The United States still does not have a handle on testing six months into the coronavirus pandemic.

The nation has conducted more than 4 million tests in the past week, more than ever before. But big jumps in testing capacity have been effectively erased by record-breaking increases in new infections as states reopen their economies. The supply chain problems that hampered testing early on never entirely went away and still threaten the ability of labs to conduct testing for everyone asking.

The renewed testing crisis threatens federal and state officials’ ability to quell an outbreak that public health experts say could spin out of control in the coming months.

Here are five reasons the US still does not have enough testing to safely reopen:

Commercial labs across the country are still having trouble getting adequate stocks of reagents, the chemicals they use to prepare samples for testing. Disposable pipette tips, which labs use to transfer samples from transport containers into testing machines, are emerging as another issue, said Julie Khani, president of the American Clinical Laboratory Association.

“There are labs that are going to be faced with stopping collecting of samples altogether, or limiting samples to high-risk populations for example,” Khani said. “These are the really difficult challenges that are facing laboratories. We’re doing everything we can do to avoid that.”

And 22 per cent of the nation’s public health labs said in late June that they had a week’s supply or less of reagents and other crucial testing components.

Disruptions in any part of the long supply chain for testing materials can quickly lead to bottlenecks, labs and public health experts warn. And some states say federal efforts to distribute testing supplies have sometimes created more work.

The Trump administration has on multiple occasions sent Washington state testing supplies that were badly packaged, unlabeled, incompatible with the state’s equipment or otherwise unusable, the state’s health secretary, John Wiesman, wrote in a letter this week to Health and Human Services testing tsar Brett Giroir.

In one case, the federal government sent 250,000 testing swabs packaged in bulk that the state then had to sterilise and repackage, Wiesman wrote in the letter, obtained by POLITICO. Though the letter thanks the administration for the supply distribution effort and says things are much better than the severe shortages the state experienced earlier this year, it notes that ongoing supply problems “threaten to limit our overall testing capacity at a critical time in the pandemic response,” he said.

Samples are piling up faster than labs can analyse them, which is lengthening turnaround times for results – complicating efforts to contain the virus.

But the soaring rates of new infections across the country are just one part of the equation. Part of the rising demand is the result of a recent push to test residents of prisons and nursing homes, who are especially vulnerable if the virus starts spreading in their facilities, Giroir told reporters Wednesday. Some businesses are also conducting mass testing of their workers and hospitals are testing people undergoing elective surgeries.

And if states’ reopening plans reach the point where travel returns to a normal volume, that could drive up the need for tests ⁠ – potentially pitting visitors against residents in places like Hawaii. “We can complete between 5,000 and 7,000 tests per day, which we feel is adequate in terms of managing the disease,” Hawaii Gov. David Ige told POLITICO. “But reopening will create a real dilemma and testing challenge for us once we get anywhere close to a normal volume of tourism.”

In recent weeks, federal officials have said they are exploring a strategy called sample pooling to help preserve testing supplies while expanding capacity. The strategy combines samples from multiple people and tests them as a group. If the result comes back positive, each person in the group is tested individually.

“My assessment is that the data is very strong that pools of at least five and up to 10 are going to be highly validatable and can be put into use,” Giroir said. “By the time the universities get back, I think pooling will be very mature.”

China and some other countries have already used pooling to screen large numbers of people. In late May, the city of Wuhan tested millions of its citizens this way to help stamp out cases before they caused a second wave of infections.

But pooling isn’t a one-size-fits-all solution, says Scott Becker, CEO of the Association of Public Health Laboratories. The approach works best in areas where coronavirus prevalence is low, the number of samples in a pool is limited and high-quality labs conduct the testing, he said. “I am concerned as I was with [antibody tests] that the policy and the regulatory side may be getting ahead of quality,” Becker added.

Testing can identify people who are sick, but by itself it’s not enough to break chains of infection. That requires tracing the contacts of people who are ill so they can be tested and quarantined to avoid further spread of the virus.

