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Are There Better Ways to Track Covid Cases?

An increasing reliance on at-home testing and the closings of mass testing sites are making official case counts less reliable, scientists say.

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When the highly transmissible Omicron variant of the coronavirus arrived in the United States last fall, it pushed new case numbers to previously unseen peaks.

Even then, the record wave of recorded infections was a significant undercount of reality.
In New York City, for example, officials logged more than 538,000 new cases between January and mid-March, representing roughly 6 percent of the city’s population. But a recent survey of New York adults suggests that there could have been more than 1.3 million additional cases that were either never detected or never reported — and that 27 percent of the city’s adults may have been infected during those months.

The official tally of coronavirus infections in the United States has always been an underestimate. But as Americans increasingly turn to at-home tests, states shutter mass testing sites and institutions cut back on surveillance testing, case counts are becoming an increasingly unreliable measure of the virus’s true toll, scientists say.

“It seems like the blind spots are getting worse with time,” said Denis Nash, an epidemiologist at the CUNY Graduate School of Public Health & Health Policy who led the New York City analysis, which is preliminary and has not yet been published.

That could leave officials increasingly in the dark about the spread of the highly contagious new subvariant of Omicron known as BA.2, he said, adding, “We are going to be more likely to be surprised.” On Wednesday, New York officials announced that two new Omicron subvariants, both descended from BA.2, have been circulating in the state for weeks and are spreading even faster than the original version of BA.2.

The official case count can still pick up major trends, and it has begun to tick up again as BA.2 spreads. But undercounts are likely to be a bigger problem in the weeks ahead, experts said, and mass testing sites and widespread surveillance testing may never return.

“That’s the reality we find ourselves in,” said Kristian Andersen, a virologist at the Scripps Research Institute in San Diego. “We don’t really have eyes on the pandemic like we used to.”
To track BA.2, as well as future variants, officials will need to pull whatever insights they can from an array of existing indicators, including hospitalization rates and wastewater data. But truly keeping tabs on the virus will require more creative thinking and investment, scientists said.

For now, some scientists said, people can gauge their risk by deploying a lower-tech tool: paying attention to whether people they know are catching the virus.

“If you’re hearing your friends and your co-workers get sick, that means your risk is up and that means you probably need to be testing and masking,” said Samuel Scarpino, the vice president of pathogen surveillance at the Rockefeller Foundation’s Pandemic Prevention Institute.

Tracking the virus has been a challenge since the earliest days of the pandemic, when testing was severely constrained. Even when testing improved, many people did not have the time or resources to seek it out — or had asymptomatic infections that never made themselves known.
By the time Omicron hit, a new challenge was presenting itself: At-home tests had finally become more widely available, and many Americans relied on them to get through the winter holidays. Many of those results were never reported.

“We haven’t done the groundwork to systematically capture those cases on a national level,” said Katelyn Jetelina, an epidemiologist at the University of Texas Health Science Center at Houston.

Some jurisdictions and test manufacturers have developed digital tools that allow people to report their test results. But one recent study suggests that it may take work to get people to use them. Residents of six communities across the country were invited to use an app or an online platform to order free tests, log their results and then, if they chose, send that data to their state health departments.

Nearly 180,000 households used the digital assistant to order the tests, but just 8 percent of them logged any results on the platform, researchers found, and only three-quarters of those reports were sent on to health officials.

General Covid fatigue, as well as the protection that vaccination provides against severe symptoms, may also prompt fewer people to seek testing, experts said. And citing a lack of funds, the federal government recently announced that it would stop reimbursing health care providers for the cost of testing uninsured patients, prompting some providers to stop offering those tests for free. That could make uninsured Americans especially reluctant to test, Dr. Jetelina said.

“The poorest neighborhoods will have even more depressed case numbers than high-income neighborhoods,” she noted.

Monitoring case trends remains important, experts said. “If we see an increase in cases, it’s an indicator that something is changing — and quite possibly that something is changing because of a larger shock to the system, like a new variant,” said Alyssa Bilinski, a public health policy expert at the Brown University School of Public Health.

But more modest increases in transmission may not be reflected in the case tally, which means that it could take officials longer to detect new surges, experts said. The problem could be exacerbated by the fact that some jurisdictions have begun updating their case data less frequently.

Dr. Nash and his colleagues have been exploring ways to overcome some of these challenges. To estimate how many New Yorkers may have been infected during the winter Omicron surge, they surveyed a diverse sample of 1,030 adults about their testing behaviors and results, as well as potential Covid-19 exposures and symptoms.

People who reported testing positive for the virus on tests administered by health care or testing providers were counted as cases that would have been caught by standard surveillance systems. Those who tested positive only on at-home tests were counted as hidden cases, as were those who had probable unreported infections — a group that included people who had both Covid-19-like symptoms and known exposures to the virus.

