Four months into the U.S. coronavirus epidemic, tests for the virus finally are becoming widely available, a crucial step toward lifting stay-home orders and safely returning to normal life. But while many states no longer report crippling supply shortages, a new problem has emerged: too few people lining up to get tested.
A Washington Post survey of governors’ offices and state health departments found at least a dozen states where testing capacity outstrips the supply of patients. Many have scrambled to make testing more convenient, especially for vulnerable communities, by setting up pop-up sites and developing apps that help assess symptoms, find free test sites and deliver quick results.
But the numbers, while rising, are well short of capacity – and far short of targets set by independent experts. Utah, for example, is conducting about 3,500 tests a day, a little more than a third of its 9,000-test maximum capacity, and health officials have erected highway billboards begging drivers to “GET TESTED FOR COVID-19.”
Why aren’t more people showing up? “Well, that’s the million-dollar question,” said Utah Health Department spokesman Tom Hudachko. “It could be simply that people don’t want to be tested. It could be that people feel like they don’t need to be tested. It could be that people are so mildly symptomatic that they’re just not concerned that having a positive lab result would actually change their course in any meaningful way.”
Experts say several factors may be preventing more people from seeking tests, including a lingering sense of scarcity, a lack of access in rural and underserved communities, and skepticism about testing operations.
“We know there’s a lack of trust in the African American community with the medical profession,” said Ala Stanford, a pediatric surgeon in Philadelphia who started a group to provide free testing in low-income and minority communities, which have been particularly hard hit by the virus. The effort, which offers testing in church parking lots, has serviced more than 3,000 people in recent weeks.
“You’ve got to meet people where they are,” Stanford said.
Another major hurdle: lingering confusion about who qualifies. In the earliest days of the outbreak, Americans were told that only the sickest and most vulnerable should get tested while others should stay home. Last month, the Centers for Disease Control and Prevention relaxed its guidelines to offer tests to people without symptoms who are referred by local health departments or clinicians.
Some states have since relaxed their testing criteria dramatically. Georgia Gov. Brian Kemp, a Republican, has encouraged “all Georgians, even if they are not experiencing symptoms, to schedule an appointment.” And Oklahoma Gov. Kevin Stitt, a Republican, urged residents earlier this month to “call 2-1-1 and find a location close to you, even if you don’t have symptoms and you’re just curious.”
Elsewhere, officials scarred by shortages have been hesitant to follow suit.
“A lot of states put in very, very restrictive testing policies . . . because they didn’t have any tests. And they’ve either not relaxed those, or the word is not getting out,” said Ashish Jha, who directs the Harvard Global Health Institute. “We want to be at a point where everybody who has mild symptoms is tested. That is critical. That is still not happening in a lot of places.”
According to the COVID Tracking Project, the nation is currently testing about 330,000 people a day, a rate that, if sustained, would cover about 3% of the population a month. That’s double last month’s average, achieving a goal set by the White House, but still far short of the number most independent analysts say will be needed to avoid another wave of death and illness in the months ahead.
Last week, Jha and other Harvard researchers estimated that the United States should be testing at least 900,000 people a day, or about 8% of the population per month. At that rate, they say, local officials would get a clear sense of the spread of the virus, would be able to detect clusters of infection in the early stages and could move to isolate people who test positive or have been exposed, a process known as contact tracing.
A White House estimate, obtained by The Washington Post, shows the nation has sufficient lab capacity to process at least 400,000 tests per day, and potentially many more. But in surveying the states, The Post found that few are testing at full capacity. In 20 states that provided detailed information, the number of tests performed was roughly 235,000 per day lower than their technical capacity, with the biggest gaps in California and New Jersey.
Lab capacity remains untapped for many reasons, including lingering supply shortages. While most states say they are now able to test people in hospitals, nursing homes, prisons and other front-line settings, many continue to be hampered by a lack of personal protective equipment (PPE), nasal swabs and reagents, the chemicals necessary to process tests.
California, for example, has sufficient lab capacity to conduct nearly 100,000 tests a day, but is averaging less than 40,000. At a news conference last week, Gov. Gavin Newsom, a Democrat, cited continuing “supply-chain constraints.”
And in Chicago, a major chain of urgent-care clinics temporarily halted mobile testing last week when it ran out of test kits. “We are currently unable to test for COVID-19 in Illinois,” said a message posted Sunday on the website of Physicians Immediate Care, adding that the chain hopes to resume testing Monday.
As states trying to encourage people to return to normal life ramp up testing, experts worry that widespread shortages could return.
“Right now, in some locations in this country, they don’t have adequate testing to test all symptomatic patients,” said Angela Caliendo, board member of the Infectious Diseases Society of America and a vice chair in the Department of Medicine at Alpert Medical School of Brown University. “So when you open up and you start testing people that are asymptomatic, you’re going to put a lot of pressure on the supply chain.”
The federal government is working to remedy the problem, including by investing $75.5 million through the Defense Production Act to increase swab production. The Food and Drug Administration has eased regulations to permit use of swabs made from polyester in addition to nylon and foam, and the Trump administration has pledged to supply 12.9 million swabs directly to states this month, a promise many governors are banking on.
