The Georgia Department of Public Health’s recent announcement it would expand testing for the novel coronavirus brought praise and sighs of relief from those dismayed that the state ranked among the worst in the proportion of citizens tested.
Now that any resident with symptoms is eligible, public health officials will learn more about the disease’s grip on the state, and who is suffering the most.
But the expansion of testing and infrastructure needed for Georgia to halt the spread of COVID-19 may be of a different order of magnitude entirely, public health experts, state health care leaders and others cautioned, especially now that Gov. Brian Kemp has quietly begun working on a plan to ease the lockdown.
» COMPLETE COVERAGE: Coronavirus in Georgia
The state's ability to reopen the economy without causing more deaths rests on its capacity to test, identify and track a far greater percentage of those who have the disease. Estimates on the number of tests needed vary, but the nation's leading experts believe states must identify and track all symptomatic coronavirus cases to get the pandemic under control.
“It is a big undertaking, but we have got to do it,” said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials (ASTHO), the nonprofit that represents the nation’s public health agencies.
“If we do want to open the economy, we have to have the disease under control, otherwise we’ll be right back to where we were before,” said Plescia, who was previously with the North Carolina Division of Public Health and director of national cancer control programs at the Centers for Disease Control and Prevention.
» RELATED: Kemp devising plan to reopen Georgia for business
» MORE: Confusion, scarcity lead to haphazard testing in state's virus response
Georgia must perform diagnostic testing on as many people as it takes to keep deaths at the lowest rate possible, said Dr. Howard Koh, a former U.S. Health and Human Services assistant secretary under President Barack Obama. He previously ran Massachusetts’ public health department.
"Every state has to make this commitment," said Koh, a Harvard University professor. "Every state has to step up and make this a sustained priority for the indefinite future."
Testing is central to the Trump administration's new road map to reopening the country. Places with declining infections and strong testing would begin a three-phase gradual reopening of businesses and schools.
Testing in Georgia has been hampered by the uneven availability of test kits, the protective gear needed to administer them and enough labs to process them. Lab capacity has improved but shortages of swabs, gowns and kits remain. The reliability of testing has also become a focus of recent discussion, as practitioners learn more about how they can yield false negative results.
Antibody tests to detect if someone was exposed to the virus are also coming online, and may have the potential to help chart the virus’ spread, though public health experts continue to debate how useful they are, at least for now, in determining immunity.
The beginnings of an infrastructure that can take on the testing challenge exists in Georgia, Plescia and others said. But to get the response right will require state agencies to build up the public health system like never before, mobilizing resources, cash and manpower that some worry currently lie beyond its reach.
State officials have yet to describe publicly any short- or long-term testing strategy, or disclose what factors they’re considering as they shape one. But members of Gov. Kemp’s coronavirus task force said such discussions are taking place.
The state Department of Public Health (DPH) did not make its officials available for comment on its testing strategy and infrastructure. Spokespeople for the Georgia Emergency Management and Homeland Security Agency, which is finding and distributing needed supplies, did not reply to repeated requests for information on what role it is playing in procuring testing supplies.
State authorities have acknowledged the testing system’s shortcomings, and said in hindsight, prior restrictions on testing only medical personnel, first responders, high-risk people and the very sick were probably too tight.
“We can definitely do more than we’re doing,” Kemp said Thursday. “We can definitely help, but we need the private sector to step up. We need to have a test where people can basically immediately test themselves before they leave the house and go to work.”
"The government in my opinion is not going to be the answer," Kemp said.
Georgia has improved its position in the past week from 45th to 42nd nationally in tests per capita, but New York, Louisiana and Rhode Island have tested its residents at rates four times Georgia’s, an AJC analysis of data through Thursday found. Yet the nation as a whole lags behind South Korea and other nations that are setting the global standard for testing.
Setting the strategy
Such monumental testing goals are a tall order for any state, and may be especially difficult in Georgia, where spending per resident on public health ranks 37th in the nation.
Current testing infrastructure across Georgia’s 18 public health districts covering Georgia’s 159 counties is “spotty,” said Dr. Harry J. Heiman, a clinical associate professor at the Georgia State University School of Public Health.
"We've under invested in public health forever," Heiman said. "Public health is one of those things nobody cares about until someone gets sick."
Like many southern states, Georgia ranks near the bottom in health outcomes and health disparities. It has more obese people than most states and higher rates of hypertension, kidney disease, lung disease, diabetes and other conditions upon which the coronavirus tends to prey.
Rural areas such as Albany, which is home to one of the worst outbreaks in the world based on death rate, rank among the state’s worst.
The state’s public health offices gained experience tracking and monitoring potential cases as part of a national effort to halt the spread of the 2014 Ebola virus outbreak in West Africa.
But interest in spending state dollars to build this infrastructure appears low, said Laura Harker, a senior policy analyst at the Georgia Budget and Policy Institute.
“I don’t know if I see the will to increase the state’s investments,” Harker said.
Whatever political and budget challenges the state faces, setting a safe, timely and effective strategy to achieve such goals is crucial in the coming weeks, said Koh. It must be suited to patients’ needs, and distribute resources equitably.
State officials are responsible for making sure Georgia has enough supplies, staffing and space, and must coordinate between between private and public efforts, Koh said. They should track and monitor the state’s testing capacity from all sources — including commercial sites and labs.
“This is what public health does — to assure people a system is working on their behalf,” Koh said.
Private sector help
But government resources won’t be enough, said Allison Chamberlain, acting director of the Emory Center for Public Health Preparedness and Research.
"Is a massive investment in that going to get us as quickly where we need to be? Or can we supplement what we have with the private sector? To me, it's going to take both," Chamberlain said.