The researchers used the responses to calculate how many infections might have escaped detection, weighting the data to match the demographics of the city’s adult population.
The study has limitations. It relies on self-reported data and excludes children, as well as adults living in institutional settings, including nursing homes. But health departments could use the same approach to try to fill in some of their surveillance blind spots, especially during surges, Dr. Nash said.

“You could do these surveys on a daily or weekly basis and quickly correct prevalence estimates in real time,” he said.

Another approach would be to replicate what Britain has done, regularly testing a random selection of hundreds of thousands of residents. “That’s really the Cadillac of surveillance methods,” said Natalie Dean, a biostatistician at Emory University.

The method is expensive, however, and Britain has recently started scaling back its efforts. “It’s something that should be part of our arsenal in the future,” Dr. Dean said. “It’s sort of unclear what people have the appetite for.”

The spread of Omicron, which easily infects even vaccinated people and generally causes milder disease than the earlier Delta variant, has prompted some officials to put more emphasis on hospitalization rates.

“If our goal is to track serious illness from the virus, I think that’s a good way to do it,” said Jason Salemi, an epidemiologist at the University of South Florida.

But hospitalization rates are lagging indicators and may not capture the true toll of the virus, which can cause serious disruptions and long Covid without sending people to the hospital, Dr. Salemi said.

Indeed, different metrics can create very different portraits of risk. In February, the Centers for Disease Control and Prevention began using local hospitalization rates and measures of hospital capacity, in addition to case counts, to calculate its new “Covid-19 community levels,” which are designed to help people decide whether to wear masks or take other precautions. More than 95 percent of U.S. counties currently have low community Covid-19 levels, according to this measure.

But the C.D.C.’s community transmission map, which is based solely on local case and test positivity rates, suggests that just 29 percent of U.S. counties currently have low levels of viral transmission.

Hospitalization data may be reported differently from one place to another. Because Omicron is so transmissible, some localities are trying to distinguish between patients who were hospitalized specifically for Covid-19 and those who picked up the virus incidentally.

“We felt like, because of the intrinsic factors of the virus itself that we’re seeing circulating in our region now, that we needed to update our metrics,” said Dr. Jonathan Ballard, the chief medical officer at the New Hampshire Department of Health and Human Services.

Until late last month, New Hampshire’s Covid-19 online dashboard displayed all inpatients with active coronavirus infections. Now, it instead displays the number of hospitalized Covid-19 patients taking remdesivir or dexamethasone, two frontline treatments. (Data on all confirmed infections in hospitalized patients remains available through the New Hampshire Hospital Association, Dr. Ballard noted.)

Another solution is to use approaches, such as wastewater surveillance, that don’t rely on testing or health care access at all. People with coronavirus infections shed the virus in their stool; monitoring the levels of the virus in wastewater provides an indicator of how widespread it is in a community.

“And then you combine that with sequencing, so you get a sense of what variants are circulating,” said Dr. Andersen, who is working with colleagues to track the virus in San Diego’s wastewater.

The C.D.C. recently added wastewater data from hundreds of sampling sites to its Covid-19 dashboard, but coverage is highly uneven, with some states reporting no current data at all. If wastewater surveillance is going to fill in the testing gaps, it needs to be expanded, and the data needs to be released in near real time, scientists said.

“Wastewater is a no-brainer to me,” Dr. Andersen said. “It gives us a really good, important passive surveillance system that can be scaled. But only if we realize that that’s what we have to do.”

Dr. Scarpino, of the Pandemic Prevention Institute, said that there were other data sources that officials could leverage, including information on school closings, flight cancellations and geographic mobility.

“One of the things we’re not doing a good enough job of doing is pulling those together in a thoughtful, coordinated way,” Dr. Scarpino said.

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Do you think rideshare and delivery drivers need better protections?

Rideshare and delivery drivers in Massachusetts are on strike today to protest low wages amid nationwide inflation. Drivers for companies like Uber, Lyft, and Grubhub gathered today at the State House to put pressure on lawmakers to make these corporations provide higher wages and union rights.

“Uber is making record profits by underpaying us. It’s exhausting, especially as we struggle to provide for our families,” said Uber driver and Massachusetts Independent Drivers Guild member Ehab Hilali in a statement. “I sometimes work 60 hours a week just to pay my car insurance, gas, and other work expenses. That’s why we’re calling on our politicians to fix this now. We need the right to form a union so we can finally hold Uber accountable and negotiate higher pay for drivers.”

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Because drivers for these apps are considered independent contractors, many don’t make enough to keep up with the rising cost of living, and benefits are not guaranteed. In 2021, Boston Uber drivers earned a median of about $26.50 an hour, according to Uber.