Last week, President Donald Trump announced that the federal government will distribute $11 billion to help states get additional supplies, part of a $25 billion testing budget approved by Congress.
“I said from the beginning that the federal government would back up the states and help them build their testing capability and capacities, and that’s exactly what’s happened,” he said.
But reagents remain a problem. In the District of Columbia, health officials have access to a public health lab, a research lab and six hospital labs, which together have the capacity to process at least 3,700 tests per day, said LaQuandra Nesbitt, director of the D.C. Department of Health. But reagents must match the labs’ testing machines; in recent weeks, the labs have managed to purchase only enough to conduct 1,500 tests per day.
Still, even that supply has outstripped demand, with about 1,000 D.C. residents seeking tests each day. In late April, the city expanded its guidelines to permit grocery store clerks and other critical workers to get tested regardless of whether they have symptoms. Further changes prioritized people over 65 and with underlying health conditions. Meanwhile, former first lady Michelle Obama has urged people in robocalls to take advantage of the free service.
Testing has been similarly slow to ramp up in Virginia, where guidelines posted on the state’s website limited testing mostly to people with symptoms who were hospitalized, living in communal settings or working as health-care providers.
Hilary Adams, a 28-year-old Web coordinator for the American Society of Clinical Oncology, said her doctor refused to order a test in late April even though she had a sore throat and headache, suffers from asthma and lives with her father, who had tested positive. She was told to stay home and quarantine.
“Just living with that level of uncertainly and anxiety was really, really stressful,” Adams said.
After being criticized for low testing rates, Virginia officials posted relaxed guidelines on May 5. That day, Adams’ doctor finally ordered a test – which came back negative. Virginia has since reported an increase in testing from about 4,000 per day to nearly 7,000.
“We’ve said from the very beginning that we needed more PPE. We have that now. Then we said we needed more testing supplies. We have that now,” said former Virginia health commissioner Karen Remley, who co-directs a testing task force appointed by Gov. Ralph Northam, a Democrat. “Now we’re working on education and bringing people to the table.”
A national strategy could make that effort more effective, said Danielle Allen, director of Harvard’s Edmond J. Safra Center for Ethics, which last week published a $74 billion road map that calls for 24-hour contact tracing and isolation facilities for people who test positive. Although many states are building those services, the patchwork approach means scarce resources may not be efficiently deployed.
For example, inviting anyone to get tested, rather than focusing on hot spots or areas of high vulnerability, is “not going to be that valuable,” said Jan Malcolm, the health commissioner in Minnesota, where policymakers are building toward 20,000 tests per day and considering hiring more than 4,000 contact tracers.
Kentucky illustrates the transition many states are making. In the first few months of the pandemic, the state had major shortages of testing materials and had to send many samples out of state for processing. Then in March, Gov. Andy Beshear, Democrat, tapped a pair of local lab companies to scale up operations.
Gravity Diagnostics, a 140-person firm in Covington, blew out a wall to expand its main lab and hired 15 more people. It has processed nearly 40% of all tests in the state, as well as tests conducted at Kroger mobile health clinics across the nation.
By last week, Beshear said Kentucky had secured all the components needed to further ramp up testing, including a significant supply of swabs from the federal government. With businesses starting to reopen, Beshear is urging everyone to get tested. The state recorded an average of 5,700 tests a day over the past week, a sharp uptick.
“We can provide all the capacity in the world,” Beshear said. “You’ve got to show up and take a test.”
The story is similar elsewhere. In Wisconsin, officials last week listed a daily capacity of 13,400 tests, spread across 52 labs. But daily reported tests have averaged only around 4,800. To bump up the numbers, Gov. Tony Evers, a Democrat, has ordered the National Guard to set up mobile testing sites and told doctors to test anyone with symptoms.
In Florida, tests are averaging about half the statewide capacity of 30,000 per day. Jared Moskowitz, director of Florida’s Division of Emergency Management, said the state has opened sites to improve access, including one in front of Hard Rock Stadium in Miami Gardens, where he spoke at a news conference this month. Still, Moskowitz acknowledged that “less and less people are coming to these sites, and we’ve seen that decline in the numbers.”
And in Arizona, 5,400 people turned out for a Saturday “testing blitz” held May 2 in dozens of community locations for people with symptoms or who think they have had contact with the virus. Health officials had been hoping for 10,000, and have since extended the blitz to every Saturday in May.
Although Massachusetts has tested nearly 6% of its population – one of the highest rates in the nation – even Gov. Charlie Baker, a Republican, has been frustrated by a lack of interest in testing. Earlier this month, Baker chastised Bay State residents for refusing tests even in highly vulnerable settings such as nursing homes.
“There’s some people who, for whatever reason, don’t want to be tested,” Baker told reporters. “And we’re just going to have to find a way to work through that.”
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The Washington Post’s Jenna Portnoy and Chris Mooney contributed to this report.