Chamberlain envisioned the state pressing employers to shoulder responsibility for testing, much like how many companies provide flu vaccines to workers.
Amazon CEO Jeff Bezos, one of the nation’s largest employers, is calling for dramatic ramp-up of testing and his e-commerce giant is developing its own lab to potentially test its global workforce.
Georgia needs to coordinate a supply chain and staffing that can produce at least hundreds of thousands more tests, and make testing equipment that provides results within minutes, or at least within 24 hours, widely available. But testing does need to be decentralized, and include major involvement from the private sector, which currently processes the vast majority of tests.
ASTHO and Johns Hopkins Center for Health Security recently recommended that the country add some 100,000 paid or volunteer workers to trace and notify the people who have come into contact with those who have tested positive.
Massachusetts, the only state known to have released a comprehensive testing and tracking strategy, plans to hire 1,000 contact tracers. Based on Johns Hopkins' figures, Georgia would need to hire some 1,600 people at a potential cost of more than $50 million to follow this approach.
Internationally, Germany and South Korea tested faster and at a rate about double what Georgia had through Thursday, and the nations deployed widespread contact tracing to isolate cases of the disease. Because Georgia and the U.S. have been slow to ramp up testing, and were forced to lock down for lack of contact tracing, experts said states might need to deploy far more tests than Germany or South Korea.
Testing in Georgia
For weeks, testing has been rationed in Georgia to only the very sick, and to health workers, first responders and those living and working in long-term care facilities who have symptoms of COVID-19. On Wednesday, state officials said testing would be expanded to people displaying symptoms of COVID-19, which includes fever, fatigue and a dry cough. State officials say people with coronavirus symptoms can make an appointment for testing by calling their county health department or after getting a doctor’s referral. Health departments will screen patients over the telephone and direct them to a testing site.
Georgia alone might need tests for at least 20% of its population — or enough for about 2.1 million people — in the months ahead, said Justin Bellante, CEO of Atlanta-based BioIQ, a health company that connects employers and health plans with testing.
Based on current testing rates, it could take 580 days to reach Bellante’s 20% mark, an AJC analysis shows.
Confusion and complications
While testing availability has grown, the process of finding one remains chaotic and confusing for patients and even doctors. Information on state-run test sites is easy to find, but they have limited supplies, and not every patient can be tested immediately at them.
No central website lists all the medical practices, urgent care centers and other private sites in Georgia that are willing to test the public — an essential part of pandemic response, experts said.
"It shouldn't be this complicated," said state Rep. Teri Anulewicz, D-Smyrna, who has fielded calls from sick constituents who are frantic to find testing.
Dr. Melanie Thompson, principal investigator of the AIDS Research Consortium of Atlanta and a practicing physician, said her practice is using its professional networks and resources to find testing sites. It sets its own criteria on how it will use the few tests it receives from commercial labs.
Thompson’s practice currently has enough supplies to test only five of its patients, many of whom are living with HIV.
“I know everybody is trying very hard, but I do think we’re lacking a strategic approach, and that really does begin at the state and federal levels,” Thompson said.
Family physicians could help unburden the state’s hospital system by ramping up their testing, but many practices lack gowns, face shields, masks, and respirators required to protect their personnel, said Dr. Jeff Stone, an Acworth doctor and president of the Georgia Academy of Family Physicians.
“There are some practices in the state that are struggling to get any kits,” Stone said.
Many sick Georgians feel lost in the system.
John Prescott of Norcross started suffering from a high fever, body aches, swelling in his throat and a nagging cough two weeks ago. His doctor’s office had him wait in a tent outside after he filled out a form about his symptoms.
On his chart he found out why. “Suspected COVID-19,” it said.
Prescott was swabbed for strep throat, which came back negative, but not for the coronavirus. He said he couldn’t get an appointment at a testing center at Georgia Tech, and a nearby urgent care didn’t take his insurance.
Prescott, who works for a delivery company, said he isn’t allowed to return to work until he’s tested.
“I feel fine now, but that doesn’t mean I don’t have it,” Prescott said. “I could spread it to somebody, and I don’t want to do that. I need to get back to work. I got my stimulus check but that will only last so long.”
‘We shouldn’t be discouraged’
Georgia officials will have to be creative to scale up its testing capacity quickly. But the good news is that there are a lot of potential solutions, experts said.
The state legislature could raise $400 million for testing and other coronavirus response needs by enacting an existing proposal to increase its tobacco tax, which is currently the third lowest in the nation, policy analyst Harker said. Expanding Medicaid could bring even more. Congressional Democrats are also pushing to include $30 billion to accelerate testing in the next appropriation for the pandemic.
New types of antibody tests currently in development, including one at Emory, can show who had COVID-19 in the past. Further study of antibodies might reveal if any provide protection against the disease and may ultimately lead to treatments, though experts have serious concerns over whether they can show a recipient is protected from contracting the disease again. Nonetheless, learning who had the virus could supplement the data on who’s sick with it and provide a clearer picture of how it’s spreading.
State agencies can lean on technology to automate some of the contact tracing needs, and recruit students at public health schools to work with local agencies to augment their ranks, Emory expert Chamberlain suggested.
Every city and county can post where testing is available on their websites, Koh said.
Contact tracers do not need advanced degrees, so public health departments can hire workers furloughed or laid off from the YMCA, church organizations, and other groups that often partner with local and state governments on public service projects, said Plescia, the head of the group for the nation’s public health agencies. If state government hiring processes are too slow, it can contract with local universities to hire and train them.
States have a clear opportunity to gain more control over the pandemic, Plescia said, and resources are coming.
“Yes we’ve got to do this,” he said. “No, we shouldn’t be discouraged.”