications on schedule since the start of the national lockdown ([ 11 ][11]). A national survey of 19,330 individuals in South Africa found that 13.2% indicated that their medication for chronic disease was inaccessible during the lockdown ([ 12 ][12]). Furthermore, hospital admissions for HIV and TB declined as a result of hospitals reducing nonurgent admissions in preparation for a surge of COVID-19 cases and owing to closures to reduce exposure to COVID-19 patients. The potential negative impact on the continuity of care for HIV and TB patients could have substantial repercussions for both treatment and control, including development of drug resistance ([ 6 ][6]). The biological and epidemiological interaction of COVID-19, HIV, and TB is not well understood. Patients immunocompromised by HIV or with TB lung disease could be more susceptible to severe COVID-19. However, preliminary results from a study of 12,987 COVID-19 patients in South Africa indicate that HIV and TB have a modest effect on COVID-19 mortality, with 12% and 2% of COVID-19 deaths attributable to HIV and TB, respectively, compared to 52% of COVID-19 deaths attributable to diabetes ([ 13 ][13]). The small contribution of HIV and TB to COVID-19 mortality is mainly due to these deaths occurring in older people, in whom HIV and active TB are not common. Integrated medical care for these three conditions is important as COVID-19 patients coinfected with HIV or TB start attending health care services in larger numbers. South Africa's COVID-19 response, especially the lockdown, has led to substantial economic hardship, particularly among the poor and vulnerable. This has had a disproportionate impact on women, many of whom are self-employed or day laborers without a safety net ([ 14 ][14]). This may have a longer-term effect on increasing diseases associated with poverty (such as TB) and with gender, such as HIV, for which young women bear a disproportionate burden ([ 15 ][15]). The social determinants of HIV and TB will need to be carefully monitored to assess the impact of COVID-19. The effect of the lockdown on the economy, including declining taxes, is also likely to negatively affect funding for HIV and TB programs, among many others. New and ongoing research on HIV and TB prevention and treatment have been severely affected by the COVID-19 epidemic. At the initiation of the lockdown in South Africa, the National Health Research Ethics Committee suspended all medical research, including clinical trials. Research progress on these two conditions has also slowed because several of the country's AIDS and TB researchers are redirecting their efforts to COVID-19. However, COVID-19 research efforts have increased collaboration and created new approaches to speed up therapeutic and vaccine development and testing, which will likely have long-term benefits for medical research beyond COVID-19. Several countries in Africa have well-developed HIV and TB clinical trial infrastructure that could contribute to COVID-19 vaccine trials. Past investments in infectious disease training and research have generated handsome returns to the COVID-19 response, highlighting the importance of maintaining these investments in the future. 1. [↵][16]1. S. S. Abdool Karim , N. Engl. J. Med. 382, e95 (2020). [OpenUrl][17] 2. [↵][18]UNAIDS, Global AIDS Update 2019: Communities at the Centre (2019); . 3. [↵][19]WHO, Global TB Database: 2000–2018 (2018); . 4. [↵][20]National Institute for Communicable Diseases, Impact of COVID-19 Intervention on TB Testing in South Africa (2020); . 5. [↵][21]1. A. Rademeyer , The Ask Afrika COVID-19 Tracker: Unpacking the Significant Social Change Brought On by the COVID-19 Pandemic (2020); . 