The Trump administration's new Covid-19 testing strategy says that states must devise their own testing plans, monitor infections, and contain any outbreaks. The federal government has also recommended that all states should test a minimum of 2% of their population in May and June. The proposal, however, does not explain how the target was arrived at. The plan, however, emphasizes that testing a majority of the US population, recurrently, is “neither feasible nor necessary to assure safe return to work, school, and other activities.” Instead, it says that existing testing capacity, if properly targeted, is sufficient to contain the outbreak. “A targeted strategy based on diagnosis, contact tracing, and smart surveillance is the optimum approach – especially when combined with syndromic surveillance and hygiene,” it says.
The 81-page document -- Covid-19 Strategic Testing Plan issued by the US Department of Health and Human Services (HHS) -- says that the overall target for the US for May and June is 12.9 million tests. “On a state-by-state basis, the targets ranged from a minimum of 2% of the population tested, to 14.9% each month. The federal government recommends all states to have an objective of testing a minimum of 2 percent of their population in May and June, pending additional new data on infections and the impact of reducing mitigation,” says the report. It asks states to detail how a minimum of two percent of the state’s population will be tested each month beginning immediately along with plans to increase that number by the fall of 2020.
According to the report, the US has now performed over 12 million nucleic acid tests, with more than two million tests completed each week, and the “numbers continue to grow.” The report also says that in early March, only a few thousand tests for Covid-19 were performed each day. In mid-May, that number is approximately 300,000 per day, and “growing steadily at 25%-30% per week.” “With expanded and sustainable supply chains, novel 'front ends' (retail stores, community-based testing sites) for testing, and states becoming empowered with enhanced knowledge and funding, we will maintain our testing capacity and continue to grow these numbers significantly over the next several months,” says the document.
The World Health Organization (WHO) has suggested that an adequate test positive rate should be between 3 and 12%. A test positive rate above 10% likely reflects inadequate testing, meaning that testing should be increased to cast a wider net. The plan says that epidemiologists and public health officials say that if 10% of tests are positive during a seven-day average, then states are “likely testing enough to assure broad coverage of the population.” According to the document, 41 states have achieved that percentage. The jurisdictions with the highest positivity rates (DC and Maryland) are now below 20%, and each of these plans to perform four times their cumulative totals as of April 21 during May and June. Based on the data available from May 8 to May 15, 2020, the US positivity rate averaged over that seven-day period is 7.5% and is continually decreasing.
“The WHO set an objective that the percent of tests being positive should be 10% or lower, demonstrating that 10 times as many people are being tested as have the disease. This indicates enough testing exists to ensure broad coverage of the population. The amount of testing needed in a community is situational (based on geography, transmission, vulnerable populations, etc), but in general, achieving this benchmark begins to ensure rapid diagnosis of symptomatic and asymptomatic individuals,” says the report.
However, scientists say that the amount of testing is orders of magnitude lower than what the US needs. A report in April had said that if the US fails to do at least 500,000 tests a day by May 1, it is hard to see any way the nation can remain open. It had said to reach a 10% test positivity rate operating under the assumption that the US is not missing too many cases would imply that about 1.5 million people need to be tested per day (in April) and by May 1, about 580,000 people per day. “While we estimate that we should be testing between 500,000 and 600,000 people per day, this is clearly on the low side,” said researchers from Harvard Global Health Institute, Brigham and Women’s Hospital, and the Harvard TH Chan School of Public Health.
Strategies outlined for states
On April 27, 2020, President Donald Trump released a testing blueprint for reopening America, which it said was designed to facilitate state development and implementation of testing plans and rapid response programs. The blueprint laid out an 8-part plan in three stages -- from building the foundation for a diagnostic test and strengthening the supply chain for testing to coordinating with governors to support testing plans and rapid response programs. The current document “supports the implementation of the 8-part plan by providing additional guidance and information about diagnostic technologies, platforms, and inventory.” It says the specific number of tests that are required in each state, and in each geographical region within them depends on multiple factors such as the percent positives in a state, territory, or tribe, characteristics of the population, and the degree of mitigation employed in that community.
States have been asked to establish a robust testing program that ensures adequacy of Covid-19 testing, including tests for contact tracing, and surveillance of asymptomatic persons to determine community spread. The plan says states must assure provisions are in place to meet future surge capacity testing needs and rapid result testing for local outbreaks. It says state strategies should evaluate and utilize testing across their ecosystem (in commercial, academic, medical center, and public health laboratories). The proposal recommends that when developing testing strategies, states should consider testing technologies, use cases for these technologies, and available inventory.
States should also include plans for testing at non-traditional sites, such as retail sites, community centers, residential medical facilities, or pharmacies. It also asks states to plan for testing at-risk and vulnerable populations including the elderly, disabled, those in congregate living facilities such as prisons, racial and ethnic minorities and other groups at risk due to the high frequency of occupational or non-occupational contacts, and testing of individuals engaged in critical infrastructure sectors, such as food and agriculture and healthcare workers.
Strategies should be considered “living documents” and adapted as needed to account for the latest information about disease transmissibility and immunity. “States and jurisdictions should apply the different types of SARS-CoV-2 testing that are appropriate for different environments, fit for purpose, and currently available. The Centers for Disease Control and Prevention (CDC) guidance on prioritizing applications of the various types of tests (nucleic acid, antigen, and antibody detection) and testing materials will be crucial for how states plan, adapt and implement robust testing strategies,” it says. Once states submit their plans, HHS will review each to ensure that the testing plan is sufficient to mitigate the spread of the virus, protect vulnerable groups, and accounts for enough testing supplies and reagents to cover all groups including underserved populations, says the report.
The report also estimates that by September, the US will be capable of performing at least 40-50 million tests per month. It says the federal government will work with states to support the development and availability of as many fully enabled tests as possible. To ensure that states have the collection supplies that they need through December 2020, the federal government plans to acquire “100 million swabs and 100 million tubes of viral transport media,” and distribute these supplies to states as requested to meet their individual plans. “The federal government is supporting and encouraging states, territories, and tribes to build a multi-layered approach that incorporates and fully leverages all components of the testing ecosystem,” says the document.
Meanwhile, four congressional Democrats have issued a statement calling the testing plan “disappointing” and accusing the Trump administration of not taking responsibility for testing on a national scale. “After six months and nearly 100,000 lives lost, the Trump administration still does not have a serious plan for increasing testing to stop the spread of the virus. This disappointing report confirms that President Trump’s national testing strategy is to deny the truth that there aren’t enough tests and supplies, reject responsibility and dump the burden onto the states,” reads the statement.
“We still need clear explanations for how targets were set, how they will be met, and what will be done if they are not. The Trump administration still does not take any responsibility for ramping up our nation’s testing capacity, instead pushing the burden onto the states – forcing states to compete with each other to procure vital supplies to administer tests from the private market,” says the statement. As of May 27, US has reported over 1,681,410 coronavirus cases, and the death toll is 98,929.