Massachusetts, let’s get more ambitious with coronavirus testing

June 4, 2020
Boston Globe
By The Editorial Board

Given the size of our COVID-19 outbreak and our biomedical firepower, the state should pursue a more aggressive testing strategy.

Gov. Charlie Baker’s administration deserves credit for ramping up coronavirus testing in Massachusetts after the federal government botched the rollout of COVID-19 tests, forcing states to manage the outbreak while flying nearly blind. In mid-March, only 2,000 people had been tested in this state, making it impossible to pinpoint where the virus had spread. Now, after months of coordination between state officials and local labs, research centers, and health care facilities, Massachusetts is testing an average of 10,000 people every day. More than 600,000 tests have been performed overall, which is sixth in the nation on a per-capita basis, according to the Kaiser Family Foundation. (Rhode Island is No. 1 in that regard by a large margin.)

Judging by the current status of the outbreak, notably the declining numbers of deaths and hospital admissions related to COVID-19, the state’s overall strategy of testing, social distancing, and using masks is working — for now. But if Massachusetts is to sustain this trend even as more people travel and return to work or school, public-health officials would benefit from substantially more test data, because that would increase the chances of stopping infected people from spreading the virus. Without the insights that could come from many more tests, strategically deployed, the reopening that’s underway could be more restrained than necessary. It also could be a prelude to a second shutdown in the fall.

Given the size of the outbreak in Massachusetts, which is third in both total deaths and cases per capita, we’re not testing nearly enough people to have a granular picture of where the virus truly lurks. Outside of dense, high-risk settings such as prisons, hospitals, and nursing homes, tests are primarily being done on people who have symptoms or know they have been in contact with someone infected. That leaves out many infected people who have no symptoms and thus have the potential to create new hot spots of contagion.

The Baker administration acknowledges that there are holes. Right now, labs in the state have the capacity to handle 30,000 tests a day. Baker intends to boost that number to 45,000 by the end of July and 75,000 by the end of the year. Along the way, the state also expects to increase the percentage of the available capacity that is actually put to use, according to Marylou Sudders, the state secretary of health and human services who heads the COVID-19 Response Command Center. For one thing, she says, more testing centers are opening throughout the state. And newer kinds of tests don’t require an invasive swab far up your nose, making it less likely that people will try to avoid the experience.

Nonetheless, the administration’s testing targets still appear to be too low. Even 75,000 a day isn’t necessarily enough to support frequent testing of people in large housing centers, workplaces, and schools. “In order for Massachusetts to be testing the sick and their contacts, high-risk populations like nursing home residents and prisoners, and front-line workers in essential roles at adequate levels, we will need to develop capacity for around 125,000 tests per day in the medium term and 250,000 tests per day or more in the longer term,“ Steve Pagliuca, the Bain Capital co-chairman who led a reopening advisory task force of the Massachusetts High Technology Council, told the Globe editorial board.

The state’s testing targets are also short of what’s possible in our world-leading biomedical community. Case in point: just one center, the Broad Institute of MIT and Harvard, which has been analyzing a few thousand tests a day, on Friday boosted its capacity to 35,000 per day. Broad officials say they could ramp up to 100,000 tests a day within a few weeks. The institute is attempting to line up philanthropic or government funding to support such an increase.

“If there is one state in the country that should be able to pull off ubiquitous testing — getting to the level of testing where you don’t have to think about `Do I have enough tests to do this screening here, or to open up the colleges?’ — it’s Massachusetts,” says Dr. Ashish Jha, director of the Harvard Global Health Institute. “I want us to set our ambitions higher.”

Increasing the number of tests is not a solution by itself. There is still a limited supply of tests, so it matters greatly where testing is happening; public-health officials are wise to ensure enough tests are available in the highest-risk communities rather than opening testing up to anyone, anywhere, at any time. It’s also crucial that tests are read in no more than a day or two and that their resulting data flows efficiently to contact tracing operations that quickly track down the people who have been exposed to someone who just had a positive test. “People ask me, ‘what’s the one thing we need to do in this pandemic?’” says Dr. Tom Frieden, former head of the Centers for Disease Control and Prevention, who now heads Resolve to Save Lives, a public-health organization. “And I say: the one thing we need to do is recognize there is not one thing we need to do. The bottom line is that testing needs to be part of a comprehensive strategy.”

Fortunately, though, Massachusetts has a strategy. A program supported by the nonprofit Partners in Health is employing about 1,500 people as contact tracers to supplement the epidemiological detective work happening in local public-health departments throughout the state. Dr. Emily Wroe, a director of the effort, says the program is in good position to handle data from substantially more tests.

Sudders told the Globe’s editorial board that with a capacity for 45,000 daily tests this summer and 75,000 by December, it’ll be possible to routinely hunt for the virus in the highest-risk settings, including nursing homes, senior centers, assisted living facilities, universities, and other busy workplaces, while also having enough tests for anyone with suspicious symptoms and for people who’ve been in close contact with an infected person. That assumes, however, that many people — including nursing home residents and workers in jobs with a high degree of potential exposure — will be tested every two weeks. In the analysis by the Massachusetts High Technology Council, a daily capacity of 127,000 to 252,000 tests would allow many sets of workers to be tested weekly.

That’s a more expensive proposition; the Council estimated that while testing 54,000 people a day would cost $50 million to $80 million a month, testing at higher levels would cost $110 million to $380 million a month. Those costs and any markups would primarily be borne by insurance companies and employers, depending on the purpose of the tests. But many employers might be willing to cover weekly testing of their employees in hopes of helping to avert another economically devastating shutdown. At the Broad Institute, employees are being tested twice a week.

It’s also possible that the average cost of tests will fall well below the benchmark assumed by the Council. The Broad says scaling up to a daily capacity of 100,000 would cut the current per-test price by more than half. Some centers might also reduce costs by “pooling” tests: Samples from large groups of low-risk people can be combined to see if the virus can be ruled out in all of them at once. If not, then the costlier step of individual analysis can proceed.

Since the pandemic began, the insufficient supply of tests and related equipment has been a national tragedy. Tests remain more scarce than they should be. But there’s still a chance to fix many of the problems and properly gird for a resurgence of COVID-19 in the fall. Sudders says the state has mainly resolved the challenges of obtaining a proper supply of nasal swabs and protective gear for the workers who administer the tests.

The next step, then, is for the state to get more ambitious about how many people can get tested. Aiming higher might well save lives while helping us return to daily life as we once knew it.