The company takes 25% in fees for every trip they complete, but some drivers told MassLive that they’ve recently seen service fees of up to 50%. Some are discouraged from continuing the job, which has led to complaints from riders in the past.

During the height of the COVID-19 lockdowns when fewer rideshare drivers were available, Boston.com readers expressed frustration at the long wait times and delayed service.

“Lame public transport, labor laws scaring gig workers…common man suffers,” one reader said.

We want to hear from rideshare and delivery app drivers in Massachusetts about your recent experiences. Do you want to see higher wages and union protections? Are you struggling to make ends meet as everyday prices rise?

Share your thoughts with Boston.com by filling out the survey below or e-mailing us at community@boston.com and we may feature your response in a future article or on our social media channels.

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At Berkeley Law, a debate over Zionism, free speech and campus ideals

On the first day of the fall semester, Erwin Chemerinsky, the dean of the law school at the University of California, Berkeley, learned that a student group created a bylaw that banned supporters of Zionism from speaking at its events.

Chemerinsky said he rarely used profanity but did so in that moment. As a constitutional law scholar and co-author of a book about campus free speech, Chemerinsky said that he knew the group, the Berkeley chapter of Law Students for Justice in Palestine, had the legal right to exclude speakers based on their views.

But he also knew the bylaw, which eight other student groups also adopted, would be polarizing within the law school and used as a cudgel by forces outside of it.

Santos was registered to vote at a modest townhouse in Queens that he does not own, but he moved away before the election. His former landlord, Nancy Pothos, 72, said Santos had been a tenant for two years before moving at the end of August.

Santos’ campaign spokesperson and his lawyer didn’t respond to a list of questions about his company, possible discrepancies in his biography or the criminal case in Brazil.

The controversy, pushed along online by conservative commentators, hits two of the pressure points in campus politics today. The bylaw was adopted as antisemitism is rising across the country. And some critics of academia have cast left-wing students as censors who shout down other viewpoints, all but strangling, they say, honest intellectual debate.

That collision of issues all but guaranteed a tense debate over free speech, even if a broad swath of speech experts say that student groups are allowed to ban speakers whose views they disagree with.

“A student group has the right to choose the speakers they invite on the basis of viewpoint,” said Chemerinsky, who is Jewish and a Zionist. “Jewish law students don’t have to invite a Holocaust denier. Black students don’t have to invite white supremacists. If the women’s law association is putting out a program on abortion rights, they can invite only those who believe in abortion rights.”

Chemerinsky said that excluding speakers based on race, religion, sex or sexual orientation would not be allowed, but he noted that the student groups were excluding speakers based on viewpoint. True, he said, many Jews view Zionism as integral to their identity, but such deep passions do not change the law.

Other legal experts noted that the controversy showed just how mangled the understanding of the First Amendment had become, even at a place like Berkeley, the epicenter of the 1960s free-speech movement. The debate, they said, should focus on whether these bans align with the academic ideal of open, intellectual debate. Even if student groups can prohibit speakers, should they? And should such bans be codified — formally adopted with a bylaw?

“There’s a real confusion about freedom of speech as a cultural value and freedom of speech as a legal concept,” said Will Creeley, the legal director of Foundation for Individual Rights and Expression, a free-speech advocacy group.

The issues are not limited to the Justice in Palestine group. Campus groups often invite only those they agree with. Hillel, the Jewish student group with hundreds of chapters on college campuses, also has rules prohibiting speakers who “delegitimize” Israel.

In August, Law Students for Justice in Palestine announced that it, along with the eight other groups, had adopted a provision that it would “not invite speakers that have expressed and continued to hold views or host/sponsor/promote events in support of Zionism, the apartheid state of Israel and the occupation of Palestine.”

The student group said the ban was meant to promote the welfare of Palestinian students and was part of a broader provision aligned with the boycott, divestment and sanctions movement against Israel.

Some Jewish students expressed concern and tensions flared within the law school. Noah Cohen, a law student at Berkeley, said the bylaw was an example of how antisemitic rhetoric was being normalized in the United States. Cohen, who described himself as a Jewish supporter of Palestinian rights and statehood, said the bylaw made him and many other Jewish students feel “singled out and targeted.”

In public statements, Law Students for Justice in Palestine rejected the accusation that its bylaw was antisemitic. It says that being Jewish is an identity, while Zionism — the support for a Jewish state — is a political viewpoint. It welcomes and supports Jewish speakers who are not Zionists, the group said.

“Supporting Palestinian liberation does not mean opposition to Jewish people or the Jewish religion,” the group said in a statement to the Berkeley law community. Members of the group did not respond to messages seeking an interview.

