Cities around the country want to reopen for business while protecting the public’s health. To reopen the American economy safely and with complete confidence, the path depends on several critical factors that must be concurrently in place – challenging to achieve but doable.
- Widespread testing to diagnose COVID-19 and track status of spread across populations
- Robust contact tracing to identify, trace and safely isolate people who are infected
- Sufficient health care capacity in personnel, facilities and equipment to treat those sick with COVID-19
- Therapeutic treatment and preventive vaccine
An effective vaccine is at least a year away and (promising prospects for the antiviral Remdesivir notwithstanding) it will be many months before a safe, evidence-based treatment is identified. Hence the first three factors must be firmly in place to allow for a staggered approach to reopening and eventual recovery.
- A jurisdiction’s reopening should be based on science and tailored to the needs of its community.
- Precipitous opening in timing or scope could result in repeated rise in COVID spread, forcing wave after wave of future shutdowns — even more devastating than one prolonged shutdown in undermining consumer and market confidence.
- Continued physical distancing and a staged lifting of stay-at-home restrictions are also vital during this transition.
What Testing Does
Testing combined with aggressive isolation and contact tracing can help jurisdictions manage the viral spread, reduce risk to lives, and allow a reasonable level of economic activity. Testing allows cities to ascertain whether they are on the rising, falling or peak of the infection curve by providing:
- Diagnosis of Individuals who may be infected and contagious, their prognosis and clinical needs.
- Surveillance at the Population level to see who might be infected/susceptible/sick, where they are in space and time, the heterogeneity (race, ethnicity, age, etc.) of these people, and to assess interventions.
- Jurisdictions who don’t have testing capacity to reach everyone can consult CDC’s guidelines on priorities for testing.
Availability of Testing
COVID-19 tests used to detect or diagnose infections are currently insufficient and inconsistent. We need a central coordinating force to manage testing for the country, otherwise states will compete to get enough tests and test components. This impedes much needed testing supplies from getting to areas of greatest need. Sufficient tests only occur if testing components are in the same place at the same time. These include:
- Supplies (swab, viral transfer mediums, reagents), CLIA-approved labs with qualified technicians using FDA EUA approved processes to run tests; trained personnel to properly collect specimens; and sufficient PPEs for these workers and facilities where they can collect specimens (e.g., ER, clinics, tents set on exterior grounds).
- A note on Serology Tests for Immunity – This is not a substitute for the Diagnostic test for COVID, and neither the tests’ accuracy nor protective extent of potential “immunity” is confirmed. Current best estimate is at most 2-3% of the U.S. population may have immunity – not nearly enough for a corps of COVID-Immune individuals to open the economy. 70-90% is necessary for Herd Immunity to prevent spread of any contagious disease.
Equity Issues Affects Who Gets Tests
Access to testing goes beyond availability of testing kits and labs. Even with an abundance of tests:
- Where the test facility is or testing time may not be aligned with residents’ work schedules.
- Messaging on the need for gateway providers, i.e., “call your doctor first” could be a barrier.
- Cost of testing and cost of health care is often a barrier.
- Paid sick leave often elude people on hourly and service jobs.
- And possible racial or ethnic bias in testing exist.
Current Status of U.S. Testing
At this writing, the U.S. average is short of 200,000 tests/day. To safely open and prevent surge, a minimum of 500,000 to 750,000 tests/day is necessary. Federal coordination and DPA (Defense Production Act) authority can ensure adequate supplies and distribution around the country. This is unlikely to happen left to the market alone.
Contact Tracing is an Essential Companion to Testing
To ensure cities can make safe, confident progress toward returning to work and school, contact tracing must go hand-in-hand with a massive expansion of diagnostic testing in every community. COVID-19 can cause large outbreaks quickly, so even one missed case can significantly undermine control efforts.
- Each jurisdiction needs a comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case. This includes safely isolating the sick and quarantining those exposed.
- This will require a massive expansion of the U.S. public health workforce: with a minimum of 100,000 Contact Tracers (paid or volunteer), distributed across the country to reach communities large and small.
- Health Departments are experts in training and deploying contact tracers. People with a high school level education can be trained on requisite skills: case management and cultural/racial concerns. Recruiting from the local communities (e.g., the community health worker model) can ensure contact tracers have sensitivities to local culture, similarity in race/ethnic backgrounds, and the knowledge on local resources to support a safe, effective quarantine.
Role of Contact Tracer
Contact tracers notify people who had been in contact with those who are sick or known to be infected (these contacts must then quarantine for 14 days); periodically gather accurate information on symptoms; provide support to alleviate fear and anxiety and link the individual to additional services and supports (e.g., groceries, safe housing, health services or childcare); and investigate and follow up with contacts.
- Mobile contact tracing applications can increase efficiency, but do not replace human contact. It can provide a system to record and store user locations and self-reported symptoms. Issues of privacy are yet to be resolved.
Recommendations for City Leaders on Test, Contact Tracing and Reopening
In a landscape of uncertainty, city officials bring credibility and relationship at the local level to:
- Work with local health department to ascertain rate of new infections – Encourage data sharing and connectivity of systems (hospital, urgent care, ERs, labs, public health, public/private institutions) to take advantage of information and knowledge from testing.
- Navigate federal, state and local partnership for sufficient testing – Advocate for federal and state policy fixes to supply chain and other issues limiting testing capacity. States can take ownership of testing coordination, undergirded by the federal government on financial, logistical, supply chain support.
- Advance equity by matching testing and contact tracing capacity with areas of greatest need – Work with healthcare organizations to establish testing sites in underserved areas; address location and cost issues and sufficient outreach workers to reach people in vulnerable neighborhoods.
- Identify laboratories with CLIA/EUA authorization to perform tests serving their area and identify they have sufficient capacity.
- Ask your local health department for a breakdown of testing by race and geography to understand who in your community currently has access to testing. Work to ensure equitable access to tests in accessible settings (e.g., community health clinics).
- Mobilize testing and contact tracing for priority populations in high risk settings: essential workers and individuals experiencing homelessness, residents of nursing homes; contacts of people who are sick or known to be infected; and areas with a high concentration of African Americans and people of color.
- Address testing and tracing in culturally appropriate manner in city communications, including partnering with trusted messengers, e.g., faith community.
- Be aware of vendors peddling “real-time” test results and/or “home-based” tests. Available “quick tests” lack consistency in quality and access are limited. The FDA just authorized the first test kit for at-home COVID-19 specimen collection. Cities can visit FDA’s website for approved tests.
- Play a role in tracking and reporting on tests – Support required reporting by laboratories clinics and local and state health departments. Cities can also advocate for policies that collect data on testing by race and ethnicity, as well as by age and gender.
- Leverage city officials’ power and influence by communicating to the public – Assert local official’s credibility and closeness to city residents by speaking to their hearts as well as minds. Appeal to the collective interest and collective response.
Centers for Disease Control and Prevention
- Testing for COVID-19
- Evaluating and Testing Persons for Coronavirus Disease (priority for testing)
Johns Hopkins Bloomberg School of Public Health
- A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the U.S.
- Contact Tracing 101: The Public Health Strategy that Could Help Control Covid-19 and Speed Up Reopening (podcast)
NACCHO Position Statement – Building COVID-19 Contact Tracing Capacity in Health Departments to Support Reopening America Society Safely
U.S. Food & Drug Administration – CLIA Approved Laboratories and EUA Processes and Devices
About the Authors:
Kitty Hsu Dana is the Program Director for Health & Wellness at the NLC Institute for Youth, Education, and Families.