Next testing debacle: The fall virus surge

The U.S is now conducting more than 3 million coronavirus tests a week, a big improvement over the shortages and failures that worsened the pandemic this spring. But the country risks another dangerous testing deficit this fall when schools and businesses try to reopen.

Safely reopening schools and businesses could require up to 30 million tests per week, rather than the current three million, certain experts say. And if surging coronavirus cases collide with flu season, the demand could be even higher.

“We could have a situation that would stretch us,” said Nate Smith, secretary of the Arkansas Department of Health. “We’re likely to see people who are infected with both at the same time. No one knows exactly how that’s going to look.”

Coronavirus testing czar Brett Giroir — who is set to return to his regular duties at the federal health department later this month, with no replacement lined up — has repeatedly said that the U.S. has enough testing capacity. He predicts that the country will be able to test at least 40 million to 50 million people per month by September.

That’s a big number. But many public health experts say it’s not big enough to meet the likely demand, given that the virus is still spreading in much of the country, according to a number of public health experts. These experts aren’t just worried about the number of tests that labs can process. They are concerned about the logistical challenges of testing so many people, and the lag in setting up adequate contact tracing to find who may have been exposed.

The administration reversed a disastrous start on testing that saw everything from CDC lab contamination to shortages of special nasal swabs. Testing capacity now outstrips demand in some cities, in part because the public remains confused about who can and should be tested for the virus — or where tests are available.

The disconnect has emerged as President Donald Trump has repeatedly downplayed the importance of testing and shifted responsibility for it to the states. His administration has gone largely silent on the ongoing threat of the virus and is doing little to encourage Americans to get tested after potential exposure.

In the meantime, new coronavirus infections are spiking in at least 20 states as economies reopen and people gather in large crowds ranging from packed beaches to mass protests for racial justice.

Ashish Jha, director of the Harvard Global Health Institute, says Giroir’s prediction of 40 million to 50 million tests per month by September won’t be enough to tamp the virus down as the country returns to work and school.

“I believe that we will need two or three times that number of tests, if not more, if we're going to have a shot at keeping our economy open and keep our people protected during the fall and winter,” he said.

Others say that problems with organizing efforts to take samples from enough people and contact tracing overshadow any concerns about the number of tests U.S. labs can process.

“I don’t think testing capacity will be the issue,” former FDA Commissioner Scott Gottlieb said in an interview. “Collection will be the issue.” Expanding the ability of individuals to collect an at-home sample and mail it into a lab will be necessary to preserve scarce personal protective equipment and to ensure accurate testing, the former Trump official has argued.

Tom Frieden, who led the Centers for Disease Control and Prevention under President Barack Obama, cautioned that total testing numbers are only one aspect of the larger public health response — and governments must also make efforts to trace and isolate people who test positive to protect their families, friends and coworkers.

“Testing that isn’t integrated into a comprehensive program that follows up with isolation and contact tracing has very little value,” Frieden said.

While many states have beefed up their contact tracing programs in recent weeks, the country is far short of the 300,000 tracers that experts say is needed. Some states are still hiring and training staff weeks after reopening their economies, and many potentially exposed people have been unable or unwilling to share information when contacted.

Public health officials also need to keep a close eye on what percentage of tests are positive, which can indicate an emerging hot spot, focus testing on high-risk populations and respond quickly when new upticks in cases are detected, he added.

One former HHS official told POLITICO the administration and the CDC need to publicize national guidelines on how and when individuals should be tested for the coronavirus.

“It’s not just numbers, it’s making sure people know which test to use and when,” the official said. “We’re all talking about having enough testing for the fall, but what specifically are we aiming for here?”

In recent weeks, demand for tests has dropped off, even as capacity has improved and more Americans are resuming activities outside their homes. The Trump administration estimates that U.S. labs have the capacity to run 30 million coronavirus tests in June, but that they will only end up processing about half that number if the current pace of testing continues.

State and local officials say that months of hearing that only people with severe symptoms, people who had just traveled internationally and people who were in close contact with someone Covid-19 positive could access a test took a toll. Now that those shortages have been largely addressed, public awareness has not kept pace.

“There have been testing sites that just haven’t had a lot of traffic,” said Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories. “Not even necessarily in the last two weeks, but even before that we saw the general demand from people go down.”

