With his car keys, Geoff Baird attacked a box that had just come from China to the parking lot at a UW Medicine office in Seattle’s Northgate neighborhood. Baird, who manages UW Medicine’s laboratories, ripped greedily into the cardboard.
“Tubes and swabs!” he called out, holding a vial with hot-pink liquid sloshing inside.
Amazon workers unloaded another 83 boxes filled with critical COVID-19 testing kits. Baird rushed to his lab to verify their quality.
“Hopefully it’s not Q-tips and Kool Aid,” he said.
The unboxing was a climactic scene in a frenzied, weekslong global logistics project involving Anita Nadelson, a Seattle businesswoman who typically imports items like dry erase boards; a mystery doctor who is a brother-in-law of the boss of Strawberry, a Chinese saleswoman and business contact of Nadelson; and Jeff Wilke, one of the most powerful executives at Amazon.
Their story and the international cast of characters brought together for this public-health mission illustrates the lengths authorities and scientists are willing to take to increase testing, perhaps the most important metric as officials consider lifting social- and physical-distancing restrictions.
“If you loosen up before you have the ability to really ramp up your testing and case finding and contact tracing, this epidemic can rebound quite vigorously,” said Dr. Jeff Duchin, health officer at Public Health – Seattle & King County.
But without test kits, laboratories can’t produce more results.
For weeks, Washington state has been short on testing kits containing nasopharyngeal (NP) swabs and a liquid that preserves specimens for diagnostic testing.
Baird, the interim chair of the University of Washington Department of Laboratory Medicine, said the UW Medicine Virology Lab can process some 5,000 specimens a day. On Tuesday, the lab processed just 1,953, according to the lab’s Twitter account.
“We can do more testing than what we are doing,” Baird said, adding that in recent weeks he had been barraged with requests from health officials and hospitals for testing kits. “It’s an important bottleneck.”
The solution he sought underscores just how fragile the medical supply chain remains, how competitive the market for has become.
Shortages of everything
The nationwide shortages of testing materials fall into two main categories: the supplies needed to take a sample and transport it to the laboratory, and the items needed for analysis.
“It’s like everyone is trying to bake a cake at the same time,” said Dr. Yvonne Maldonado, a professor of health research and policy at Stanford Medicine. “… There are shortages of everything in the recipes.”
NP swabs — thin sticks with furry tips that medical professionals stick up a person’s nose until they can scrape the palate where the nasal and oral cavities meet — are running low nationwide.
Once the sample is taken, it’s placed into a vial with a solution called viral transport media, meant to keep the specimen from drying and disintegrating.
Right now, orders for transport media are backlogged. To make up for the shortage, some labs have been producing their own solution. Nonetheless, many hospitals are still lacking.
“Even though anyone can get tested, people who have test kits are essentially rationing them to patients with the most severe symptoms,” said Cassie Sauer of the Washington State Hospital Association.
On the analysis side, a chemicals shortage has plagued testing nationally for about a month, said Omai Garner, the lab director of clinical microbiology for UCLA Health.
“It has been a constant struggle, a constant negotiation with vendors,” said Garner, whose lab performs about 800 COVID-19 tests a day.
Under the initial test procedure approved by the Centers for Disease Control and Prevention (CDC), labs needed a particular chemical to extract RNA from the virus, Garner said. Supplies quickly dwindled.
The federal government’s approval of more types of tests partially closed that gap. Now, labs depend on commercial-testing manufacturers to provide kits with a proprietary assortment of solutions or chemicals, collectively known as reagents. The manufacturers themselves are now running short on reagents. That’s slowed the production of lab test kits.
“If companies don’t have enough manufacturing capabilities to meet the need, then that has to be addressed at the federal level,” Garner said.
In Washington state, hospitals have mostly had to fend for themselves in the marketplace for testing supplies, Sauer said, although the state has been procuring some materials. There’s no central way to monitor facilities’ testing inventory in the state.
Shortages have been nearly constant. Less than a week after the COVID-19 outbreak was first identified at a King County nursing facility, local health officials already were asking for testing kits.
Public Health – Seattle & King County on March 4 sent state officials a list of supplies it needed for the Life Care Center of Kirkland staff, asking for 200 nasal and throat swabs, and the same number of test tubes to transport the specimens, according to records reviewed by The Seattle Times.
During roughly two weeks in March, government agencies and healthcare organizations submitted at least 45 requests for swabs or testing supplies, according to a Times review of Washington state Military Department request logs.
“I know how to get anything made”
The path toward new swab supplies began with a simple gesture from a friend.
“… Been asking my factories in China to try to get N95 masks,” Nadelson, co-owner of a design firm, texted Baird on March 16. A supplier had offered 30. “Is that worth having sent, or wait for more?”
