Friday, April 24, 2020

A Possible Third Solution to End the Pandemic

This is my thinking on the pandemic situation, and a possible solution.

First of all, it’s not “just the flu”. It is something much more dangerous. Catching this virus is a bit like playing a round of Russian roulette. You’ll probably be fine, but you could end up dead. For those of us less at risk, the danger is still present, but it’s as though the gun is pointed towards someone else, someone more vulnerable, because we can easily pass the virus along to them without even realizing that we have it.

There’s also the issue of long-term effects. This disease is new, so we really have no idea. It’s likely that more severe cases, those requiring hospitalization, present serious risk of permanent damage to the heart, lungs, and other organs. It’s even possible to lose a leg. We also don’t know how long immunity lasts or what will happen if people catch it a second time next year. We hope that it will be milder the second time, but it could be worse.

It is my belief that the best cure for any disease is to avoid the disease.

As such, I want to avoid ever catching this virus. I’m optimistic that we will eventually have a good vaccine, but until then I need to avoid those who are contagious.

The great challenge with avoiding this virus is that people with minimal symptoms are responsible for much, if not most, of the disease transmission. If everyone had a light on their forehead that turned from green to red when they were shedding virus, it would be easy to stop the spread.

But for now, we need to behave as though anyone could be spreading this virus. It appears that the virus travels through the air, so whenever possible, it’s important to avoid crowds of people or indoor spaces with shared air. The virus is about the same size as the particles in cigarette smoke (though it would usually be part of a larger droplet), so I find it helpful to imagine a smoker exhaling smoke, and what it would take to avoid inhaling too much of that second-hand smoke.

Disease severity seems to be determined in part by the degree of exposure. Even if we don’t avoid the virus 100%, reducing it by 80% could be the difference between something mild and something life-threatening. This could be a reason why so many otherwise young and healthy doctors and nurses have been killed by this virus.

This is also the reason why it’s important that everyone wears a mask or other face covering when they are in a shared space. Unfortunately, I’m still seeing people at the supermarket with their mouths uncovered, potentially spreading the virus everywhere. Masks are such a simple, low cost intervention that can be implemented immediately using something as basic as a t-shirt or scarf. It’s not a perfect solution, but covering your mouth reduces both the radius of spread, and quantity of droplets emerging from your mouth. Again, even if we are only stopping 80% of the viral particles, that could be enough to save someone’s life. It’s confusing to me that we’ve implemented harsh and expensive lockdown measures, but have been slow to implement a basic mask mandate.

Again, the best cure for any disease is to avoid the disease. But the second best cure for any disease is early detection and treatment.

With early detection, we can get the best known treatments (which could be as simple as rest and hydration) and hopefully prevent the disease from progressing to the more serious and more dangerous stages. With time, we will know more and have better treatment options, which is another reason to avoid catching the virus for as long as possible.

Early detection also means that extra steps can be taken to avoid spreading the disease to anyone else. I’m not elderly or overweight, I don’t have diabetes or high blood pressure, and I don’t work in a hospital or other high risk environment. For me the odds favor a milder experience, though as always there are no guarantees. However, there are other people in my life who are more vulnerable. If I’ve become infected, I would like to know as soon as possible so that I can avoid putting anyone else’s life at risk.

Unfortunately, testing has been very limited, and the thinking around testing has been limited by a mindset of scarcity and rationing. This is why the disease spread throughout our communities largely undetected in the early months of 2020. We had no evidence of community transmission because we specifically prohibited testing for community transmission!

Our thinking around testing should be the opposite of scarcity and rationing. We need an abundance of testing, made available to all.

I want a test that is fast and easy so that I can use it every day and detect the disease at the earliest possible stage, before I begin transmitting it to others. In this way, I can ensure that I’ll get the best possible early treatment, minimize the risk of serious complications, and avoid unknowingly spreading it to my family, friends, and co-workers, some of whom could literally die. These two things taken together would make the virus much less frightening and harmful.

Again though, early detection is only the second best cure. My first choice is to never catch the virus.

Therefore, I want a test that is fast, easy, and abundant, so that it can be made available to everyone, every day. In this way, everyone gets the same advantages that I’m seeking. Even better, thanks to early detection, those people who do catch it can avoid transmitting the virus to others, including me.

