Disclaimer: The views and opinions expressed by this author are their own and do not represent the official position of the Barbados Today.
by Karen Butcher Kent
Sitting back and watching the dizzying events of these last two weeks in Barbados, I have been reminded of an old public health parable a professor told me years ago at the start of graduate school.
The story tells of a person who is walking by a river and sees an almost lifeless body in the water. He jumps in, pulls the drowned person to shore, performs CPR, and almost as soon as he has revived that person, he sees another drowning person in the water.
He jumps in, pulls that person to shore, resuscitates him, and again and again and again he finds himself frantically rushing to save a never-ending stream of people from the river. He calls for help and is joined by a man—or let’s say a woman—who frantically helps him rescue the drowning people from the water for some time.
Eventually, they even develop a better rescue system so that they are losing fewer people to the rapid current. But then the second rescuer runs away. The first rescuer hollers out to her: “Where are you going? There are so many people drowning, I need help here!” To which she responds: “I’m going upstream to find out why so many people are falling into the river.”
That is what effective public health is about—not just about responding to health crises, or about getting more well-resourced and systematic in our response to health crises—it is about going upstream and addressing the root causes and systemic vulnerabilities that lead to the health crisis in the first place.
And right now, our travel protocol is quite obviously our biggest vulnerability; it is the elephant in the room that our government, however well-intentioned, continues to skirt around.
Since I came back home to Barbados in October, I’ve talked about this non-stop, though perhaps not to the right people. So, I will say it here, simply. Our travel protocol has a huge design flaw and, until it is changed, it will continuously leak cases of COVID-19 into the country.
And here is why — PCR tests are not perfect under any circumstances, but they are extremely unreliable when administered to infected people within the first couple days of infection. In the early days of infection, a person does not have a lot of the virus in their body as yet; and if a nasal swab misses collecting cells infected with the virus, or just doesn’t pick up enough of the virus, it can produce a negative result.
We have known this for a long time. Studies conducted by my colleagues at Johns Hopkins University last May showed that over the first four days of infection (before the typical time of symptom onset), the probability of a false-negative result in an infected person is very high.
On the day of infection, there is about a 100 per cent chance that a standard PCR test will not detect the virus; and on day 4 of infection, that number only drops to 67 per cent. Put simply, even the gold standard PCR tests will miss most COVID infections (and give false negatives to more than half of infected people) within the first four days of infection.
So why are we wasting tests administering them to inbound travellers a day or two after arrival? And why are we placing so much confidence in the results of these too-early tests, that we then release inbound travellers from quarantine without restrictions? These are the questions we need to be addressing.
As a Barbadian, I travelled back to the island in late October last year (like a refugee, fleeing widespread disease and what seemed like impending civil war in Washington, DC). After spending about six months almost entirely on lockdown at my US home (no restaurants, no stores, no gyms, no backyard barbeques or birthday parties, no beaches, nothing), I travelled for more than a day through two large busy airports, dragging my three young children (read: germ-magnets) through crowded check-in lines, security lines, gate lines, bathroom lines, restaurants, and planes.
So, I saw firsthand, and in stark contrast to the isolation of previous months, the number of high-touch surface touching and close-proximity physical interactions that are still unavoidable in air travel today. The fact is: air travel is a high-risk, high-exposure activity. Some people will inevitably get infected on their travel day.
The travel day is the critical high exposure event. We cannot continue to test visitors out of quarantine a day or two after arrival. The five-day clock for retesting should not start when visitors have their first test in their home country; the clock should start when they arrive here on the island. And even then, we should be prepared to occasionally have some
false negatives.
Furthermore, we need to address the system of group quarantine. On a visit to the island in December, my husband spent about a week at a government quarantine center, waiting for results of a test that was administered the day after he arrived from the US.
During that time, he slept in a room with about 15 other strangers and, while more cautious than most, he joined in in some of the activities that the quarantined visitors had arranged to entertain themselves. And every day some people left, having received negative PCR test results, and some new people came.
If you test someone on day 2 after they arrive and then they spend nearly a week mingling with other travellers before getting a test result, that test result is no longer meaningful. If any one of those people turns out to have COVID-19 (and subsequently gets a positive test result, or even a false negative result), they have potentially infected many others who may have already been released into the community. This has been and continues to be a significant vulnerability.
Even if we have not found evidence that these vulnerabilities in the testing and quarantine protocol have led to clusters—and I expect we haven’t since it is hard to find chains of asymptomatic transmission, especially when some of the links in those chains may have already left the island— we cannot rule out the possibility that it has indeed happened, and that it will continue to happen again and again.
After the economic damage exerted by the last ten months of COVID-19, I understand our leadership’s reluctance to shut down travel again—although that is something we really need to consider given the current state of things here, the high incidence of COVID-19 in the US and UK, the emergence of new more virulent strains, and the relatively short window until we can start requiring that all visitors arrive with both a negative test and a COVID-19 vaccine record. But to be honest, we don’t need to close Barbados’ borders to be safer. A first and most important step is to fix the leaky travel protocol.
Karen Butcher Kent, MPH, is a Senior Research Program Manager at Johns Hopkins University Institute
for Health and Productivity Studies.
