Looking for COVID-19 Under the Streetlight

For those who don’t know what the streetlight effect is:

A policeman sees a drunk man searching for something under a streetlight and asks what the drunk has lost. He says he lost his keys and they both look under the streetlight together. After a few minutes the policeman asks if he is sure he lost them here, and the drunk replies, no, and that he lost them in the park. The policeman asks why he is searching here, and the drunk replies, “this is where the light is”.

What is frustrating about our COVID-19 response (among several things akshually) is that we’re not looking for the cases we need to find. Consider the recent ‘Biogen outbreak’ in Boston where, at last count, 70 out of 175 attendees at a meeting hosted in Boston, Massachusetts, by Biogen (a tech company) tested positive for COVID-19, with at least six hospitalizations. While this is disturbing for many reasons, it is, to use the phrase, a “known known.” Attendees from Italy were the likely source, and it’s clear how this outbreak happened (if not who exactly was the ‘patient zero’).

The cases we need to identify are the cases where it’s unclear how the person contracted COVID-19, such as the case in Snohomish County, Washington. This kind case indicates that it’s out there in the community, yet almost no communities, other than Seattle, where academic researchers went rogue, are doing anything other than looking under the streetlight.

Leaving aside the ongoing testing problems (the latest is that there might be a shortage of RNA prep kits), even if testing capacity weren’t a problem, the fact that our testing criteria have been so narrow–to the point where they can be thought of as ‘anti-surveillance’–is making impossible to even detect these ‘unclear’ transmission cases (i.e., we don’t know from whom they acquired COVID-19). Here, from the D.C. Department of Public Health, are the testing guidelines that are in place nationally, as of March 11 (might have changed since then):

Screen Shot 2020-03-11 at 10.36.50 AM

To summarize, you have to have COVID-19 symptoms and meet one of the following criteria:

  1. Travel within the last fourteen days to Iran, China, Japan, South Korea, or Italy.
  2. Been in an area with confirmed COVID-19 transmission within fourteen days of onset. Presumably, this means parts of New York and Washington state.
  3. Been in contact with a confirmed COVID-19 patient within fourteen days of onset.
  4. Lived in a long-term care facility within fourteen days of onset.

With these criteria, we would have never detected the Snohomish county case. Anyone non-traveling ‘normie’ who came down with COVID-19 wouldn’t be tested, if that person had not contacted a known COVID. Unfortunately, these are exactly the cases we need to know about, so we can determine when we need to institute serious social distancing measures*. As bad as the Biogen outbreak is–and it does need to be contained–it’s the cases that don’t make sense epidemiologically that indicate we need to break the glass.

In most countries, until significant measures were taken, cases increased massively every day (one estimate is ~33% per day). If we wait for dozens of unclear community-acquired cases, it’s far too late. Due to the testing snafus, we might not be able to perform the tests we need to anyway, but it’s not clear how we would find these cases, even with adequate supplies.

*I find it remarkable that the federal government hasn’t ordered all employees and contractors who can work from home to do so.

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3 Responses to Looking for COVID-19 Under the Streetlight

  1. Pingback: The coronavirus and exponential growth | Phil Ebersole's Blog

  2. Chipper says:

    I believe that these same national criteria are being used in Massachusetts, except that there’s an additional big OR box that says “OR if you’re a Boston Celtic” — the entire team is being tested.

    All the community spread cases aren’t being tested and so the people that catch it from them aren’t tested because they didn’t get it from anyone who officially has Covid-19. It’s crazy.

  3. Ciocarlia says:

    OPM as of March 13 still has on its homepage a March 7 statement that “the CDC continues to remind the American public that the immediate health risk from COVID-19 is considered low.” At my agency we’ve gotten emails telling us to be ready to telework, but that’s it. Finally today my boss sat everyone down, said HE will be working from home beginning Monday, and invited us to do the same. Political appointees should be ordering us to work from home. But they aren’t. We’re on our own.

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