State COVID-19 Testing Landscape

Four months into the novel coronavirus pandemic, every state is scaling up its capacity to conduct diagnostic and serologic testing and working to sustain it for the duration of the pandemic. Some are targeting certain populations, counties, towns, or businesses while others are implementing a statewide program. There seems to be no general model for statewide or state-based testing. This memo outlines a variety of state examples, models, and resources for COVID-19 testing we have identified across the country.

States have achieved varying levels of success at meeting goals for testing sufficient numbers of people to track the course of the pandemic. Daily metrics on states’ COVID response, including their ability to meet a per-capita adjusted testing target of 500,000 tests conducted per day across the U.S., can be found at Covidexitstrategy.org.

Recommendations

1. Reduce or eliminate financial and administrative barriers by making it free to people and not requiring a health insurance card or proof of residency.
2. Make testing convenient by hosting sites where people live or work. Utilize pop-up sites, walk and drive-thrus, and places where communities organically gather and feel safe.
3. Prioritize testing in conjunction with steps to reduce transmission in congregate living settings like nursing homes, prisons, and homeless shelters or industrial workplaces like food processing plants.
4. To maximize testing participation, leverage partnerships and multi-stakeholder collaborations with people and organizations that have established trust in communities.
5. As states expand testing beyond confirmation of suspected cases (based on symptoms or exposure to a COVID-positive person), incorporate strategies to monitor incidence and prevalence in communities. This data will help inform when future surges may be on the horizon.
6. Pair testing strategies with contact tracing and supports for isolation to stem the spread of the virus.
7. Congress and the federal government are uniquely positioned to provide additional, critical funding to states and should act quickly to sustain these public health efforts.

Outstanding Challenges and Opportunities for COVID-19 Testing

While this memo outlines the state of COVID-19 testing across the U.S., it is worth noting the outstanding opportunities and challenges that have yet to be addressed with compelling evidence or best practice.

1. Nearly all states (examples: Wyoming, Wisconsin, Virginia, South Carolina) are leveraging CARES Act, CDC or other federal funds, to pay for testing and disbursing funds to state health departments and local governments through executive order or legislative approval. Some large municipalities like Dallas County, Texas, have received direct subsidies from federal funds. States like Minnesota are also providing funding to supplement federal support, but this will be a challenge for many to accomplish, given that most states are facing budget deficits due to the struggling economy. Congress and the federal government are uniquely positioned to provide additional, critical funding to states to fully sustain these public health efforts.
2. People want a health care system that is understandable, transparent, and easy to navigate. COVID-19 testing is no exception. While the Families First Coronavirus Response Act required insurers to cover testing for COVID-19, coverage and cost sharing is proving complicated, with some insurers classifying tests as not medically necessary in some situations. People will be hesitant to seek testing if they fear they will not be able to afford it. Providing clarity and certainty around the cost and coverage of all testing, including surveillance testing, will be essential in convincing the public to be tested. These potential ongoing costs underscore the need for additional funding to fill gaps that may emerge in insurance coverage.
3. Like contact tracing, testing for COVID-19 does not happen in a vacuum. In many cases, it is building or expanding a system on top of generational mistrust, and inequitable access to care, particularly for marginalized communities. This dynamic undermines our ability to effectively test, diagnose, and treat people for the virus in the near term, as well as their health and wellbeing overall.

State of COVID-19 Testing in the U.S.

Types of Testing being used by States

Diagnostic Tests: States are deploying a combination of nasal swab and saliva-based testing for COVID-19.

• Oklahoma was among the first states to introduce saliva based testing for COVID-19 with a focus on nursing home residents and employees, and Arizona recently shifted saliva-based testing via a partnership with ASU Biodesign Institute, who developed their own saliva tests.
• Many states use swab-based testing for community sites. Research is ongoing that considers shorter-length swabs, or swabbing the throat, much like a strep test. In Maine, officials are creating “Swab and Send” sites to supplement existing testing locations across the state to ensure residents can obtain a test within 30 miles of their home.

