With Arizona and other states considering reopening their economies on May 1, health experts said the state isn’t yet doing enough COVID-19 testing or collecting good enough data to responsibly lift stay-at-home orders.
Arizona has done 51,000 tests through Saturday, a fraction of the COVID-19 tests needed to judge how widespread the outbreak is in a state this size. Measured in tests per million residents, Arizona was in the bottom 10 states nationwide last week.
And data the state provides is widely seen as inadequate. The state is missing demographic data about positive cases and deaths, its location data mixes hospitals with private residences, and the state won’t provide data about cases and deaths on Indian reservations or in nursing homes.
“It just isn’t going to work unless you have crystal clear data,” said William Haseltine, an infectious disease expert and president of the global health think tank ACCESS Health International. “If Arizona doesn’t have that they are miles away from being prepared to reopen.”
New guidelines from the White House call for states to reopen their economies once they see a downward trend in documented cases or positive cases for 14 days.
But Dr. Mario Ramirez, former acting director of the Office of Pandemic and Emerging Threats under President Barack Obama, said there hasn’t been enough testing to determine whether coronavirus cases are truly dropping.
“What I think is being missed … is we don’t have good data on how many people are actually testing positive,” Ramirez said. “The uncertainty that you are experiencing in Arizona, you know, I think is reflective of what a lot of people are seeing all across America.”
He estimates Arizona needs about 3,200 tests per day — or 100,000 tests per month — to safely reopen, based on data from South Korea. Through high-volume testing and rigorous monitoring of those who are infected, South Korea limited deaths to only 232 people despite being one of the first countries hit by an outbreak.
In the seven weeks since widespread testing began in early March, Arizona has tested 51,000 people.
The state has begun ramping up testing, administering an average of nearly 12,000 tests in the three weeks ending April 11. But Ramirez estimates there needs to be about 22,000 tests a week to start reopening.
Ramirez also said he worries the public thinks if someone is tested once then they are good forever. In reality, he said, people will have to be tested multiple times because the tests aren’t 100% accurate and because they can still be exposed to the virus after a negative test.
“Real surveillance means you are probably testing people over and over again,” Ramirez said.
The current PCR testing—which detects the current presence of the virus— is only about 70% effective, he said, adding “so if you figure that you know somebody who is truly positive that you miss it three out of 10 times, obviously that’s not acceptable. You need to test that person at least twice.”
Gov. Doug Ducey has said the state needs more tests.
“We need more, a lot more,” the Republican governor said at a news conference on April 14. “And there’s not a governor in the country who doesn’t need more testing, with a greater availability of testing and more rapid turnaround of results.”
He said he wants to open the state as soon as possible “when it is safe and healthy to do so.”
“Our goal is to make the right decision at the right time” focusing on public health and data, Ducey said.
The University of Arizona announced last week that it plans to test 250,000 people over a month for COVID-19 antibodies, to determine if they have had the virus. These tests, called serology tests, don’t detect if someone currently is infected with the virus, but can determine if an individual has antibodies to defend against the infection.
Serology tests are “vital to know who is at risk and who isn’t,” giving those who are not at risk more freedom of movement, including returning to work, Haseltine said.
“If you have a high concentration of antibodies against the virus, you’re likely to be protected,” he said. “Not 100%, but more likely than not.”
Haseltine, who is a former professor at Harvard Medical School, said both the PCR testing and serology tests are critical to safely opening the economy.
“The two kinds of testing have to be available and they need to be available to test most people repeatedly,” Haseltine said.
Without tests, ‘you have a blindness’
Eric Forgoston, an applied mathematics professor at Montclair State University, is building mathematical models of the scope and spread of the new coronavirus in New Jersey.
There is a lot of uncertainty in models currently used to predict infection and death rates, he said. That’s because there is uncertainty in the data being put into the models, mainly because of a lack of information about testing.
