March 30, 2020 -- On March 19, emergency management officials in Nashville gave reporters a glimpse of new drive-thru testing sites for COVID-19 that were expected to greatly expand the city’s ability to check sick residents for the deadly coronavirus, which is plowing through the U.S. and has crippled the economy.
More than a week later, the white tents erected in an old Kmart parking lot are still sitting idle. The site hasn’t been able to open yet because the city lacks testing supplies -- the specialized swabs that reach all the way to the back of a person’s nose and throat to collect a sample.
After a person has their nose or throat swabbed, those samples then have to sit in a bit of liquid called transport media to get to a lab. Across the nation, both of those things are hard to get. Labs trying to test coronavirus patients are also running out of specialized chemicals called reagents that technicians use to rinse genetic material out of the swabs that is then checked for the virus.
“What we need are the tests,” Alex Jahangir, MD, director of Nashville’s coronavirus task force, told The Tennessean newspaper in Nashville. “Every single day, many times a day, we’ve spoken with our state partners, the unified command, and I’ve called private labs. There is not a stone that we are not turning over to get these tests.”
After Gov. Bill Lee and the Tennessee Air National Guard intervened to supply the kits, the Kmart site was set to begin doing tests by appointment Wednesday. Two others were set to open Monday morning.
Across town at Vanderbilt University Medical Center, which developed its own in-house test for the new coronavirus, the hospital had increased capacity enough to process as many as 600 tests a day. To date, it has performed more than 6,000 tests -- almost half of all the testing reported in the state. But it, too, hit a wall when it ran out of a critical reagent. The hospital has since been able to reorder it, according to spokesperson Craig Boerner, but the shortage has caused a 2- to 3-day delay for results.
More than 2 months after the coronavirus epidemic landed in the U.S., not everyone who needs a test can get a test.
Call it a second wave of testing failures. After early problems at the CDC and the FDA delayed by weeks the rollout of COVID-19 tests to states, labs have run into problems again. This time, they are hunting for critical supplies. The supply shortages are hitting now just as many parts of the country were finally getting their testing programs running smoothly.
“It is a widespread problem across the U.S.,” says Eric Blank, DrPH, the chief program officer at the Association of Public Health Laboratories. He says that even big commercial labs like Quest and LabCorp are feeling the testing pinch. And as the virus strikes more countries, American labs are competing for supplies needed around the world.
In a statement, Quest Diagnostics says that it can currently run about 30,000 tests per day and that it has reported results for about 106,000 COVID-19 tests since March 9, when it started processing them. The current wait for results is 4-5 days.
“Although we are rapidly expanding testing capacity, demand for the testing is growing faster, and we cannot accommodate everyone who wants testing and meet tight turnaround time expectations,” the company said.
LabCorp says it can perform around 20,000 tests per day.
‘I Have No Idea When I Will Get the Tests Back’
The shortages mean that hospitals and health departments are still prioritizing people who can get tests. New York City, for example, is testing only hospitalized patients, Blank says.
“It is being addressed. We would hope that within the next couple of weeks, we would see some easing of that, and that’s about as optimistic as we can make it,” he says.
Julie McSweeney, a 50-year-old school counselor from Austell, GA, had been struggling for a few days with diarrhea and a sore throat. On Sunday, March 22, she woke up with shortness of breath that was so severe that she went to a local hospital for help. Tests for flu and strep throat were negative, and because her symptoms were serious, the ER doctor referred her for a COVID-19 test.
She was able to get swabbed the next day, through a drive-thru site operated by the county health department.
“I have no idea when I will get the tests back,” she says. The hospital told her it could take a week to 10 days.
The wait has been an anxious one.
“My big concern is my family,” she says. “What if I gave it to them? They seem fine right now, but you just don’t know.”
Lack of testing has been devastating to the U.S. Without enough testing, public health departments can’t effectively see the spread of the virus. They also can’t isolate patients to break the chains of transmission. Without surveillance and suppression, the only weapon left to fight the virus is a blunt one -- social distancing. Experts believe stay-at-home orders may now need to last for months to ease the epidemic that’s unfolding here.
“You cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected,” WHO Director-General Tedros Adhanom Ghebreyesus said in a March 16 media briefing. “We have a simple message for all countries: test, test, test. Test every suspected case.”
According to the latest data gathered by the COVID Tracking Project, more than 540,000 tests have been run in the U.S. But those tests have been done unevenly. Arkansas, for example, has only run about 2,000 tests, while Nevada, which is just slightly larger in terms of population, has done more than three times that many. Mississippi, which is slightly smaller population-wise, has conducted about 50% more.
Ashish Jha, MD, a professor of global health at Harvard’s T.H. Chan School of Public Health, says his school’s studies estimate that the U.S. should be doing 150,000 tests a day. We’re only about two-thirds of the way there now, according to the latest data collected by the COVID tracking project.
Lack of Protective Equipment
“The CDC … is not giving us the resources to do it properly -- it’s very frustrating,” says Anjali Viswanathan, MD, an internal medicine doctor in a private outpatient practice in Roselle, NJ.
The office did not have the special “nasopharyngeal” swabs that the CDC recommends using for the diagnosis with a flexible shaft to reach back into the nasopharynx.