Serologic/Antibody Tests:

• New York is conducting an antibody testing survey to develop a baseline infection rate. The preliminary results of phase two show 14.9 percent of the population have COVID-19 antibodies.
• Wisconsin announced plans for COVID-19 antibody testing, with a goal to identify people who have been infected in the past.
• Connecticut announced that it would partner with Yale, Quest Diagnostics, and the Jackson Laboratory to do a serological test prevalence study of a simple random sample of Connecticutians (n=1,400).

Random Sampling to survey COVID-19 incidence and prevalence in the community

• Missouri will execute community sampling, by setting up testing sites in various counties across the state. Any Missouri resident, symptomatic or asymptomatic, in these counties who wishes to be tested can do so at these testing sites.
• The Massachusetts State Lab will conduct randomly sampled testing in tandem with the Harvard School of Public Health, to include at least 5,000 households linked to the US Census’ American Community Survey sample to provide more complete demographic, risk, exposure, and health care data to complement these test results.
• Oregon announced a statewide study that will track 100,000 Oregonians’ temperatures and symptoms over a 12-month period. Additionally, Oregon State University launched a new initiative called the Team-based Rapid Assessment of Community Epidemics (TRACE) project which sends teams of OSU student volunteers and health workers to randomly selected homes in communities in Benton County to collect samples.
• New York health officials sampled 3,000 New Yorkers at twenty grocery stores across the state in April, using the data to estimate what percentage of the population has contracted the virus and recovered.
• Utah health announced the start of Utah Health & Economic Recovery Outreach (HERO), in partnership with the David Eccles School of Business at the University of Utah.This project will collect data from 10,000 residents across four counties. Participants will be randomly selected to accurately determine the spread of COVID-19

Examples of community and private partnerships

Public-Private Partnerships

• States like New York, Massachusetts, Indiana and New Jersey are working with local independent pharmacies and national pharmacies like CVS, and Walmart to establish testing sites throughout their communities.
• States like Virginia, Maine, and Ohio are working with private sector partners to expand their lab capacity. Massachusetts is expanding its ARCHITECT platform in a partnership with Abbott Laboratories to conduct antibody testing in conjunction with planned viral testing.
• Louisiana has contracted with 11 partners as part of its comprehensive testing plan that will increase testing across the state, especially in congregate settings where the risk of spread is high.

Partnerships with Academic Institutions

• Tennessee has enlisted the help of Meharry Medical College, a historically black medical school in Nashville, to run its testing in the city and help with COVID-19 outreach.
• The University of Wyoming and the Public Health Laboratory have played key roles in assisting with the State’s COVID-19 testing program – including supplying personnel and supplies.
• Minnesota has called upon the University of Minnesota to assist in developing predictive modeling for COVID-19, and has partnered with the Mayo Clinic and the University to provide rapid, widespread testing for COVID-19 across the state.

States working with the National Guard

• Wyoming has leveraged the National Guard’s 84th Civil Support Team set to deploy a mobile laboratory to support increased COVID-19 testing.
• Other states like Tennessee, Virginia, Washington and Oklahoma are leaning on the National Guard to assist with operations and incident command centers for testing.

Examples of Place-Based Testing

Pop-up & Temporary Locations

• National Guard troops are staffing mobile testing sites in Texas, Vermont, Louisiana, and Michigan.
• New York announced the state is opening 14 new temporary testing sites at churches located in communities particularly impacted by COVID-19, in partnership with Northwell Health, an integrated health care delivery system and SOMOS Community Care, a network of providers that serve low-income people.
• Georgia, Massachusetts and Minnesota have provided pop-up COVID testing sites for people involved in protests, vigils, and community clean-up efforts.

Drive-Thru Sites

• Pennsylvania has plans to open 10 additional drive-thru testing sites throughout the state, and Mississippi is supplementing clinic locations with additional drive-thu sites.

Large-Capacity Testing

• North Dakota Governor Burgum announced massive testing events in Fargo – this adds to several other testing events the state has put on to test it’s residents. Testing is provided free and there is no insurance or proof of residency required.
• Maryland Governor Larry Hogan announced that the Maryland Department of Health will begin operating a free COVID-19 testing site at the Baltimore Convention Center beginning Wednesday, June 17.