Better to wait, Baird wrote. N95 respirators are needed by the thousands.
“The real shortage nationally is nasopharyngeal swabs,” he told Nadelson, launching her on a quest.
Nadelson began by scrolling through Alibaba, the online Chinese commerce giant, then contacting and whittling down the factories she thought could provide equipment while texting Baird for technical advice.
“We work with 25 factories in China,” Nadelson said of her company, Three By Three Seattle. “I know how to get anything made.”
She soon settled on the most promising manufacturing prospect, and asked a trusted sales contact known to Nadelson as Strawberry, who works nearby in Shenzhen, to check out the plant.
Strawberry collected sample test kits, but struggled to ship the liquid. With air freight disrupted, it would take weeks for samples to arrive in Seattle.
Then, Strawberry hit on a promising lead. Her boss had a family connection to a doctor in Hubei, the Chinese province hardest hit by COVID-19. The doctor, whose identity is not known to Nadelson or Baird, could place an order for swabs with the factory, which also supplied health workers in Wuhan. Were they interested?
“Geoff decided early on he was going to take this big leap of faith,” Nadelson said. They put in an order for 80,000 kits for UW Medicine, hoping to distribute the kits throughout the state, and Seattle Children’s added to their order another 20,000 kits.
Nadelson fronted $125,000 later to be reimbursed by UW Medicine.
But layers of red tape, customs regulation and international shipping logistics problems — complicated by COVID-19’s impact on worldwide freight and supply chains — remained troublesome, and Baird wanted the tests stateside, and fast.
He fired off an email to Jeff Wilke, CEO of Worldwide Consumer at Amazon, whose contact information Baird had from a mutual connection.
Amazon has made a humanitarian and a public relations push to source and deliver medical supplies in COVID-19’s wake.
On the afternoon of March 30, Baird “asked if we had any resources in China that could fly them here in a hurry,” Wilke said in a statement to The Seattle Times. Amazon found space on a chartered flight last Saturday.
Baird obsessively tracked the flight’s progress to Seattle.
“It could be the great Shanghai airlift of 2020,” Baird said, while the supplies were airborne. Or, “I could have bought 100 grand in packing peanuts.”
At first, disappointment
After the jubilant unpacking and back at the UW Medicine Virology laboratory, the mood shifted. A crestfallen Baird met in the laboratory lobby with Dr. Jason Love, a pathologist for MultiCare hospitals in the Tacoma area.
Instead of NP swabs, the Chinese factory had sent nasal swabs, for use in the nostrils.
“Cotton,” Baird said, as if it were a dirty word, fearing the swabs contained material not suited for COVID-19 testing.
“I’m disappointed,” Love said, trying to figure out how he could stretch strained supplies further.
But spirits for both men lifted on Monday amid new developments.
Baird determined both the nasal swabs, which were actually polyester, and the transport media were acceptable for COVID-19 testing.
“It’s going to work for us and help a lot of people,” Baird said.
And a new preliminary preprint study of about 500 patients at the Everett Clinic, who sampled themselves inside their vehicles, showed that nasal swabs could be effective.
Sample collection for new coronavirus tests with nasal swabs were nearly as accurate as sampling as the NP swabs, according to test results from a study published Monday on the preprint server medRxiv, which has yet to be peer-reviewed. The preliminary study did not examine asymptomatic patients.
Dr. Yuan-Po Tu, the lead author of the preprint, said sampling with nasal swabs could help preserve key personal protective equipment. Medical professionals must wear protective equipment when administering NP swabs because patients often cough or sneeze during the more invasive procedure.
“By having the patient collect the specimen themselves, all you need is a surgical paper mask and you just stand back and you watch,” Tu said.
Michael Teng, an associate professor in internal medicine at the University of South Florida who was not involved in the preliminary report, said its findings track with similar studies of other respiratory viruses, and added that nasal swabs could be less effective at detecting the virus in people without symptoms, an important consideration as public health strategies increasingly rely on broader testing.
Baird said there is no perfect sampling method. “All tests have false negative rates because the virus lives in the lungs” primarily.
Also on Monday, experts began to suggest COVID-19 cases may have crested in volume and started to trend downward. That eases demand on test kits.
Love on Wednesday said he was feeling more optimistic about swab supply because his lab was no longer maxing out its machinery’s capability. COVID-19 testing needs have fallen off at his hospitals significantly.
Duchin said health officials would take 20,000 of the swabs procured by Baird and Nadelson, saying they would fill gaps in supply at places like shelters and long-term care facilities.
Also on Monday, a package arrived that buoyed Baird’s mood. It included samples of NP swabs from one of the first factories Nadelson contacted in March.
“They’re perfect,” Baird said. “I think we’ve opened up a supply line.”
Staff reporters Ryan Blethen and Daniel Gilbert contributed to this report.