LabCorp suggested that Viswanathan’s staff could use viral nasal swabs to test for COVID-19. “These tests are similar to the viral swabs we use in our office to detect influenza, adenovirus, and other viruses and are different from the ones used by the health department,” says Viswanathan.
In the end, she decided against having her staff do the testing because they lacked the full personal protective equipment.
But when a third patient with asthma and chronic obstructive pulmonary disease (COPD) asked to be tested, Viswanathan and her staff decided to try the viral nasal swabs and keep their distance. The 48-year-old man, who was also a cigarette smoker, had a higher risk of pneumonia from COVID-19, says Viswanathan.
“He pulled into our parking lot and took a plastic bag containing the test out of a separate box we had placed there. From our doorstep at least 15 feet away, we instructed him to do four swabs -- for COVID-19 and to rule out influenza and strep. We then put the test in a special container that LabCorp provided.”
His test was negative. “When I discussed the result with him, I still told possible,” says Viswanathan.
Since she did the nasal swab, the CDC revised its guidance to allow health care workers or patients to collect nasal swabs as an acceptable alternate to the nasopharyngeal type.
Adam Wheeler, MD, is chief executive officer and medical director of Big Tree Medical Home, a direct primary care clinic in Columbia, MO. During the pandemic, his clinic is staying open but is doing only online, over-the-phone, and drive-up care. When Wheeler received 20 diagnostic tests from Quest in mid-March, he created a drive-up testing area in his parking lot, and the medical staff tested about five people. They shared his N95 construction mask, which he acknowledged was a “suboptimal” practice.
But once University of Missouri Health Care and Boone Hospital Center opened their free drive-thru testing stations, Wheeler started sending patients there for testing. “They have a 1-day notification of test results, compared to up to 7 days for Quest,” says Wheeler.
More Tests Coming
The good news, according to Blank, is that all 50 states, along with Puerto Rico and Guam, are at least able to test. But many are still rationing scarce supplies.
Georgia, for example, is prioritizing testing for certain groups, including those who are hospitalized with severe illness, health care workers and first responders, and those who are living in group settings where the disease may spread quickly. Others can be tested with a referral from a doctor and an appointment at a testing center.
Abbott Laboratories announced Friday that the FDA has authorized the use of its new COVID-19 test that can be done in doctor’s offices and gives results within a few minutes. The test runs on the company’s ID Now system, which is already used across the country to run quick tests for the flu, strep throat, and respiratory syncytial virus. Two other companies, Mesa Biotech and Cepheid, have also announced FDA authorizations for rapid point-of-care tests.
But even these rapid tests won’t be available everywhere, at least for a while.
Abbott, for example, says it will start delivering 50,000 tests a day starting on April 1, and it will be working to scale to more than 1 million in a month.
Demand is almost certainly many more times that.
Abbott says it is working with the Trump administration to send the tests to areas where they will do the most good.
Who Gets Priority for Testing?
States that were contacted for this story said they follow CDC guidance to determine who should get a test. According to the CDC, current priorities for testing, in order, are:
- Hospitalized patients
- Health care workers who have COVID-19 symptoms
- Patients in long-term care facilities with symptoms
- Patients 65 and over with symptoms
- Patients with other health conditions with symptoms
- First responders with symptoms
- Critical infrastructure workers with symptoms
- People who do not meet any of the above categories with symptoms
- Health care workers and first responders
- People with mild symptoms in communities that have high COVID-19 hospitalizations
- People who don’t have symptoms
The CDC also says that doctors should use their judgment to determine if a patient has signs and symptoms of COVID-19 and whether they should be tested. COVID-19 is a reportable disease, so any doctor who runs a test must report the results to the state health department.
The latest CDC guidance on testing to clinicians recommends working with their state and local health departments to coordinate testing through public health laboratories, or working with clinical or commercial laboratories to obtain tests.
But those avenues came up short when Viswanathan tried to get testing for a patient who seemed like a textbook case.
The 28-year-old woman, a single mother, had visited Italy, including Milan, for 10 days in early March and then had a cough, a low-grade fever, and shortness of breath. The woman also worked at Newark Airport screening people, so she was concerned about infecting others.
Despite calls to the New Jersey Department of Health, two hospitals in New Jersey, including Trinitas Regional Medical Center where Viswanathan is an attending doctor, and three private labs -- Quest, LabCorp, and Accu Reference -- the answer was the same: Her patient was too young.
Viswanathan’s practice has since received 15 diagnostic test kits with the nasopharyngeal swabs to test for COVID-19. Her staff have also scrounged up a few N95 masks. The staff will give the new tests, but more will be needed along with personal protective gear.
In addition, a new drive-thru testing center has opened in New Jersey’s Union County, for residents only, in partnership with local universities and hospitals.
Viswanathan says testing results can change public behavior.
“At least having something on a piece of paper that says ‘you have this virus, stay at home and don't infect others,’ especially the elderly grandmother or the immunocompromised relative, could go a long way in the coming months towards prevention, which is my ultimate goal. Knowing who is positive can keep these patients from spreading it,” she says.
Easier access to testing and more accurate numbers of who has the disease in the general population, like in South Korea, “could keep our vulnerable population safer, and contain the virus somewhat more quickly.”
Janice McDonald contributed to this report.