Commercial labs have reported for several weeks that they have capacity to spare. Julie Khani, president of the American Clinical Laboratory Association, said that the number of labs running of coronavirus tests is increasing, and the facilities are adding new testing platforms.

Local governments are trying to boost demand by opening free testing sites and pushing their residents to get tested — especially as new hot spots emerge. But state officials say that ongoing shortages of swabs, chemical reagents and other supplies are hampering their efforts to develop the mass testing regime that will be needed in the months ahead, as the economy reopens and flu season begins.

“During flu season we know we have a significant number of people who present with symptoms that could be COVID-19, and those people will all need to be tested to prevent any onward transmission,” said Reed Schuler, a senior policy advisor to Washington governor Jay Inslee. “That will be true for every state — whatever your daily or weekly testing numbers are for the summer, they need to be much higher in the fall and winter.”

Without a comprehensive national testing strategy, cities and states are creating a patchwork of plans of how many people to test and when.

Pennsylvania, relying in large part on a National Guard “strike force,” plans to test every single nursing home resident and staff member in nearly 700 facilities by July 24, and to do the same for about 1,200 other long-term care facilities after that.

In the last few weeks, Washington, D.C., has deployed mobile testing units and opened free, no-appointment walk-up sites at city firehouses and curbside tents — including one downtown close to where thousands regularly gathered to demonstrate.

The new sites have led to a surge in demand. The city tested 5,985 people during the second week in June compared to just 1,534 the first week of the month. But that is still far below D.C.’s daily testing capacity of 5,500, the mayor’s office said. On most days, fewer than 1,500 people are tested at all public and private sites citywide — and DC’s positivity rate only recently dipped below double digits.

Public health experts say both real and perceived hurdles remain to ensure adequate testing.

“Just because a state happens to have capacity doesn’t mean there aren’t still barriers that exist around testing,” said Tom Inglesby, director of Johns Hopkins University’s Center for Health Security.

“Transportation could also be an issue when people may not have cars. The site may not be distributed in a way that allows access, particularly for people of low economic status.”

Several state officials told POLITICO that they are trying to move from a testing system based on individual demand to regular screening of broad groups of people, such as nursing home or prison residents — but ongoing supply shortages and technology delays are hampering those efforts.

“We’d like to be able to do widespread population-based testing, but for that we need a very accurate point-of-care rapid test with very good sensitivity,” said Rachel Levine, Pennsylvania’s health secretary.

“If we had an oral or nasal swab that can give results in 15 to 20 minutes, that could be deployed in hospitals, the food industry, manufacturing plants, maybe even schools. But for now, that's still aspirational.”

White House coronavirus coordinator Deborah Birx and other administration officials have said that antigen tests — which take minutes to process and can be administered in point-of-care settings — will be key to testing wide swaths of Americans in the fall.

The FDA has authorized only one such test so far, however. And antigen tests generally produce a higher rate of false results than the more complicated PCR tests now in wide use. That could limit the antigen tests’ usefulness.

“They should really only be used in symptomatic individuals, ideally, when you're in a situation where you're testing populations with high prevalence or high positivity rate,” Wroblewski said. “They could be really good for nursing homes or prisons that might be experiencing outbreaks when you want to segregate positive people quickly.”

Without the ability to predict what kinds of tests and how many will be available in the fall, state and local officials are using a broad range of tools to fight the pandemic. In Pennsylvania, for example, Levine is relying heavily on containment measures such as aggressive contact tracing and ramping up preparation for the flu season.

“We will double and triple our efforts to get people immunized for flu,” she said.

And in Washington State, Schuler says safely reopening schools will depend more on “infection control within facilities, cohorting and preventing mixing between populations” than testing alone.

“Even if you screen out several people at the beginning, you’re doing nothing to prevent community transmission that someone could acquire the very next week,” he said.

But there is no question that testing will remain a linchpin of the coronavirus response heading into the fall.

“What's most important to know is if testing is done in the right way: soon after patients feel sick, intensively in nursing homes in other concrete facilities, and followed with prompt isolation, contact tracing and quarantine,” Frieden said. “The essence of an effective public health response is quickly finding and acting on new information.”

Brianna Ehley contributed to this report.