Pencils Down

Is it time to stop testing for Covid?

• photo by Harvey Potter

As I write this at 38,000 feet, on a return flight from Tel Aviv to Newark, I still can’t believe that this past week actually ended up happening.  

We came to Israel for the week of Passover to celebrate a bat mitzvah that our friends had already cancelled once because of Covid. But while the skies were finally opened, Covid stalked us like a jealous ex who will just not leave you alone.

In the weeks before we left New York, cases started ticking up again. The culprit in this latest surge is probably a BA.2 subvariant, which is highly contagious: when one patient gets it, their family members and other close contacts invariably follow.

Israel still has strict Covid testing entry criteria in place, which require two negative PCR tests, one within 72 hours of travel and another at the airport upon arrival. Rachel and I were traveling with our three younger kids. Between our exposures at work and their exposures at school and sports – where no one is wearing masks anymore and every day brings news of another positive friend – I saw the likelihood of ten negative PCR results as pretty remote.

But amazingly, it happened, ten negative tests.

We settled into our airbnb, and the next day went to the bat mitzvah, where we danced and mingled with scores of maskless guests, relatively secure in the knowledge that everyone was recently Covid negative. It was a lovely evening, made sweeter by contrast to the social isolation and deprivations of the past two years – thank you, Covid, for that at least.

By the next morning, the first positive report came in.

One of our friends was feeling under the weather after the party, and did a home test back at the hotel. I can only imagine how he felt as the second red line on the card materialized into view.

After that, people started falling like flies.

Whoever was still negative would meet for breakfast, spend afternoons together at the beach, carpool for outings, go out for dinner - after all, we were all on vacation. And every morning would bring new reports of positive contacts from the day before – someone who felt fatigued, or had a tickle in their throat (must be allergies) or a cough, and would then test positive on a home rapid.

It was a weirdly schizophrenic experience - while everyone was extremely concerned about the practical consequences of a positive test, such as missing a flight home or being stuck in isolation, no one seemed particularly worried about the disease itself, at least not to the point of missing a fun activity.

And, in fact, there was a good reason for this: no one got that sick.

Everyone was vaccinated, everyone was boosted, and almost everyone already had Covid. In one case, a boy tested positive who had recovered from Omicron less than two months earlier. 

This is something we have been seeing at WFM for a while now, since the beginning of the Omicron surge – since the vaccine, really. Whereas Covid started out as deadly pneumonia, it has been transformed it into a viral upper respiratory illness (ie viral URI), whose symptoms range from nothing to the common cold or flu.

Of course, given everything we’ve been through, this transition takes some getting used to; our mentality around Covid has changed more slowly than the biology of the disease. As a result, we find ourselves in the problematic situation of imposing social restrictions that have become disproportionate to the medical risks.

One of the soundest principles in clinical medicine is that you don’t perform a test if it won’t change your management. In the case of Covid, this principle no longer justifies asymptomatic screening or even testing for mild disease.

I have been treating Covid practically every day since the beginning of the pandemic, and it is now rare that I do anything for patient with Covid that I would not do for a patient with a viral URI or influenza.

Now, I could test everyone with a cold to see exactly which virus they have, but that would be a huge waste of resources if I am going to recommend the same conservative treatment regardless of the result.

Why should I do so with Covid?

Let’s examine some possible reasons.

First, maybe we should continue widespread testing in order to limit the spread of disease.

I would reject this argument for several reasons. While it is admittedly hard to prove a counterfactual, all this testing doesn’t seem to limiting the spread of anything, probably because by the time you test positive most of the spread has already occurred. This is especially true considering how inaccurate rapid tests are proving to be (if I had a nickel for every negative rapid in the past few weeks that turned out to be PCR positive I could retire).

Also, it makes no sense to take extreme measures to limit the spread of a mild disease. Think again of the common cold – it is good etiquette to stay home, sneeze into your arm, and wear a mask, but no one is keeping you off the plane or cancelling your school trip because of it, nor should they be.

Second, maybe we should continue widespread testing in order to protect the immune-compromised.

I am very sensitive to this argument, both as a doctor with such patients, and as the father of a daughter with Ulcerative Colitis who ended up in the hospital after getting Covid.

But I would reject it nonetheless. Again, because it doesn’t work: my daughter Noa, as a college student, is subject to some of the most stringent Covid testing protocols anywhere and that did not protect her.

Also, because of the inconsistency: immune-compromised patients are more likely to suffer complications from any infection, including viral URI (upper respiratory infection) and Influenza  – that’s why we call them immune-compromised - but this has never been considered  a good reason to screen or test universally.

Third, maybe we should continue widespread testing in order to protect the unvaccinated.

Here the argument is more fraught. On the one hand, the unvaccinated are still a huge chunk of the U.S. population, and they are much more likely to be hospitalized with Covid; on the other hand, unlike the immune-compromised, they have a choice in the matter. Testing and quarantining everyone for their sake is a little like banning motorcycles because some people refuse to wear helmets.

But even putting all judgment and moralism to the side, the fact remains that from a practical perspective, no amount of testing will prevent the unvaccinated (who also tend to dislike masks) from eventually getting Covid. It is just a matter of time.

This is not to say that we should stop all precautions and treatments for Covid. I believe in selective testing, such as before meeting with high risk people. And in treating sick, high risk, and older patients with medications such as Paxlovid and monoclonal antibodies. And in masks.

Shortly after boarding our flight, the pilot made a public announcement.  As long as the plane was on the ground in Israel, masks were still required. But as soon as we were in the air, as per the new guidelines, we could take off our masks.

Everyone cheered.                                         

Not me. I see no good reason to take off my mask on the plane (or to let my kids do so, to their annoyance). Since the U.S. is only requiring a negative rapid for entry into the country, I am 99% certain that Covid boarded with us, and I would prefer to avoid it – along with any other viral illness for that matter - no matter how mild it is. Same for the subway. Same for the exam room.

In essence, I am arguing for a return of Covid to the doctor’s office, where decisions can be made by medical professionals based on standard criteria for testing and treating disease – things like risks, benefits, co-morbidities, side effects, and pretest probabilities.

So if you get sick, be a good citizen and do whatever you can to not spread it around. If you will be in contact with a high risk individual, then get tested for Covid (and Flu!) to see whether that’s a good idea. If you are a high risk individual yourself, talk to a doctor, you may be a good candidate for targeted treatments.

A patient recently asked me when Covid will finally be over.

It all depends on what you mean by over, I said. Think of a hurricane. In order to say that it’s over, do you need a sunny day? Or is a regular rainy day good enough?

Congratulations, humanity (and I say this with zero irony), we have essentially reduced Covid to a viral URI/ Flu, the medical equivalent of a rainy day.

Now, let’s start thinking about it that way.