“We need good testing data, which unfortunately throughout this country, not just in Arizona, we don’t have — even in some of the major hot spots,” Forgoston said. “We still don’t have enough to know exactly who has been infected. And that goes for both infectious individuals who are showing symptoms, as well as those who are not showing symptoms. And unless you have that data, really good data, on who’s being infected, then it’s very difficult to know what the transmission rate is.”
Without that information, it’s impossible to safely end social distancing and mitigation policies, Forgoston said.
“It cannot really be done in an effective manner unless you have good testing, good contact tracing, good serological testing to know who has antibodies,” he said. “Otherwise … you have a blindness really to what is going on.”
Forgoston said it’s clear social distancing measures work. To end them without knowing the true extent of the virus’ reach would expose vulnerable people to the illness.
“You’ll just have another disease outbreak,” he said. “All you’ll have really done is pushed the epidemic down the road a little bit and you haven’t achieved much.”
The testing is key to help determine who is has COVID-19 as well as who is asymptomatic but still spreading the disease, he said. But right now even people with symptoms can’t get tested.
Sally Eddings, 72, who lives in Parker, said she doesn’t believe Arizona’s coronavirus case numbers because of her experience after falling ill.
She developed a cough and severe body aches that were so debilitating she couldn’t stand up. She had a 102-degree fever that came and went for two weeks. She lost her appetite and sense of taste.
“I am a lifelong coffee drinker but I couldn’t gag down a cup of coffee,” she said.
Despite her symptoms Eddings couldn’t get a test. She called her local hospital and health department, which told her to call elsewhere. There have only been 67 tests administered in La Paz County as of Saturday, according to the Arizona Department of Health Services.
She talked to her doctor and another hospital and was told she wouldn’t be tested unless she was unable to breathe. She was directed to stay at home.
“By that time I was so weak I was unable to drive,” she said. “I was basically just ignored. They didn’t want to know.”
The overall picture of the pandemic can’t be right if there aren’t enough tests, Eddings said. “There’s no other conclusion.”
Test and trace
Dr. Cara Christ, ADHS Director, said last week that some of the state’s models show hospitalizations for COVID-19 won’t reach their peak until May, raising questions about how the state might safely reopen on May 1.
ADHS spokesman Chris Minnick said Christ will say more publicly about the models this week.
Forgoston said it’s natural for the public to wonder about the differences in what different models predict, especially when one predicts 60,000 deaths nationwide, while another predicts 100,000 deaths.
There are differences in the models because there isn’t good testing data, he said. “The usefulness is in looking for a range of outcomes,” Forgoston said.
He said models are useful for making predictions, but leaders shouldn’t rely on only one. They should look at many to draw their conclusions.
Haseltine, the former Harvard Medical School professor, said rigorous contact tracing, where health authorities track down everyone who has potentially been exposed, is needed before reopening the economy. Arizona has not done a good job of contact tracing, which involves requiring people who’ve been exposed to isolate themselves and to be monitored by health officials.
Haseltine said people who have been laid off during the pandemic could be hired by health departments to help do this work.
“It requires training, manpower, organization and access to tests, and it requires compliance by the population,” he said. “And if the compliance isn’t voluntary it should be made mandatory with sentencing, fines and imprisonment if necessary. That’s tough medicine but it’s the only way to get back to work.”
Ramirez, the emergency room doctor who worked in infectious diseases in the Obama administration, said until the country has enough tests and can trace those who test positive, we won’t know if “case counts are decreasing the way they need to, to open back up safely.”
Ramirez, who is also managing director of Opportunity Labs, a consulting organization that has designed a road map for re-opening the nation’s schools, said accurate testing data will continue to be necessary well into the future.
“There is every possibility that there will be a second wave of this thing in the fall or winter months,” Ramirez said. “What happened with the 1918 flu (pandemic) is that we had this initial wave, people got lulled into a false sense of security, and then the second wave was much bigger. And now we live in a different time or we have the capability and the capacity to prepare for that. But it takes some intentional thinking.”