America is still failing on coronavirus testing

The state of coronavirus testing in America means that an end to social distancing is likely a long way off.

Two and a half months after the first reported coronavirus case in the US, America still doesn’t have the capacity that it needs to track all cases — a prerequisite for ending social distancing, according to a range of public health experts, health care providers, and private labs.

More testing is a cornerstone of every plan that calls for ending the social distancing measures that have shut down huge swaths of the economy and confined many Americans to their homes. The idea, as outlined in plans from the left-leaning Center for American Progress (CAP) and the right-leaning American Enterprise Institute (AEI), is that widespread testing will let public health officials detect and subsequently contain any future outbreaks before everything has to be locked down.

As Jeffrey Martin, an epidemiologist at the University of California San Francisco, put it, “The only way that a society can function is if the brushfires are identified and put out” — before they turn into a wildfire.

There have been some recent improvements in testing capacity, with the reported number of daily tests increasing by tens of thousands in the past two weeks. But experts say the US is still very far from where it needs to be.

“All of the talking points about how we have made massive progress has let everybody say that okay, this problem has been solved,” Ashish Jha, the faculty director of the Harvard Global Health Institute, told me. “But it hasn’t.”

As of April 6, Quest Diagnostics, one of the largest private testing facilities in the US, still had a backlog of roughly 80,000 tests as it faces more demand than it can handle. Adjusted for population, the US has tested at just 74 percent the rate of South Korea — where widespread testing has been credited with containing the country’s outbreak — and is even further behind Germany, Italy, and Canada.

On the ground, the lack of widespread testing makes it difficult for many, if not most, people with relatively mild symptoms of Covid-19, the disease caused by the SARS-CoV-2 coronavirus, to obtain a test. If you’re hospitalized with the disease, there’s a good chance you can get tested. But if you’re in an outpatient setting, experts said testing remains very difficult if not impossible.

And even those who get tested can expect delays in getting results, with labs generally taking days — or even a week or more — to run and report tests.

Every day this problem continues, America remains further away from reopening its economy, at least safely, and overcoming the current outbreak. Testing is crucial: It gives officials the means to isolate the sick, quarantine their contacts, and deploy community-wide efforts if necessary. Without that, the only way to deal with the outbreak is more social distancing, which further cripples the economy, or letting the disease run its course — which, in the case of Covid-19, could result in hundreds of thousands, or even millions, of deaths.

So no matter how many improvements there have been, America still needs more testing.

“It’s one of those things that is absolutely astounding,” Krutika Kuppalli, a fellow in the Johns Hopkins Center for Health Security Emerging Leaders in Biosecurity program, told me. “Three and a half months into this outbreak, we’re still talking about the basic issue of we need to get testing up and going.”

America is still playing catch-up on testing

Ideally, testing could be used to check not only everyone with symptoms but also their close contacts, who could subsequently be isolated or quarantined as well. More testing could also allow random community sampling, whether through home tests or by checking samples collected in doctor’s offices as part of other check-ups. This would allow public health officials to not only track and contain every individual case but also detect and curtail broader community outbreaks.

The US is simply not there yet. “The country still has a problem with testing,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me.

The nation was already behind, largely due to failures under President Donald Trump’s administration. The Centers for Disease Control and Prevention (CDC) sent out its own faulty tests and failed to correct the error for weeks. The Food and Drug Administration (FDA) maintained regulatory barriers to private labs conducting tests even after the federal government declared a public health emergency in January. And the government failed to supply labs with enough testing supplies. That all amounted to a “lost month,” the New York Times reported, between late January and early March as Covid-19 cases grew in the US. (The CDC, FDA, and White House didn’t respond to requests for comment.)

That along with the continued problems reflect America’s general lack of preparedness for pandemics — a problem many experts warned about even before the Covid-19 outbreak. Experts emphasized that proper preparedness would have allowed the US to quickly scale up testing nationwide, whether by easing regulatory hurdles, coordinating efforts, fixing supply lines, or doing anything else that’s necessary.

Things have improved in recent weeks: During the week of April 6, the US completed roughly 150,000 tests a day, according to the Covid Tracking Project. That’s a big improvement from early March, when tests numbered below the dozens (and later the hundreds). But the daily total hasn’t improved much compared with the week of March 30, when the US completed an average of more than 130,000 tests a day.

There is no widely accepted number for how many tests America should run each day, but the current number is generally considered far too low by experts. Jha put the ideal at 500,000 tests a day. Scott Gottlieb, former FDA commissioner and coauthor of the AEI report, suggested that everyone who goes to a doctor could be tested, which would amount to more than 500,000 a day. A Harvard model proposed millions of tests a day.

On the ground, the testing shortage is apparent. Though LabCorp, another large testing company, no longer has a backlog (unlike Quest Diagnostics, which had a backlog of 80,000 as of April 6), a spokesperson for the company told me that turnaround for results is still around three to four days, with longer delays in places that are hit particularly hard by Covid-19.

Health care facilities trying to test have also faced issues. After calling around suppliers, Elaine Cham, a pathologist at UCSF Benioff Children’s Hospital in Oakland, California, repeatedly found it could take weeks to get the proper materials for in-house testing, which “would be way faster,” Cham said. “We could get results in hours instead of days,” she added.

While many of the initial problems with testing were linked to strict criteria around who could get a test, the problems today are predominantly about supplies. Complaints vary, but labs say they don’t have enough swabs, test kits, reagents, personal protective equipment (PPE), staff, or machines to run the specific tests required.