But even as the US scales up testing to record levels, the country is woefully behind on contact tracing. The federal government has largely left that task up to understaffed and underfunded state and local health departments that are unable to keep up with the caseload.

Experts and government officials warned months ago that the country would need a minimum of 100,000 contact tracers to reopen safely. But states are working with only one-third that number, a shortfall that has helped fuel the recent spike in cases.

Rather than establish a national strategy for contact tracing, the Trump administration has given feedback on state plans and admonished the public to maintain physical distancing and practice robust handwashing.

Alaska’s chief medical officer, Anne Zink, told lawmakers and reporters Thursday that her small staff at the state’s Department of Health is starting to be overwhelmed.

“For the majority of this pandemic, 96 per cent of our patients were contacted within two hours of being positive. That’s quickly eroding,” she said at a round table held by Sen. Bill Cassidy (R-La.). “Our cases are increasing, our public health staff is exhausted, and people are having bigger and bigger group gatherings. It used to be to get four or five contacts, and now you have 50 or 100 or ‘I don’t want to talk to you on the phone.’ And so the ability to trace is becoming incredibly challenging.”

More than 20 million people in the United States live in coronavirus “testing deserts” – and people of colour are disproportionately represented in those counties without testing sites, the Surgo Foundation reported this week.

“If you’re a Black person living in rural America, you’re nearly three times as likely to be living in a testing desert where deaths are rising, compared to any average rural American,” said Dr. Sema Sgaier, the group’s executive director.

The pandemic quickly exposed deep racial disparities in Americans’ overall health and access to coronavirus testing and care. Congress has pushed the Trump administration to do more to track and address the virus’ disproportionate impact on communities of colour.

The Centres for Disease Control and Prevention has established a partnership with Morehouse College, a historically Black institution, to work on a national infrastructure to track how the pandemic is affecting racial minority groups – and to help serve them better. The administration has also worked to set up testing sites at pharmacies and federally qualified health centers that serve “high social vulnerability communities.”

But lawmakers and advocacy groups say the administration’s efforts are late and inadequate.

CDC Director Robert Redfield was forced to apologise to Congress earlier this month for not providing complete information on racial disparities in the pandemic as required by law. The administration released a report last week showing the Black people contracted Covid-19 nearly three times as often as white people, and were hospitalised four times more than white people. Hispanic and Asian people were also more likely to become infected and hospitalised than white people.

“The administration failed to plan in a comprehensive way for nationwide challenges like scaling up testing and contact tracing, and ignored – and exacerbated – existing health disparities that left Black, Latino, and Tribal communities to face the worst of this crisis,” said Sen. Patty Murray (D-Wash.)

The Trump administration has shied away from developing a national testing strategy, although it has helped route supplies to labs and connect hospitals to labs with spare capacity.

But Democrats and public health experts say the United States needs a nationwide plan – including stronger federal efforts to secure key supplies.

“The Trump administration really just wants to turn the page from Covid-19 even though we’re seeing skyrocketing numbers across the nation,” said House Energy & Commerce Chair Frank Pallone (D-N. J.). “This crisis demands a national testing plan, and it’s extremely frustrating to watch the administration continue to kick the responsibility to the states.”

Ahead of the July 4 holiday weekend, health officials and experts pleaded with Americans to slow the spread of the virus by practising social distancing and wearing a mask in public. Several states – including Texas, Florida and California – have paused reopening efforts and ordered bars to close as case numbers spike. Texas Gov. Greg Abbott issued an executive order Thursday that mandates mask wearing in most public settings.

“Especially this weekend, we should be meeting or engaging in outdoor activities while maintaining physical distancing of at least six feet,” said Joshua Barocas, assistant professor of medicine at the Boston University School of Medicine. “I would urge people to stay home if they’re even feeling the slightest bit unwell.”

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