Many public health experts agree that getting America's coronavirus epidemic under control will require widespread and repeated testing, but the country hasn't yet implemented such an effort and, currently, it doesn't have the ability to do so, Atul Gawande, a surgeon at Brigham and Women's Hospital and a professor of health policy and management at the Harvard T.H. Chan School of Public Health, writes for the New Yorker.
However, Gawande identifies three key mechanisms that could help America quickly solve its coronavirus testing "mess"—potentially in a matter of weeks.
Coronavirus testing in the United States is marred by a variety of problems, Gawande writes.
Chiefly, the country lacks the infrastructure needed to ensure coronavirus tests are widely available for patients in need. Nearly every part of the testing process—having adequate number of supplies, testing sites, and laboratories to conduct and process testing effectively and efficiently—is suboptimal in the United States, in large part due to years of deficient funding and the absence of a federal strategy to implement widespread coronavirus testing, Gawande contends.
As a result, Americans often have difficulty accessing coronavirus tests, Gawande notes. He explains that testing facilities are too scarce to conduct the level of testing needed in the country, and patients sometimes face long waits to get tested. Further, while Congress has directed health insurers to completely cover patients' costs for coronavirus testing and related medical visits, some patients still face out-of-pocket costs and bills for coronavirus tests and related care. And even if patients can access coronavirus tests, many have waited days or weeks for their results—meaning those results may be obsolete by the time patients receive them, Gawande writes.
Further complicating the problem is that America needs to reach beyond testing people who think they may be infected with or have been exposed to the coronavirus—a baseline that the country hasn't yet been able to adequately reach, according to Gawande. The country needs to ensure Americans also can access so-called "assurance testing," or testing that may not be medically necessary but is used to ensure people aren't infected and spreading the virus to others as the country begins reopening businesses and easing social distancing measures, Gawande writes.
Although America currently doesn't have the capacity or ability to ramp up testing in this manner, Gawande identifies three mechanisms that could help the country to quickly solve its coronavirus testing "mess"—potentially in a matter of weeks.
Currently, the most commonly used coronavirus test in the United States is the polymerase chain reaction (PCR) test. The tests require specific and technical supplies, steps, and machines, and they can take six to 12 hours, at a minimum, to produce results, Gawande writes. And if labs are backed up with samples to process because of high demand, results can take even longer, he notes.
America's capacity to process those tests can be expanded, however, Gawande writes. For instance, Gawande writes that many small laboratories throughout the country have the capacity to processes tens of thousands of PCR tests per day, but they lack the logistical infrastructure that larger laboratory companies have to collect the tests and work with providers and payers to administer and cover the tests. Connecting those smaller labs with providers and public health authorities could help to quickly expand America's capacity to process the tests, which could speed up results and help to better contain the coronavirus' spread, Gawande writes.
Expanding the types of coronavirus tests that are available could also help to address America's testing shortfalls, according to Gawande. He notes that, while other coronavirus tests that have been authorized by FDA for use in the United States are less accurate than PCR tests, they're also lower cost and easier to use—with some able to be administered at points of care, and some producing results in as few as 15 minutes.
Such tests could be used both for screening patients with suspected coronavirus infections and for assurance testing, Gawande writes. However, increasing access to those tests comes with many of the same obstacles as increasing access to PCR tests, largely because the United States lacks the public health infrastructure to support the logistical and delivery aspects needed to ensure Americans can get the tests—and results—quickly and widely.
To solve this problem, Gawande writes that a national grid is needed—similar to the national grid America has in place to deliver electricity.
According to Gawande, South Korea serves as an example for how such a grid can work. He notes that, shortly after South Korea saw its first few coronavirus cases in January, the county's equivalents of the United States' CDC and FDA met with clinical laboratories and medical manufacturers to develop PCR tests for the virus and manufacture supplies needed to perform the tests. Then, South Korea's government implemented an accelerated approval process for those tests, eventually authorizing 118 laboratories to process the tests—including 46 labs that received authorization within about two weeks after South Korea's first coronavirus cases emerged.
Next, South Korea's government coordinated with health care providers throughout the country to establish testing sites; set up a national scheduling system that "also allowed [officials] to balance the testing loads" by "connecting laboratories that had extra capacity to test sites where that capacity was needed;" and pledged to cover patients' testing costs. Today, South Korea has around 600 test sites with, patients typically receiving their results in one day, Gawande writes.
According to Gawande, San Francisco officials set up a similar grid in the city, establishing a network of no-cost drive-thru and walk-in test sites, as well as a scheduling system that people who live or work in the city can access online or by phone.
"San Francisco, one of the first American cities to be hit by the pandemic, has also been one of the best at curbing it," he writes. That's largely because "San Francisco's leaders recognized the importance of universally available testing; residents needed to have an easy way to get tested regardless of what insurance they had or didn't have, regardless of what relationship they had or didn't have with a clinic, and regardless of whether or not they had a doctor's order," Gawande contends.
Technological improvements also could help to speed up and expand coronavirus testing in the United States, Gawande writes—but, again, only if there's a sufficient delivery system to implement them.
For example, Gawande notes that sewage testing could be a cost-efficient way to test large numbers of people for the coronavirus at once. People infected with the novel coronavirus will shed the virus in their stool, he explains. In sewage testing, a sample of wastewater from a building goes through the PCR testing process. If the test detects the coronavirus' presence, inhabitants of the building then can be tested individually.
Rapid, at-home tests also may be on the horizon, Gawande writes. "Simpl[e] paper-strip antigen tests are in development that people can administer at home," and while those tests likely would be less accurate that PCR and some other coronavirus tests, "false negatives can be reduced by repeat testing—and that's possible, because they're cheap and fast," Gawande contends. He notes, "Advocates imagine people having a pack of strips at home and testing themselves every day or two in order to provide assurance for their school or workplace."
Gawande writes that, overall, America's coronavirus epidemic "has given us all a master class on infectious disease, diagnostics, and the reality that individual health is inseparable from community health."
He concludes, "As the former Surgeon General C. Everett Koop once said, 'Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.' The pandemic has brought Americans a further lesson: our best chance for long, flourishing lives in the future requires that we build the foundations of our public health now" (Gawande, New Yorker, 9/2).
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