Allie Vruggink and her boyfriend, Jeremy Quillian, followed the Centers for Disease Control and Prevention’s coronavirus guidelines fairly rigidly, so they isolated themselves in their home in Holland, Michigan, when they were told a friend may have exposed them to the virus.
They decided to get a test, but were able to get one quickly only because Quillian appeared to have symptoms: headaches, a cough and loss of taste. Since Vruggink works for a hospital, she was able to get a test that provided results within 24 hours. Even though Quillian, who works in construction, had symptoms, he was told his results would take longer — 48 to 72 hours.
But after 72 hours, Quillian didn’t have his results. He now felt fine, and because Vruggink's test came back negative, Quillian's boss asked him to come back to work. Unsure whether the couple could afford any more missed days of pay and believing their results would be the same since they lived together, Quillian returned to work.
Two days later, he got his results: positive for the coronavirus.
“Because Michigan had a big blowup of cases, I guess there were more tests than they could handle. Even now, I think it’s about a week's wait for most people,” Vruggink said.
More than eight months into the pandemic, the United States' testing infrastructure is again being challenged. While there are tests available, the country's testing system is struggling to catch up to the worst public health emergency in modern history — even as experts have warned repeatedly that the winter would be a tremendous challenge. Now the U.S. is regularly reaching a record number of deaths and hospitalizations each day.
The lack of a coherent national strategy, experts said, is causing the wheels to fall off the system at large. The inability to quickly and efficiently test large swaths of the population has frequently blurred the path forward, and it foreshadows challenges in the eventual distribution of a vaccine.
This report is part of NBC News’ in-depth coverage on the “Race for a Vaccine,” a network-wide, week-long series airing across all programs and platforms, including NBC Nightly News, TODAY, Dateline NBC, MSNBC, NBCNews.com and NBC News NOW.
“A testing strategy is a very important piece to not only prevention, but also response,” said Saskia Popescu, an epidemiologist and infection preventionist at George Mason University. “Testing impacts percent positivity, which has been widely used to understand community transmission — so if this is off, it can be quite impacting on how we communicate things. I think our ultimate challenge isn’t in just having accessible and quick testing, which we’re struggling with, but also communicating that a test is a single moment in time and what that means for people.”
A plethora of tests but hurdles to get them
The United States has conducted 180 million tests since the beginning of the pandemic and, as of November, the country had the capacity to conduct 125 million tests, Brett Giroir, the White House coronavirus task force's “testing czar” and assistant secretary for health, told reporters last week.
Experts say that for communities to remain open, people need to get tested regularly and comply with contact tracing, mask wearing and social distancing. That way people can know whether they are infected and isolate when there is a localized spike.
“Testing frequently is one of the essential tools that we have right now to be able to understand where these infections are spreading, and for people to have assurance that they're negative before they participate in an activity that could put other people at risk,” said Blythe Adamson, an adviser to Testing for America, a nonprofit that supports making low-cost, reliable Covid-19 testing more available, and an infectious disease epidemiologist who formerly worked on the White House coronavirus task force.
We have chronically neglected public health in the U.S. and then we’re surprised that they’re struggling to keep up?
But getting access to those tests — and there are a large number of different tests available — and receiving timely results is the bigger challenge, and it doesn’t appear that all states are using all of the funding available to them. Giroir said last week that the federal government had provided states $10.25 billion for testing, but they had only used $2.8 billion.
“Our public health system struggles with being underresourced, and it’s not surprising that this happened,” Popescu said. “We have chronically neglected public health in the U.S. and then we’re surprised that they’re struggling to keep up? Testing is not an easy thing to do and really means more than just providing tests.”
Convenient access to free testing is foundational, Popescu added, yet serious challenges persist.
There are delays in getting results and difficulty in finding testing sites that will accept patients without appointments made days in advance. Some states are also triaging patients, or not allowing most people to be tested unless they are showing symptoms. These issues are only getting worse with the sudden spike in cases and the holidays creating more demand for tests.
In New York City and the California Bay Area, where testing availability is much higher than the rest of the nation, people waited hours in line to get tests before they presumably joined others for Thanksgiving.
That demand ahead of the holiday was expected, and it showed how testing and timely results are strained as the country trudges into winter.
