All along, we’ve been asking, “Can testing get us out of this?” — like dieters asking if the right pill could get us out of exercise and salads.
All along with coronavirus, the answer has been, “No, it cannot.”
State and local governments in Colorado are moving fast to meet the latest pandemic surge with convenient, rapidly expanding testing centers. But they’ve been doing that all along. Meanwhile, hospitalizations have surged to record levels, contact tracing efforts are buried in case files, and counties already imposing curfews warn if behavior doesn’t change, new restrictions are next.
Threads are starting to show where the rubber of widespread mobile testing meets the hard road of spotty supplies of the most effective tests, lack of lab technicians and overwhelmed contact tracers doing triage on their own call lists. Millions of new rapid tests delivered to the state might be useful in health care settings, but are not accurate enough for population-level control.
Public and private labs can’t keep up with testing samples, meaning results have slipped from 24 hours late in summer to 72 hours and beyond — which negates any gains from quarantining while awaiting results, as an impatient public exits isolation to recirculate the virus.
To the experts, the correct answer has always been, “Testing combined with austere behavior change can get us out of this.” Doing enough testing to find asymptomatic cases, and getting those people out of circulation and retested seven days after exposure, remains at the core of fighting COVID-19.
Occasional blips in the testing supply chain — Jeffco Public Health, for example, had to shut down one of its centers nearly as soon as it opened one day last week for lack of test kits — are not what concerns Gov. Jared Polis, his epidemiology team or local and national public health directors. What bothers them is casual parties, with multiple couples, held indoors. And people lingering in retail or service centers without masks. And symptomatic spreaders not staying home.
“We need to do better, going back to what we know works,” Polis said late last week.
Testing is just one piece of the puzzle
“Testing alone is not going to get us out of this situation,” said Dr. Eric Toner, a senior scholar with the Johns Hopkins Center for Health Security and a senior scientist in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. “It is among the things we need. We still need all the other pieces.”
Toner, who tracks the pandemic across multiple states, said Colorado is “having a very concerning surge in cases right now,” and an “alarming increase in hospitalizations,” waves that continued to build over the weekend.
Colorado’s current COVID-19 hospitalizations passed 1,000 Sunday, a grim new high, likely to be broken each day this week. The seven-day rolling average of test positivity rates is above 11% and rising — virus-control protocols call for increasing tests and raising various public restrictions until test positivity drops below 5%.
Further concerning health officials is that nationally, there’s nowhere to hide. Similar surges are happening in dozens of states, and the national test positivity rate rose to 9.5% despite a huge increase in testing.
If Colorado cases keep rising, Toner said, “it’s going to be very hard to control. You’re already in this exponential growth stage and it really needs to be curtailed quickly. You’re not testing enough to keep up with all the spreading cases. If you were, the positivity rate would be steady or dropping.”
Doing enough testing to drive positive-test percentages down means the state is catching enough cases, early enough, to slow dangerous illness.
Colorado’s numbers might be headed in a different direction if more residents were acting like Julia Sandoval, 24, and her father, Frank. Julia, from Denver, works at a nursing home, and found out over the weekend that a friend and coworker tested positive. That’s triple alarm bells for anyone serious about coronavirus control, as nursing home outbreaks among the most vulnerable over-65 population drove Colorado’s worrisome spring peak.
“I wanted to be proactive and on top of things because I’m a single mom, and I can’t afford to get my residents sick, either,” Sandoval said.
Here are the hurdles Julia faced in trying to do the right thing: The nursing home offers weekly testing, but it wasn’t scheduled until Tuesday. Her health insurance is Kaiser, but they told her she needed an appointment for a test and would have to wait. She scouted the internet for immediate testing.
Frank drove Julia to a free testing site Denver was supposedly offering Saturday morning at Paco Sanchez Park, convenient to her house, but the site was closed. Someone suggested they go to Lincoln High School, so they sped over and got in a car line already overflowing parking lot at 10:15 a.m., for a site opening at 11 a.m.
The line moved fairly quickly, though by the time they left, the car line was well down the block and snaking through the neighborhood. Frank, meanwhile, gets tested every week at work.
Julia was told she’d get results in three to five days. Polis and state epidemiologist Dr. Rachel Herlihy say they want results in no more than two days, otherwise, people less conscientious than Sandoval, or with less family support, won’t stay home. And contact tracing plummets in effectiveness after three days of new contacts.
So Julia waits. As soon as she heard about her friend, she sent her daughter to be with her grandmother, and there she will stay until the test results come back. Her employer, she said, didn’t seem all that understanding about her request to stay away until she gets answers.
“What can you do?” Sandoval repeated. “I’m not going to get any of my residents sick.” As for her outpacing many Coloradans in following rules, she said, “I think it’s kind of because I’m in the health care field, I know how it gets transferred around. I have really bad asthma, so I can’t afford to get this.”
