In the 1967 film “The Graduate,” the title character played by Dustin Hoffman attends a post-graduation party where a partygoer beckons him from the boisterous crowd and gives him a single word of career advice that has become an iconic cinema quote: “Plastics.”
As COVID-19 retreats in the midwinter, the one word of advice for our scientific community going forward is “surveillance.” The pandemic has forced us to relearn that public health surveillance — maintaining a watchful eye on new COVID-19 variants as well as other bacteria and viruses that threaten us — is the basis for preventing disease outbreaks and controlling them once they occur.
In many ways, public health surveillance is similar to a national government’s intelligence surveillance. Both require a combination of human intelligence and technical sophistication to achieve their purpose. Espionage requires trained agents and high-tech equipment; public health demands expert health care personnel and advanced molecular diagnostic methods. Most important, in both cases, keeping citizens safe takes a global effort.
Right now, the greatest threat of a COVID-19 resurgence is from new coronavirus variants. The most important reservoir for those variants is China, where hundreds of millions of COVID-19 cases have been reported. Any one of China’s many new cases could spawn a new variant, possibly more contagious and/or more virulent than what we have seen to date.
It is imperative that we work with China and other COVID-19 hot spots using the most advanced molecular techniques for identifying new viral variants. This means tracking data on COVID-19 cases and establishing and recording molecular profiles of circulating viruses to anticipate trends and tailor vaccine development. It will probably necessitate a collaborative worldwide network in conjunction with the World Health Organization. Unfortunately, to this point, China hasn’t cooperated.
At home, we must ramp up one of the most important techniques developed during the pandemic — the deployment of wastewater sampling. The creation of an expanded national wastewater surveillance system by the Centers for Disease Control and Prevention to track the spread of COVID-19 variants is an early indicator of the rise or fall in COVID-19 cases and of new variants in a particular region. Wastewater sampling does not depend on whether people have COVID-19 symptoms or get tested.
Monitoring wastewater has added advantages including the possibility of discovering other viruses such as polio that threaten to reemerge in America. Wastewater sampling can assess the comparative success of COVID-19 control strategies in different regions of the country. To complement wastewater surveillance, it may soon be possible to employ airborne surveillance to look for COVID-19 and other aerosol or droplet-borne viruses aloft. Imagine not having to worry whether the crowded restaurant you enter has COVID-19 circulating above your table.
One of the difficulties during this phase of the pandemic has been ascertaining the true number of COVID-19 cases. In the U.S., there have been more than 100 million cases diagnosed and recorded by testing, but there are likely two to three times as many actual cases — people who have never been tested or those who tested at home and never reported the results. (Because the population of the U.S. is slightly more than 330 million, there can’t be much more than three times as many cases, and this discounts those who have been reinfected.)
We don’t know how much this undercount keeps us from measuring COVID-19 trends precisely. At-home testing has been a major advance in controlling spread and determining when to institute treatment. A system to report positive home tests automatically by mobile phone would be of immense benefit, and at-home tests are being developed for other potentially epidemic and treatable viruses such as influenza.
In the past, Google has attempted to predict seasonal flu patterns based on internet searches of symptoms and purchases of over-the-counter medicines. Results are mixed, but this, too, is a promising area for information technology to partner with public health to obtain real-time information. The CDC reporting system, by contrast, proved cumbersome early in the pandemic.
Twenty-eight years after his role in “The Graduate” made him a star, Hoffman starred in “Outbreak,” a riveting film about a deadly virus that threatens the U.S. Hoffman plays an Army doctor who specializes in disease control. He and his team must stop the spread of the virus before it infects the entire country, and his superior, played by Morgan Freeman, tells the team: “The fate of the nation, perhaps the world, is in our hands. We cannot, we dare not refuse this burden. I am confident each of you will do his duty.”
Life imitates art.