6. [↵][22]1. J. B. Nachega et al ., Infect. Disord. Drug Targets 11, 167 (2011). [OpenUrl][23][CrossRef][24][PubMed][25] 7. [↵][26]National Health Laboratory Service, Annual Report 2018/2019 (2019); . 8. [↵][27]1. S. Silal et al ., Estimating Cases for COVID-19 in South Africa (2020); . 9. [↵][28]1. Z. Li et al ., J. Med. Virol. 10.1002/jmv.25727 (2020). 10. [↵][29]WHO, “The cost of inaction: COVID-19-related service disruptions could cause hundreds of thousands of extra deaths from HIV” (2020); . 11. [↵][30]Gauteng Province Department of Health, COVID-19 Impacts on Health Services in Gauteng (2020); . 12. [↵][31]Human Sciences Research Council, “HSRC responds to the COVID-19 outbreak” (2020); . 13. [↵][32]1. M.-A. Davies , Western Cape: Covid-19 and HIV/Tuberculosis (2020); . 14. [↵][33]1. C. de Paz et al ., Gender Dimensions of the COVID-19 Pandemic (World Bank, 2020); . 15. [↵][34]UNAIDS, Global AIDS Update 2018: Miles to Go (2018); . Acknowledgments: We thank C. Baxter, W. Stevens, and A. Rademeyer for their assistance as well as the South African Department of Science and Innovation and Medical Research Council. Both authors are members of the South African Ministerial Advisory Committee for COVID-19. [1]: #ref-1 [2]: #ref-2 [3]: #ref-3 [4]: #ref-4 [5]: #ref-5 [6]: #ref-6 [7]: #ref-7 [8]: #ref-8 [9]: #ref-9 [10]: #ref-10 [11]: #ref-11 [12]: #ref-12 [13]: #ref-13 [14]: #ref-14 [15]: #ref-15 [16]: #xref-ref-1-1 "View reference 1 in text" [17]: {openurl}?query=rft.jtitle%253DN.%2BEngl.%2BJ.%2BMed.%26rft.volume%253D382%26rft.spage%253De95%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [18]: #xref-ref-2-1 "View reference 2 in text" [19]: #xref-ref-3-1 "View reference 3 in text" [20]: #xref-ref-4-1 "View reference 4 in text" [21]: #xref-ref-5-1 "View reference 5 in text" [22]: #xref-ref-6-1 "View reference 6 in text" [23]: {openurl}?query=rft.stitle%253DInfect%2BDisord%2BDrug%2BTargets%26rft.aulast%253DNachega%26rft.auinit1%253DJ.%2BB.%26rft.volume%253D11%26rft.issue%253D2%26rft.spage%253D167%26rft.epage%253D174%26rft.atitle%253DHIV%2Btreatment%2Badherence%252C%2Bdrug%2Bresistance%252C%2Bvirologic%2Bfailure%253A%2Bevolving%2Bconcepts.%26rft_id%253Dinfo%253Adoi%252F10.2174%252F187152611795589663%26rft_id%253Dinfo%253Apmid%252F21406048%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [24]: /lookup/external-ref?access_num=10.2174/187152611795589663&link_type=DOI [25]: /lookup/external-ref?access_num=21406048&link_type=MED&atom=%2Fsci%2F369%2F6502%2F366.atom [26]: #xref-ref-7-1 "View reference 7 in text" [27]: #xref-ref-8-1 "View reference 8 in text" [28]: #xref-ref-9-1 "View reference 9 in text" [29]: #xref-ref-10-1 "View reference 10 in text" [30]: #xref-ref-11-1 "View reference 11 in text" [31]: #xref-ref-12-1 "View reference 12 in text" [32]: #xref-ref-13-1 "View reference 13 in text" [33]: #xref-ref-14-1 "View reference 14 in text" [34]: #xref-ref-15-1 "View reference 15 in text"


Rapid Testing is Less Accurate Than the Government Wants to Admit

Mother Jones

This story was published originally by ProPublica, a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica's Big Story newsletter to receive stories like this one in your inbox as soon as they are published. The promise of antigen tests emerged like a miracle this summer. With repeated use, the theory went, these rapid and cheap coronavirus tests would identify highly infectious people while giving healthy Americans a green light to return to offices, schools and restaurants. The idea of on-the-spot tests with near-instant results was an appealing alternative to the slow, lab-based testing that couldn't meet public demand. By September, the US Department of Health and Human Services had purchased more than 150 million tests for nursing homes and schools, spending more than $760 million.