Testing capacity differs from county to county
Testing capacity and shutdown rules look very different from county to county in Colorado, even as case surges look more and more alike. Dozens of counties on the state’s dashboard are now in the red danger zone for too many daily cases, but Polis and his team are letting counties set their own rules if they prove they are trying hard.
In Mesa County, for example, home to Grand Junction and 154,000 people, the health department publishes in the Sunday newspaper a “five-star” recommended list of restaurants and other businesses that have proved they are following distancing measures and avoiding outbreaks. Businesses that make the list can stay at 50% capacity, rather than squeeze down to the 25% capacity that the rest of Mesa County had to adopt last week when it slid to Level 3 “orange” on the state pandemic dial.
Mesa County strives to keep testing free and convenient for anybody who wants it, not just symptomatic residents. The county uses a state-selected private lab contractor, Mako Medical, and the lab has been taking more than 800 daily tests on Tuesdays after the Sunday-Monday closure.
“We can meet demand and are glad to do it but demand is definitely there,” said county public health director Jeff Kuhr. Results for Mesa County residents, though, are now drifting past three days, Kuhr said.
The state and many local governments are rapidly expanding pop-up testing sites, with the state adding “spit test” locations (rather than the invasive nasal probe) at University of Northern Colorado and for Denver International Airport employees over the weekend. Denver has focused on adding smaller community-based sites like Paco Sanchez and Lincoln rather than re-open the high-volume facility it ran at the Pepsi Center parking lot earlier in the year.
CU Boulder is expanding testing opportunities for students ahead of Thanksgiving travel, asking them to get tested 48 to 72 hours before leaving to help protect their families back home.
Colorado now has a new supply of rapid-test kits with results in 15 minutes, aimed at essential workers who may be carriers but are asymptomatic. The massive volume of rapid tests will ease so-called “serial” testing, where essential workers get tested at regular intervals to keep tightening the net on new cases.
But those expansions bump up against limits, too, even as the supply of physical test kits has largely kept up with demand. The state’s own diagnostic lab is at full capacity, and has contracted with private labs to handle the larger volume, Herlihy said.
State, local or private contractors are competing for lab technicians already in short supply before the pandemic began. While health care workers could flock to overwhelmed New York in the spring, for public service and hazard pay, the health workforce will have to stay put during this fall surge because most states need their workers for local caseloads.
Training new lab technicians takes a year or more in most programs.
“Testing capacity is a lot of things, it may be supplies but it can be staffing,” Kuhr said. If Mesa County built another facility, “we’d be limited in finding people who could do it.”
Contact tracing is essential
The next challenge in Mesa and every other county is the contact tracing that must follow a positive result if the tests are to have any larger public health impact. With hundreds of new cases a week in every county, even expanded contact tracing staff are ripping out pages from long questionnaires and focusing on immediate measures.
Test results that come back after three or more days make contact tracing all the harder: Contacts forget where they’ve been and who they’ve seen, and many can’t or won’t stay home beyond 72 hours to wait for results.
In Jefferson County, where a key test site shut down early last week for lack of test kits, tracers change tactics if they are looking at a positive result that is more than three days old, said Christine Billings, incident commander for the county’s COVID-19 response. Fresher cases still get phone calls, but older cases are getting letters with advice on who to contact and how to quarantine.
“Three days is when we can make actual impact,” Billings said. The county, like much of Colorado, does need to do more testing, she said.
Polis said in an interview last week the state was not hearing of test kit shortages, and that if there were any, state emergency management officials had adequate supply to help any counties or local authorities. “If more people showed up and got tested, that would be a good thing,” he said.
State and local officials can’t just give up on contact tracing as their inboxes fill to overflowing. Besides warning the vulnerable, public health gleans crucial information on where people are failing the guidelines and where outbreaks originate.
In Mesa County, Kuhr said, outbreaks did not appear from a place many people assumed: political gatherings related to the hotly-contested 3rd District Congressional race won last week by Republican Lauren Boebert. Only five cases in the past two weeks came from large gatherings, Kuhr said.
Instead, 26% of cases are coming from informal gatherings of friends or a couple of families, Kuhr said. Another 15% come from contact within families, and about 10% from the workplace. Employees are spreading it to each other at work, but do not appear to be spreading it to patrons of retail operations, he said.
In Jefferson County, Billings sounded resigned that so many of their rising cases come from circumstances that are hardest for public officials to control.
“The stories paint a picture. A small-ish group gets together and lets their guard down. No masks, and they’re sitting in confined spaces for hours. Three days later, somebody becomes symptomatic. And it’s happening among all ages, at all income levels,” she said.
People need to know their own power as influencers, she added. “When there’s just six people, from two different households, yes, masks are weird. But if one person does it, others step up,” she said.
“We know people are so tired of all this,” Billings said. “I want to thank them, I really mean it.”