Thread by @ASlavitt

COVID Update April 20: The next narrative will be one of the states vs the federal government & who has responsibility for testing.

The Hill, governors, WH, testing cos. I got a little of everyone’s opinion.

30 minutes or so if you’re interested in following. 1/

Will also cover the overall state of things, the Senate bill, the disability community & other learnings of the day. 2/

OVERALL: NY is slowly flattening but things are precarious.

States that haven’t been touched will without significant social distancing & containment. So they will have later peaks. Why? No human has natural immunity.

We are flattening the curve not stopping it. 3/

We don’t know this virus but at this point it’s safe to say that an invisible spec making its way into your nostril or throat can pass from unknowing to unknowing person. @EricTopol current best estimate is 40% never know they have it (without testing all of us). 4/

That spec when it finds the right party may be able to not only can destroy lungs, but other organ systems— kidneys, heart, brain & gut. 5/

So much we don’t know. I talked to a young doctor who has been wrestling with her own COVID-19 today. She describes feeling her immune system was utterly befuddled at what to do, cried from pain & confusion for first time since she was a child. (She is almost recovered now.) 6/

With all this deaths/case are all over the map which we know is a function of testing.

What we do know is that deaths/population start to converge. The variance depends on containment efforts. 7/

But the countries that have beat the system will only beat it if they keep the virus out or keep it from spreading before a vaccine. 8/

If this were the flu— you got symptoms, you stayed home— even if it were deadly, it would be easier to manage.

Since it’s not— if we want to open the economy, testing is the only way to get there. 9/

So on to the testing story. We’re not ready to open up if enough testing to contain new outbreaks is one metric. And the WH said it was.

So today I’m going after “why and what happens next.” 10/

Pre-COVID tests were not built for scale. Takes a lot of labor, supplies, some big machines— but measured in hundreds not thousands/day.

If you had your cholesterol taken, you didn’t much care if it took a few days. 11/

The FDA also approved things they thought worked best— the exact best swab with the exact right chemicals that fit the exact right machine was what the FDA approved.

If Roche sold the razor it wanted to sell the razor blades (their cartridges & reagents). 12/

(Brodie and I are outside as he has business to attend to. It’s a pretty beautiful world right now.)

We’ve ramped up testing quickly to about 1 million tests/week. And then we stopped increasing.

Easy phone calls to spot many easy to see culprits:

1. Not understand & overpromising from the WH
2. Over promising from the major commercial labs
3. Load balancing (will explain) 14/

4. Limited number of the big machines
5. The uncertain reimbursement from insurers slowing down labs
6. Not allowing interchangeable parts
7. 2 negative tests needed after a positive 15/

8. Confusion on ordering— no public way of accessing tests
9. Testing swabs mostly from Italy
10. Some private labs catering to paying customers
11. Some being exported still
12. New demand from DoD May be about to pull hundreds of 1000s of tests 16/

13. Processes labor intensive
14. Access and distribution points not set up/missing ordering process/EMR integration
15. Many new EUA tests of dubious quality
16. Several governors/states haven’t figured out how to buy 17/

(Some of you are very impatient you know). 18/

I’m talking about you with your funny GIFs making @somuchweirdness laugh hysterically.

The net of all of that. Sitting down with a someone with a spreadsheet working on all this— if you iron out many these kinks— we could produce 3.5 million/week (or so).

I believe that’s good news. Because these are fixable issues. 20/

They involve:
-public design for swab
-reconsidering swab specificity need
-DPA swabs (in process)
-FDA approving faster machines
-one price reimbursement by law all insurers— no bidding wars
-interchangeable kits made by many breaking up the monopoly
-selective repatriation 21/

-fix load balancing (put supply lines behind the labs producing most & best tests)
-public clearinghouse for all test ordering with every lab in the country
-medical records for every doc all updated for ordering
-require false negatives public on each test 22/

That’s 3.5 million before we get creative on some of the big bets like...:
-saliva tests
-15 minute tests
-new tests w no reagents 23/

If you look at those items, who can do them? The states or the federal government? I think only the federal government.

And I think they are doing some. But they should be done robustly as part of a strategy in partnership with states— not clearing hurdles in the background 24/

A government who believes in laissez faire policies & doesn’t want accountability will fall short of one that decides to take responsibility & set the strategy. 25/

It’s not as if the states aren’t trying to do this on their own.
-CA creating 5-7 hubs w UCSD & UC Davis
-FL says it will enlist natl guard to test nursing homes
-GA working w CVS on rapid tests
-KY public private partnership w Kroger’s to test 20k ppl w 48 hr turnaround26/

-MA working w CVS on rapid tests
-MI offering 13 new testing sites & partnering w Walmart
-OH 3D printing 50k swabs
-RI working w CVS on rapid tests
-TN creating 15 testing sites
-TX w Walgreen’s on testing sites
-WV ordered all nursing home residents & staff tested27/

So governors can and are taking responsibility. But as long as they are bidding up costs on supplies, can’t get reimbursement, have no transparency, don’t have resources behind best quality & fastest tests, there’s only so much they can do 28/

In that context, let’s turn to the PPP. $450 billion, 3/4 for states. $75B for hospitals, $25B for testing.

In the end these things get done. They fight before the vote to get what they want. And then they will get to agreement. But among the major issues is...29/

Testing.

No one I know has even seen the language. Even the testing industry lobbyist!

But one GOP Senator told me that there is a dispute over who is accountable— the states of the Federal govt w the Feds not wanting to own this. 30/

And in a perfect federated republic in a non-crisis with abundant materials & commoditized low cost market where you could order a test on Amazon, I’m sure— that could work out. 31/

The bill will very likely get voted on in the Senate in the next couple days and then the House. I’m not sure how the kinks get worked out.

And we probably won’t see the language until it’s out. Much will be left to regulations & guidance. 32/

But big picture money for testing & contact tracing is a good thing. 33/

I have talked several times about the crisis in the disability community over COVID. I know I’m running long but I want to elaborate if you’ll allow me. 34/

Understand many many of the deaths we are seeing in nursing homes & not seeing from home are ppl w disabilities. 35/

Those living at home are also at great risk of being put in a nursing home. The people that care for them every day (largely women of color) are being impacted by CV & that care keeps them independent.36/

In nursing homes neglect & abuse are rampant BEFORE infectious diseases are rampant.

While many of us worry about PPE, ppl w disabilities do to and also breatheing devices, communication devices, medications, access to transportation that they depend on. 37/

All of the people at risk must become a priority for Congress. Particularly without testing, we have to protect our most at risk populations— not just so they survive but they can survive with the life they want.

Grateful for @RebeccaCokley & many others who can show the way.38/

You’re already asleep which is my signal I should probably stop now.

Subscribe to the podcast. Listen to today’s convo as you drift off or first thing in the morning. Peace to everyone. /end

Listen to their conversation now: smarturl.it/inthebubble

Tweet 29 has an error. It should say 3/4 for small businesses, not states.

That’s what I get for rushing. 😂