All of these challenges come as the country heads into what CDC Director Robert Redfield warned would be “the most difficult time in the public health history of the nation.”
‘Lack of access is crazy’
Testing availability can change drastically state by state, and inequitable access is noticeable. While President Donald Trump promised in March that “anybody that wants a test can get a test,” many still have not had that experience as of December.
Jacqueline Azza, 20, drove three hours from her parents’ home in Tracy, California, to get a test before flying over the Thanksgiving holiday to Atlanta, where she attends historically black Clark Atlanta University. Her semester had ended more than a week before, but she wanted to return to Georgia to help register voters before the Jan. 5 Senate runoff.
Her initial test results were negative, so she flew to Georgia. When she got there, however, she said she struggled to find a place to get tested again — a precaution she hoped to take before flying. She ended up going back to California on Sunday without one, and Azza said she may have to buy a costly home testing kit as she isolates in her parents’ home.
“The lack of access is crazy,” Azza said. “I couldn’t get a test unless I had a confirmed exposure to someone with Covid, and I couldn’t get a test unless I was feeling symptoms. But the CDC says you can be asymptomatic and still spread the virus, so I’m confused about why testing still isn’t accessible.”
Other countries, such as the United Kingdom and Germany, have more successfully scaled testing in response to the pandemic and with winter looming.
Adamson said that one reason those countries were able to build a testing infrastructure so quickly is because they have some form of universal health care, which has allowed their public health agencies to work more directly with the health care system. The United States, meanwhile, still has a patchwork model based on employee-sponsored health care and the open market.
“In the United States, by having a fragmented payer system with predominantly employer-based health insurance, it creates a bigger challenge in public health really rolling out the access to test and reimbursement for testing,” Adamson said.
While the government plays the main role in other countries, the United States fulfills much of its testing through private-public partnerships. That has seen its own bottlenecks.
Caroline Savello is the chief commercial officer for Color, a private company that is running testing sites across the country, including sites that conduct 150,000 tests a day in California. While many states have some state-sponsored testing, it's not nearly enough to meet demand. She said the only way to do frequent testing in the United States is by grinding down the cost of the systems in place, but the country remains too reliant on local health systems to play a key role.
“It just operates differently: You have to schedule an appointment, wait in the waiting room and it limits testing because they’re reliant on their own labor and resources, rather than thinking about it in a scalable public way,” Savello said. “The other problem is that, as we’ve been reopening more, a lot of people return to work and school, and a lot of these places don’t even think they can be the providers of a service like that.”
Testing hurdles foreshadow vaccine distribution challenges
Savello said the quickest way to scale up testing would be for schools, churches and community organizations to do sample testing, but the United States’ patchwork response — with each state choosing its own path and the White House failing to provide clear and consistent guidance — has not allowed that method to build out very widely.
That also signals issues ahead regarding vaccine distribution, experts warn. Because if the country has struggled to scale up its testing infrastructure, distributing vaccines will be even more difficult and their efficacy will still not diminish the need for widespread testing.
“Vaccine availability will likely not decrease the need for testing,” Abramson said. “The vaccines are not perfect. And there are many populations that may not be eligible for the first one that becomes available. Mass vaccination will need to be happening over the next few years.”
Private testing facilities are already beginning to think about how to pivot some of their functions toward vaccines when possible.
Savello said her company has begun to consider the overlap between testing and vaccine distribution.
“The testing infrastructure we’re building now is going to be absolutely critical to the widespread distribution of these vaccines,” she said. “The logistics and supply chain associated with it, the storage conditions, the fact that we need to be very targeted in terms of who gets access and that this all needs to be done through a mass public health campaign means that you need that same infrastructure in place.”
But, Savello noted, the lack of widespread institutional infrastructure remains a huge hurdle that the country as a whole will have to contend with.
“We are very much kept awake by a lot of this stuff,” she added.
Such concerns are keeping many Americans awake at night.
“You would think after the first six months we would’ve figured out some way to speed up this process and make it trustworthy, but now it’s nearly impossible to find anywhere to get tested,” Vruggink said. “Here in my town, we were one of those places that weren’t hit bad the first time, but now our hospital is at 90 percent capacity. We need this to speed up now, not slow down.”