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States may be poised to reopen prematurely, data shows, prompting some public health officials to warn of a resurgence of coronavirus cases and deaths.
A medical assistant prepares to take a swab from a patient at a new drive-thru and walk-up coronavirus testing site Saturday, April 25, 2020, in Seattle.
HALF OF U.S. STATES fall short in two critical tests of their readiness to restart their economies: Too many people are testing positive for coronavirus and states are testing too few people to limit its spread, according to a new analysis by U.S. News using data supplied by the University of Missouri.
Twenty-five states and the District of Columbia fail to meet a White House benchmark for relaxing social distancing measures based on the percentage of people who test positive for the virus, the analysis shows. Only two states,Rhode Island and West Virginia, are carrying out enough tests per capita to identify those who are infected and react quickly if infections start to mount, based on calculations by researchers at the Harvard Global Health Institute.
The data suggests that many cities and states may be poised to reopen prematurely, prompting some public health officials to warn that they may be courting a resurgence of coronavirus cases and deaths.
"I'm very concerned that they are making these decisions in a rushed manner, on the basis of hopes and dreams, rather than cold, hard reality," says Dr. David Relman, a professor of microbiology and immunology at the Stanford University School of Medicine. "Everybody will be much more reluctant to try this again if the first try is calamitous."
The challenge is that researchers in the U.S. don't have a reliable estimate of the number of people who are infected with the virus. Health officials say they lack a sufficient number of tests to track its spread.
Perhaps the best estimate of total infections in the U.S. is based on an extrapolation of the number of people diagnosed daily with COVID-19. On average, about 30,000 – or 20% of the 150,000 people tested every day – are infected with coronavirus, according to a blog post by the Harvard Global Health Institute.
Researchers say, however, that federal guidelines restrict testing to those with serious illness. This means that only those who are seriously ill, a fraction of those who are infected, get tested. Perhaps the simplest way to estimate the total number of infections in the U.S. is to extrapolate from the case fatality rate, which is believed to be 1%. The Institute of Health Metrics and Analysis projected that there would be approximately 1,150 deaths nationwide on May 1. If that is the case, at least 115,000 people, and possibly many more, are infected with the virus.
These people can infect others. One key to curbing the pandemic is to test and identify those who are infected and isolate them to limit the spread of the disease. The White House plan, "Reopening America Once Again," proposed a two-week average of 10% as an acceptable percentage of positive tests for safely moving forward – as long as the states also have a robust testing program in place.
President Donald Trump on Monday acknowledged that the U.S. got off to a slow start in ramping up the nation's testing efforts and again promised that the White House would help states dramatically expand their testing but offered few specifics beyond pressing commercial labs to make the most of their capacity.
Researchers at the Harvard Global Health Institute estimate that the U.S. will have to have at least triple the number of tests carried out daily, from about 150,000 to 500,000, for the country to safely ease restrictions on local businesses and gatherings. That translates to 1.52 tests for every 1,000 individuals in the population.
Only Rhode Island and West Virginia meet that standard, according to the new analysis. Rhode Island, with 13.4% of positive tests, is just over the White House threshold of 10% and West Virginia is far lower with 1.6%.
In just one week, from April 20 to 27, West Virginia significantly stepped up its testing, averaging 2,983 new tests per day, compared to 785 tests per day the previous week. Overall, the state nearly doubled the number of new tests from 22,155 to 43,039.
The analysis was carried out by the University of Missouri Center for Applied Research and Engagement Systems, which collaborates with U.S. News and the Aetna Foundation on U.S. News Healthiest Communities, a population health assessment of nearly 3,000 U.S. counties.
The CARES team obtained data from the COVID-19 Tracking Project, a volunteer organization that aggregates information from public health authorities and other sources, and calculated 14-day averages for the percentage of positive tests and seven-day averages for the number of tests per 1,000 people. The results were then embedded in CARES' COVID-19 Testing Dashboard, an online mapping and charting tool that provides a graphic look at testing in each state.
"The pandemic is a complex societal issue, dealing with jobs and workforce and readiness in addition to public health," says Christopher Fulcher, CARES director. "What we're visualizing here is readiness based on the testing that's being done. Are we truly ready?"
Stanford's Relman says both measures are important signposts of readiness. "You want to start at a low enough number of cases that your health system is still able to operate if there is an increase," he says. Additional testing is essential, he adds, because, when you begin reopening businesses, it will reveal "whether you've made a good decision or a bad decision."
Dr. Georges Benjamin, president of the American Public Health Association, says states should also consider other factors, such as hospitalizations and deaths, when they're formulating pandemic policy.
He observes that there are vast testing deserts throughout the U.S. "If you're in Michigan, you've tested a lot of people in Detroit, but you haven't tested a lot in rural communities," Benjamin says. "What does that mean? Michigan is a big state."
That's why aggressive, widespread testing is critical to contain the epidemic, says Dr. Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security.
South Korea and Germany – countries that have used testing aggressively to identify those who are infected, trace their contacts and isolate them to prevent further spread – have kept their percentage of positive coronavirus tests low, at about 2% and 7% respectively.
"When you see in that U.S. that our rates are 20% positive over all – and higher in some places – it means we're not doing enough testing and we should probably do more," Rivers says.
In Alabama, one of the states poised to reopen when its stay-at-home order expires April 30, 34% of tests are positive, more than triple the White House recommendation. The state tests 0.84 people per 1,000, roughly half the recommended number.
Georgia, whose hair salons and some other businesses began reopening on April 24, has a positive test rate of 18% and is testing fewer people than Alabama.California, a state recognized for investing in public health programs, is testing roughly the same number of people per capita as Alabama and Georgia.
Relman, who lives in Santa Clara, California, the first community in the U.S. to calculate its coronavirus infection rate – 2.49% to 4.16% as of April 1 – confessed being "befuddled" at the state's poor performance.
"The place I know best, a place we might have thought was in a better position than most to put in place innovative tests," Relman says, "is not anywhere near where it needs to be." He credits Gov. Gavin Newsom with having a good plan for ramping up testing, but adds the numbers "aren't anywhere near high enough."