Population-Specific Testing

Congregate Living Populations

• Many states, including New York, Oklahoma, Illinois, Michigan, Oregon and Missouri have prioritized testing for staff and residents of long-term care facilities. Illinois and Ohio have also established plans to test all staff and residents at their nursing homes for veterans.
• States are also focusing efforts on congregate populations in the criminal justice system. Maryland began universal COVID-19 testing at all state-run correctional and juvenile facilities. Ohio announced in early April that it would conduct comprehensive testing in its state-operated prisons. Wisconsin and Michigan have also outlined plans to conduct statewide testing among its incarcerated populations. The Marshall Project is documenting COVID-19 infection rates and deaths among incarcerated individuals across the country.
• New Jersey is providing saliva-based tests at its five centers for adults with developmental disabilities, in partnership with Rutgers.
• Texas will expand COVID-19 testing to all staff, residents and patients at its 23 state-operated inpatient psychiatric hospitals and living centers throughout the state.

Asymptomatic or Pre-Symptomatic Testing

• Ohio and New Mexico have announced that anyone who wants a COVID-19 test can get tested even if showing no symptoms or are low-risk.
• Rhode Island has expanded COVID-19 testing for people not showing symptoms. The expansion was to start with child care and close contact workers.
• Utah has extended COVID-19 testing to those without symptoms
• Missouri will conduct sentinel testing throughout 28 counties overseen by Corrections, Social Services, and Veterans Affairs.

Agriculture + Food Workers

• In New Jersey, a bill has been introduced in the Senate that would provide stronger protections and guidelines for farm workers, including mandated testing of all workers, and required infection control measures, provision of PPE on the part of employers. Governor Murphy’s Administration has also issued guidance and a testing plan for seasonal farm workers and employers.
• When Maine announced a massive expansion of COVID-19 testing, it included allowing seasonal and migrant farm workers to get tested without the need for a separate order from a health care provider or rewritten order from a clinician. Workers can get tested with or without experiencing symptoms.
• States have been working closely with food producers and processors to increase testing, given that many facilities have (or have the potential to) become hotspots of COIVD-19. Much like congregate living, increased testing in these settings has been paired with physical distancing, PPE, and other transmission reduction efforts.
  • Washington county health officials made it a requirement for Tyson to test all employees for COVID-19.
  • Kansas received over 7,000 additional COVID-19 testing kits, including more personal protective equipment, from the federal government. These kits were to be used on people with ties to the meat-packing industry.
  • South Dakota helped set up free drive-through testing for Smithfield Foods employees and their families in Sioux Falls, South Dakota. Employees were able to get testing whether or not they were experiencing symptoms. Testing was not mandatory but was encouraged.
  • In late April, Tyson asked all 2,800 employees to get COVID-19 testing in their parking lot – after ~1000 tested positive, Tyson carried out one-time tests of every worker at almost 20 facilities in states such as Maine, Virginia and Texas with around 30,000 being tested overall.
  • Iowa called upon the National Guard to assist in COVID-19 testing at meat packing plants. Activities included delivering testing equipment to plants, transporting kits to labs and assisting with cleaning the facilities.

Application of Equity and Culturally Responsive Approaches to Testing

• Illinois has opened eleven community-based testing sites for anyone to get tested, regardless of symptoms. There are now a total of 279 public sites for Illinoisans to access tests. Of the 279 sites, 108 are Federally Qualified Health Centers, committed to providing meaningful, culturally competent health care to everyone, regardless of insurance status or ability to pay.
• Delaware announced a two-pronged approach to shift from symptom-based testing in hospitals to proactive/active community-based outreach testing, including establishing walk-up and drive-through events in areas of Delaware that are home to citizens who are more vulnerable to the spread of COVID-19 because of long-standing inequities.
• Nashville, Tennessee has hired specialized community outreach workers, in partnership with immigrant advocacy organizations, to manage contact tracing and connect families with coronavirus testing.
• Montana Governor Steve Bullock has visited all eight tribes in the state to roll-out collaborative testing efforts in tribal communities.
• Minnesota announced expanded testing, and prioritizing vulnerable and underserved populations, including those experiencing homelessness; staff that serve vulnerable populations and health care workers; communities of color and American Indian populations.