After learning about the bylaw, Chemerinsky met with the university’s Hillel rabbi and spoke with several Jewish students, but, aside from concerns within the law school, the reaction was relatively muted, he said.

That changed, he said, after Kenneth L. Marcus, the civil rights chief of the U.S. Education Department during the Trump administration, wrote about the bylaw in September in The Jewish Journal under the explosive headline “Berkeley Develops Jewish Free Zones.”

Marcus wrote that the bylaw was “frightening and unexpected, like a bang on the door in the night,” and said that free speech does not protect discriminatory conduct.

The article went viral.

Chemerinsky said he learned about Marcus’ article, which he described as “inflammatory and distorted,” while he was in Los Angeles for a conference. Chemerinsky said he typed out a response to the article, which was appended to it, and then didn’t think much of it. That afternoon, he was deluged by emails. At an alumni event that night, the law school’s perceived hostility to Jews was “all anyone wanted to talk about.”

In an interview, Marcus, a Berkeley law school alumnus, said he was contacted by law students there who were concerned about the bylaw. He said he spent weeks trying to support them and wrote his article after Berkeley did not “rectify the problem.”

Not allowing Zionist speakers, he said, was a proxy for prohibiting Jews. The provisions, he said, are “aimed at the Jewish community and those who support the Jewish community,” even while acknowledging that the policy could allow Jewish speakers and bar those who are not Jewish.

The article stoked outrage. Sen. Ted Cruz, R-Texas, and singer Barbra Streisand both tweeted about it. “When does anti-Zionism bleed into broad anti-Semitism?” Streisand wrote.

Politicians called for action. Rep. Brad Sherman, D-Calif., said in a statement that funding to the groups should be conditional on revoking the provision. Rep. Josh Gottheimer, D-N.J., said that the Education Department should investigate “whether and how federal taxpayer dollars are used to discriminate against Jewish and pro-Israel students” at the university.

In many ways, Chemerinsky was well suited to navigate the issues. In 1999, he helped found the Progressive Jewish Alliance, a social justice group based in Los Angeles. He is also co-chair of the National Center for Free Speech and Civic Engagement at the University of California and a co-author of a book on campus speech.

But the past semester has been a challenge. Many students have been doxxed and harassed for their connection to the bylaw, Chemerinsky said. In the weeks after Marcus’ article, he added, a right-wing group that describes itself as a media watchdog drove trucks near campus comparing the students who adopted the bylaw to Hitler, and included the names of the students who were in the organizations that adopted the bylaw, even if they voted against it.

As the semester ended Friday, Chemerinsky was still dealing with the fallout.

The Office for Civil Rights at the Education Department said Dec. 13 that it would open an investigation into whether Berkeley responded appropriately, according to Arsen Ostrovsky, one of two lawyers who filed a complaint on behalf of the International Legal Forum, a group based in Tel Aviv, Israel.

Opening an investigation does not imply that the office has determined that the case has merit, according to a letter sent to Ostrovsky by the Office for Civil Rights.

Chemerinsky said the complaint, which calls on Berkeley to “immediately invalidate” the bylaw, includes the same flawed assumptions from previous attacks. He said he was confident that Berkeley was on “strong legal ground.”

“Every dean or school administrator always worries about being accused of discrimination,” he said. “I never imagined I would be accused of discrimination against Jews.”

 

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Hochul urged bolster health care for retired public workers

A bill meant to strengthen health care services for retired public workers once they enroll in the Medicare program is sitting on Gov. Kathy Hochul’s desk for her consideration.

An organization that represents a half million retired state and local government workers in New York is urging her to sign it.

The measure is meant to ensure retired people in New York who worked for municipal governments or the state do not lose Skilled Nursing Facility care once they enroll in the Medicare program upon turning age 65.

Medicare-eligible retirees under the program are allowed 20 days of coverage with a three-day prior hospital requirement. But for retirees who are enrolled in the Empire Plan, they can access up to 120 days of coverage with no prior hospitalization requirement.

The Retired Public Employees Association calls this an imbalance in health care coverage for people who need it the most as they age. The bill sitting on Hochul’s desk since Monday is meant to address it.

“Public employees work their entire careers under the promise and expectation that when they retire, their existing benefits will not diminish. It’s time for New York to uphold that promise and end inequities in skilled nursing care,” said Edward Farrell, the group’s executive director. “With the stroke of a pen, Gov. Kathy Hochul can end age discrimination by providing 225,000 Medicare-primary retirees in the NYS Health Insurance Program Empire Plan the same access to skilled nursing care that is available to Empire Plan enrollees who are still working.”
Prior attempts to make changes to the program have fallen short in recent years.

 

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