States on their own for virus testing
Procedures vary widely due to a lack of federal guidance
In Maryland, drive-thru coronavirus testing sites are now open to all residents, whether or not they show signs of illness.
In Oregon, by contrast, officials have said that generally only people with symptoms of COVID-19, the illness associated with the coronavirus, should be tested — even in the case of front-line health care workers.
In Rhode Island, officials have proactively tested all of the state’s 7,500 nursing home residents, including those with no symptoms, and are developing plans to test more people in high-risk workplaces, such as restaurants and grocery stores.
The wide range of approaches across the country comes as the federal government has offered little guidance on the best way to test a broad swath of the population, leaving state public health officials to wrestle on their own
with difficult questions about how to measure the spread of the virus and make decisions about reopening their economies.
Faced with conflicting advice from experts in the field, states are using different tests that vary in reliability and have adopted a variety of policies about who else should get tested and when — particularly when it comes to asymptomatic people who are considered low-risk for the illness.
“The states are on their own,” said Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories, noting that the kind of guidance the federal government routinely gives in screening for flu and other outbreaks “has been absent” in the COVID-19 pandemic. “There has been no coordination.”
So far, about 460,000 Americans are being tested a day — 1.5 percent of the population, and still shy of the 900,000 to 30 million that experts say need to be tested daily to capture the extent of the virus’ spread.
“The case numbers we’re seeing are probably massively undercounted,” said Divya Siddarth, a researcher who helped devise a testing strategy for Harvard University’s Safra Center that emphasizes finding and suppressing the disease in areas with fewer cases. “These (lower prevalence) regions are likely to reopen, and they’ve barely done any tests.”
Under a law passed earlier this year, the Trump administration is required to develop a national testing strategy. But an 81page document submitted to Congress by the Department of Health and Human Services late last month was not released publicly and offered few detailed recommendations.
The Washington Post obtained a copy of the plan, which set a goal for states of testing at least 2 percent of their residents in May and June. But how to meet that benchmark and whether to go further was left up to state leaders who were required to submit plans this month to HHS for review.
The Centers for Disease Control and Prevention has recommended universal testing for residents of nursing homes, which have been especially hit hard by the coronavirus. But the HHS document said the CDC was still working on guidelines for other large populations of mostly asymptomatic people — including at universities, prisons and “critical infrastructure worksites” — as well as those for integrating testing into reopening work places.
Mia Palmieri Heck, a spokeswoman for HHS, said the federal government “has provided prescriptive criteria about testing asymptomatic individuals when they affect highly vulnerable populations such as individuals who live in nursing homes, working in or visiting health care clinics or communal dining spaces.” She added that federal experts have also been advising states on developing plans to more broadly test people without symptoms to determine community spread.
The question of asymptomatic testing is particularly tricky given that the CDC late last month said that its researchers now believe as many as 35 percent of people infected with the coronavirus never show symptoms of disease.
“In some ways, this may be the Achilles’ heel of the entire testing challenge for this virus,” said Ashish Jha, director of the Harvard Global Health Institute, who has advocated for increasing the number of people getting tested.
Local and state health officials worry that the lack of coherent strategy could result in tests becoming widely available for the affluent, while remaining limited for those with fewer resources, including minority communities that have already been disproportionately affected by the virus.
As tests have become more available, officials have begun to recommend that anyone who is experiencing signs of illness, even a mild cough or sore throat, get one.
The goal is to identify and quarantine people with the disease, and then use contact tracers to track down people who have interacted with that person and quarantine them as well.
“Testing is just part of a comprehensive strategy,” former CDC director Tom Frieden said. “As you emerge from that sheltering situation, you box the virus in.”
But when it comes to testing people without symptoms, state recommendations vary.
At least half of states aim to test people identified as contacts of known positive cases, according to a Post tally, as was recommended in new guidance from the CDC this week. But many others tell those people to self-isolate for 14 days.
“Every state is figuring this out on its own, little bit by little bit,” said Philip Chan, medical director for the Rhode Island Department of Health.
A number of states and large cities, such as Detroit and Los Angeles, have opened drivethrough testing sites like those offered in Maryland.
Experts have warned that drive-thru sites often fail to collect enough information from those tested to follow up effectively. They also prioritize people who choose to show up, tending to mean tests go to better educated and informed residents and not necessarily those most likely to have been exposed to the virus.
For states looking to figure out who to test and when, advice from national experts has been abundant — but not always consistent.
Proposals from academics and other experts vary widely in their recommendations of the numbers of tests that should be performed each day, and many do not offer guidance about who should be tested.
“We should quickly get resources to places where the disease can be suppressed, then backfill tests in the places currently overwhelmed,” said Glen Weyl, an economist at Microsoft, who worked on the Harvard University proposal. “It’s like a war — you have to have more troops than the enemy in order to win a battle.”
Other researchers have proposed blanketing the country with tests, with a focus on places experiencing clear outbreaks.
Paul Romer, an economist at New York University, said there should be mass testing in hot spots that is quickly expanded to near-universal, constant testing for everyone — 23 million tests a day, noting that the cost of tests have dropped.
“It would be feasible if we just invested and made it happen,” he said.
Still, many experts agree that completely random asymptomatic testing is not an effective strategy.
“There’s been far too much of this group think around, ‘test, test, test,’ without understanding what it’s accomplishing,” said Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “You need the right test, at the right time, for the right reasons.”