Commentary: Targeted coronavirus testing is essential for health equity

While disaster responses to this pandemic alone cannot right prior injustices, prioritizing diagnostic testing for minoritized, low-income, and high-risk communities could mitigate the negative impact of COVID-19 on already marginalized communities.

The COVID-19 pandemic has exposed and worsened profound inequities in the US health care and public health system. Minoritized and low-income populations are at greater risk of COVID-19 infection and mortality. While disaster responses to this pandemic alone cannot right prior injustices, prioritizing diagnostic testing for minoritized, low-income, and high-risk communities could mitigate the negative impact of COVID-19 on already marginalized communities.

Food deserts, mass incarceration, lack of paid sick leave, crowded dwellings, economic inequality, and racism negatively impact health. This pandemic has made us acutely aware of how these and other structural determinants of health lead to worse COVID-19 outcomes.

In pandemics, the need for important resources often exceeds supply – such as in the case of personal protective equipment (PPE), critical care personnel, diagnostic tests, hospital beds, and ventilators. Allocation of scarce resources that are needed to protect and preserve life and well-being requires attention to distributive justice. Since people with heart disease, lung disease, and diabetes are at greater risk for COVID-19 complications, and since these diseases are more prevalent in low-income and minoritized populations, prioritizing testing in these communities could enable those at higher risk for severe illness and, typically, worse access to care, to be reliably monitored and promptly treated should they develop concerning symptoms. Since essential workers tend to be minority, low-income, or both, rapid detection of infection could also help reduce community spread of infection, assuming that paid sick leave and adequate housing (for isolation purposes) also are provided.

Targeted Testing And Contact Tracing To Maximize Safety And Equity

In an ideal world, mass diagnostic testing of any and all suspected cases could lead to contact tracing, identifying close contacts of confirmed COVID-19-positive individuals -- who would also be tested -- and preventing spread of disease. When scarcity does not permit mass testing, equitable allocation needs to take into consideration the risk of infection and from infection, including risks to economic wellbeing. Those most at risk for worse health outcomes, and those with precarious financial stability, need to be prioritized.

Early in the pandemic, scarce diagnostic tests were often reserved for more severely ill patients, while mildly symptomatic patients were advised to self-quarantine at home. While prioritizing the sickest people is understandable, this approach disadvantages those with worse access to care, and those who have more difficulty self-quarantining, due to employment or living conditions. To make matters worse, rich, famous and powerful individuals have accessed testing with only mild symptoms of infection, reflecting clear inequities in access. In the current phase of the pandemic response, testing of asymptomatic patients is becoming more common.

Targeted testing and contact tracing represent a more ethical approach to lifting pandemic restrictions and opening up the economy given limited test supplies. The following populations should be given priority in the allocation of diagnostic testing, based on their risk of infection and the risks they face should they become infected:

Racial and ethnic minorities: Data from all across the country show that racial minorities are disproportionately at risk for COVID-19 infection and mortality, likely due to structural inequities. Targeting testing resources (supplies, tailored messages/information and accessible sites) could alleviate ongoing and future disparities in health outcomes due to the pandemic.

People with underlying medical conditions: Individuals with underlying medical conditions, including disability, have the greatest risk of serious infection and should be prioritized for targeted testing.

People whose living conditions make physical distancing exceedingly difficult: This includes individuals working or living in crowded conditions, such as incarcerated individuals and corrections workers, houseless individuals, ship workers, and residents and staff in nursing homes. Diagnostic testing for mildly symptomatic and even asymptomatic persons (who work or live in very confined conditions) would enable protection of other residents and employees from infection.

Essential workers: Frontline health care workers, bus drivers, grocery store workers, sanitation workers, and other essential workers and their families should be given priority for testing to maintain a functioning society, mitigate impact on low-income and minoritized populations, and minimize the spread of infection. Given the need for self-isolation for those who test positive, paid sick leave and adequate housing are essential for this to succeed.

Criteria for test allocation must be transparent, explicit, simple, and consistently followed, although diagnostic testing priorities will be justifiably modified as scarcity fluctuates. One major consideration, not directly addressed by the current administration’s plan to reopen the economy, is the need for an explicit process to periodically review and revise strategies based on new data. When communities are geographically, demographically, and socioeconomically similar, testing supplies should be allocated based on evidence of greater infection rates and morbidity/mortality.

Disaster Preparedness And Scarce Resource Allocation

Pandemic planning includes guidance for allocation of scarce resources, often with an emphasis on lifesaving interventions such as ventilators and antivirals, and sometimes on vaccines and palliative care. However, attention is rarely paid to the allocation of some other resources, including personal protective equipment and diagnostic tests, despite their importance for public health.

There are two main categories of COVID-19 tests: diagnostic tests that detect the virus and serology tests that detect antibodies formed against it. Diagnostic tests have the potential to help guide treatment and isolation or quarantine decisions, while serology tests help describe the prevalence of infection. At present, the high false positive rate of serology tests means that they will only be useful after future improvements and greater understanding of immunity to COVID-19.

In this pandemic, testing is currently limited more by the scarcity of sample collection supplies (such as collection swabs, test tubes, and transport media) than by lab capacity. The first obligation of policy should be to ensure that there is enough capacity for testing to meet the public’s need. Until then, testing supplies must be allocated in a manner that minimizes health inequities.

Guidance for allocating life-saving personnel and equipment relies on the probability and degree of benefit for individual patients, often prioritizing patients who are younger, healthier, and, based on the selection criteria, white. This approach is biased against historically marginalized groups who disproportionately suffer from chronic diseases. In contrast, targeted allocation of COVID-19 diagnostic tests (and, ultimately, vaccines) could save many lives and help alleviate health disparities.

Such targeted testing has multiple public health benefits. Identifying COVID-19-positive patients in minority, elderly, low-income, and densely populated communities could save many more lives than allocating tests evenly across localities. Mass, targeted testing could allow better preparation for future surges than a reliance on hospitalization data. This is because timely diagnostic testing can detect large-scale spread of infection in a community sooner than hospitalizations, which typically occur later in the course of infection. Scarce resources such as contact tracing personnel and housing (to allow isolation) can then also be more efficiently -- and fairly -- targeted.

Collectivism Is Key

Due in part to shortages of testing supplies, most states and localities have depended on strict stay at home orders to “flatten the curve.” Collective efforts to physically distance are increasingly clashing with (very American) individualism, righteous protests of police brutality, and pressure to dial up the economy. Without an effective vaccine, evidence of long-term immunity, or proven treatments, loosening restrictions on distancing and continued acts of police brutality, a known public health issue, come with great public health risk. On the other hand, low-income workers are less likely to be able to work from home, and need to be able to support themselves during a period of growing unemployment, which is disproportionately impacting minoritized communities, and limited support from stimuli packages. Diagnostic testing can help public health departments better tailor social distancing and isolation recommendations.

This pandemic, having further exposed great inequities in health and health care, reminds us that our health as a society and as individuals is tied to one another. We need explicit, prompt attention to equity in public and private health policy decision making, attention that should not wane when the pandemic does. We can start with allocating diagnostic tests fairly to those at greater risk of infection with COVID-19 and at greater risk of death should they acquire the infection.

Originally published on Health Affairs Blog.

Huerto, Ryan, Goold, Susan, Newton, Duane. “Targeted Coronavirus Testing Is Essential For Health Equity, " Health Affairs Blog, June 15, 2020.DOI: 10.1377/hblog20200611.868893.