A Third Solution

The current consensus is that only a vaccine or highly effective treatment will end the threat posed by COVID-19. Unfortunately, developing a drug or vaccine and then proving that it is safe for widespread use is likely to take many months, if not years.

However, there is a third solution that could be implemented this year: Ubiquitous daily screening.

The virus only persists because we are unable to stop it from spreading. If we were able to identify and quarantine everyone who is contagious, including those who are asymptomatic, then we could let everyone else out of lockdown and resume ordinary social and economic activity.

Even with imperfect screening, if we are able to prevent 90% of disease transmission, then the virus’s reproductive number, or R0, will drop below one and the pandemic will quickly fade. There is no risk of reintroduction from the outside because any new outbreaks will quickly be caught and contained. If used consistently, there will be no second wave, ever.

This approach is generally considered impractical because the current medical testing technology, based on RT-PCR, is slow, expensive, unpleasant, and in short supply.

Therefore, we require a better technology, one capable of providing a test that is fast, easy, and abundant. There are a number of technologies that could be used to create such a test, but until one is proven at scale, we won’t know which approach is best. Therefore, I’ve backed teams working on three different solutions (and am open to supporting more).

The one that is most proven and ready to scale is based on a technology called LSPR. The team building it originally developed the device to monitor the status of the immune system, but it is easily adapted to detect the proteins on the surface of the virus instead of the proteins used for immune signaling. It’s able to detect even a very small number of viral particles, which is very important because we want to detect everyone who is contagious. Waiting for symptoms such as a fever or antibodies is too slow to stop the spread. What's exciting is that they are creating a very sensitive test that can be mass produced at low cost (less than $1/test).

This test gives results in ten minutes using a small amount of saliva which is taken into a disposable tube and then run through a scanner. If no virus is detected, then you’re not contagious. If the virus is detected, or the results are ambiguous, then you can take steps to avoid spreading the virus (such as wearing a mask and staying home) and will be referred to a doctor to receive appropriate care.

With this test, we can screen for the virus at the entrances to buildings and other areas, much like we currently use metal detectors to screen for weapons. Many places are already using thermometers to screen for infection, but unfortunately that is not good enough because not everyone who is contagious has a fever. I expect the virus screen will initially be deployed at essential locations such as hospitals, warehouses, and factories. Longer term, it can be used to safely reopen more crowded areas such as festivals, sporting events, and even Disneyland.

We’re planning to start operating the first scanner within a month. It's a fully automated system, similar to a kiosk or turnstile. If all goes well, there will be millions of scanners deployed by this fall, ensuring that every school and essential business can reopen while remaining safe and virus-free. Without regular virus screening, there is a significant risk of children catching the disease at school and then bringing it home to more vulnerable family members. Kids shouldn’t have to fear that by going to school they are going to accidentally kill grandma, or put a parent in the hospital.

My goal for the year 2020 is to wipe out COVID-19. That sounds unrealistic, but once we have demonstrated that viral screening is possible and effective, I believe that the benefits of this approach will become overwhelmingly obvious and institutions around the world will rush to embrace this solution.

This is a startup effort, so our success is far from guaranteed. This is why I want to raise awareness of this strategy, of this third solution to ending the pandemic. I want more people thinking about, working on, and demanding that this happen. I’m very optimistic about our effort, but it should not be the only effort. The stakes are too high to gamble our future on any one team or strategy. I’m personally supporting teams working on three different virus screening technologies (in addition to better antivirals and better vaccines). In a pandemic, it’s better to have too many solutions than not enough.

As bad as this virus is, it could be much worse. Our world is far too interconnected and too vulnerable to continue operating without any kind of virus screening. We must never again allow a pandemic to threaten our health and disrupt our society. With the ability to screen for multiple viruses, we can not only end this pandemic, but also prevent the next. We could potentially even eliminate the cold and flu (both of which have a lower R0, and are therefore more easily stopped). This will save millions of lives and trillions of dollars.

It’s easy to fall into dystopian visions of the future — a world shut down by one virus after another, where people are afraid to gather together, afraid to travel, afraid to be physically close even to those they love.

It doesn’t have to be that way. We can emerge from this pandemic better and stronger and healthier than ever. We can forever put an end to lockdowns and social distancing. Ubiquitous screening is the key.