“Any one link in the chain of supply, any restriction in the chain of supply, can suddenly create a bottleneck,” Louise Serio, a spokesperson for the American Clinical Laboratory Association (ACLA), which represents the private labs, told me. “No labs have, really, the predictable, consistent access to all the supplies we need, from reagents to test kits to PPE.”

Labs face a couple of major problems in fixing these issues. First, private and public health insurers tend to have fairly low reimbursement rates for Covid-19 tests — they aren’t willing to pay labs very much for testing — which makes it more difficult to recoup the investment required to scale up.

Second, labs have lost a bulk of their revenue flow as fewer elective tests come in, while they’ve had to pick up more costs with an influx of uncompensated Covid-19 tests. So as labs are being asked to do more, they have less money to do it.

Policymakers could step in and address some of these shortfalls. The ACLA called for stimulus funds and better reimbursements for labs — though not exactly a surprising proposal from a trade association for private labs, it’s an idea with which outside experts agreed. Jha backed more federal oversight and coordination to fix the various chokepoints, making sure labs, cities, and states are getting the funds and supplies they need to run tests.

Another issue is that the US simply needs better tests. An analysis in Mayo Clinic Proceedings suggested that the current tests could miss tens of thousands of potential Covid-19 cases with false negatives — and recommended more sensitive tests, a combination of testing, and new procedures.

Faster tests that can get results within minutes, not hours, for many samples at once would also help. And there still aren’t great, widespread tests to check for potential immunity, which could play a major role in ending social distancing. All of that will simply require scientific innovation and mass production to get faster, more accurate tests out there.

We need way more testing to get back to normal

The goal of widespread testing is not just to understand how widespread Covid-19 is in the US. It’s to leverage that information to help the country return to normal, or at least as close to normal as possible.

To be clear: Experts widely agree that some social distancing will be required until a safe and effective vaccine is developed, which could take as long as 12 to 18 months. Both the AEI and CAP plans make it clear that, for instance, large gatherings of 50 people or more should be restricted or banned, and people who are more vulnerable to coronavirus, like older adults or people with underlying health conditions, will have to remain vigilant.

But better testing and surveillance infrastructure would help ease up on social distancing for people who aren’t in those vulnerable groups.

Here’s how easing social distancing would work in practice, based on the AEI and CAP proposals and my conversations with experts:

  • First, we need extreme social distancing right now, as much of the country is already doing, to flatten the curve of new coronavirus cases. Ideally, we would never have been put in this position, because the US could have used testing and surveillance to prevent outbreaks from getting as bad as they are right now. As Jha put it, “What social distancing is doing is reversing — of course, with the cost of tens of thousands of Americans dying — the losses of two months of inaction.”
  • Second, the US could start easing social distancing and relying on testing and surveillance to make sure cases don’t spike up again. In practice, this doesn’t mean people would be packing sports stadiums or attending large concerts again, but it could mean that people could visit their friends and family, restaurants could open at reduced capacity, and maybe some schools and workplaces could reopen, potentially staggering when people are there.
  • Finally, as cases continue to flatten out and fall, social distancing could slowly be phased out more gradually. Chances are that the country won’t get back to where it was before coronavirus until a vaccine or some other treatment is available, but it will get closer and closer, with places with fewer cases perhaps going a little quicker. “You don’t go from one to 10 immediately,” Kuppalli said. “It’s crawl, walk, run.”
  • Once there’s a vaccine, things will go back to normal, more or less. Although, hopefully, the experience taught the world to be more prepared for a pandemic the next time — and there will be a next time. One idea, presented by the AEI report, is setting up a National Infectious Disease Forecasting Center, which would function like the National Weather Service, but for diseases, to help track outbreaks and mobilize responses.

One big caveat is the country has to be ready to go back to social distancing if necessary. Even the Asian countries that did a good job controlling coronavirus cases early on, like Taiwan and South Korea, have reportedly seen signs of a second wave of Covid-19. That’s in fact a reason more testing and surveillance is needed: It allows public health officials to see if social distancing is being pulled back too much or too quickly, giving them a warning that restrictions are again necessary to prevent an even bigger outbreak. After all, it’s strong testing and surveillance systems that allowed South Korea and Taiwan to detect an uptick.

“You want to make sure that whatever cases that do occur after social distancing occur at a slow enough clip that it doesn’t overwhelm hospital capacity,” Adalja said. “It’s not a question of whether there’s going to be more cases after you lift social distancing. They are going to occur. We just want them to occur at a rate that is manageable. And the only way that’s going to happen is with testing.”

Another way this plays out is that the country shifts back and forth between relaxed and stricter social distancing measures until a vaccine arrives. In a New York Times editorial, public health experts Ezekiel Emanuel, Susan Ellenberg, and Michael Levy compared it to pumping a car’s breaks on an icy road: “Either doing nothing or slamming on the brakes leads to an accident. So we pump the brakes — pushing on the brakes, then easing up, and then applying them again — and after three or four times we slow down enough to stop.”

That’s still better than a year or more straight of social distancing, since it would give the public a bit more freedom here and there. But it requires more testing and surveillance to know when it’s okay to ease the breaks and when they need to be pushed down once again.

Testing is only part of the story. Along with testing, the US will also need to build up public health infrastructure to trace sick people’s contacts and quarantine them. It might need to build living spaces where people can be voluntarily isolated or quarantined. People could download apps to their phones that would track them to see if they came in contact with anyone found to have Covid-19. The health care system also needs to be scaled up — to raise the line as well as flatten the curve. Shortages in PPE, including face masks, need to be fixed, particularly for health care workers.

But the linchpin to getting all of this right is testing. It’s the basic essential to tracking and controlling big disease outbreaks. So if we want to get our lives back to normal, it’s the first thing, experts say, we need to focus on — even today.

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