COVID-19: How will states reopen? Testing, contact tracing remain puzzles

Erin McCallister Senior Manager, Health Research Institute, PwC US April 17, 2020

States have started to band together by regions to coordinate plans to reopen their economies as early signs suggest that the number of new confirmed cases of COVID-19, at least on a national basis, has started to plateau. However, difficulties in setting up robust testing and contact tracing could keep some states in a holding pattern.

The apparent high transmissibility of SARS-CoV-2, the coronavirus that causes COVID-19; the high mortality rate for those who develop severe forms of the disease; the potential to ruinously swamp hospitals and health systems; and the lack of a suppression program to contain outbreaks early on were the main drivers for the physical distancing recommendations announced by the Trump administration in mid-March and the flurry of “shelter in place” orders announced by state governors throughout March and early April.

Two former FDA commissioners, Mark McClellan and Scott Gottlieb of the American Enterprise Institute, along with other experts, unveiled a COVID-19 surveillance road map on April 7. For states to begin reopening, the plan assumes the nation will be able to conduct 750,000 diagnostic tests per week and recommends contact tracing and self-quarantine for those who test positive.

An April 8 white paper from Harvard University’s Edmond J. Safra Center for Ethics pegs the testing benchmark at millions of tests per day, depending upon the ability to conduct robust contact tracing.

The testing estimates coincide with an April 10 report from the Association of State and Territorial Health Officials (ASTHO) and the Johns Hopkins Bloomberg School of Public Health, which outlines a national plan for comprehensive COVID-19 contact tracing. In the report, ASTHO notes that an individual infected with SARS-CoV-2 can infect two or three others. “If 1 person spreads the virus to 3 others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections,” the report states.

While the FDA has issued over 30 emergency use authorizations for in vitro diagnostics to diagnose patients with COVID-19, including high-throughput and point-of-care tests, most states cite limited testing availability or backlogs at national commercial labs.

The 750,000 tests per week benchmark highlighted by McClellan and Gottlieb equates to one test per 437 people or 0.002 tests per person, far short of the experts’ benchmarks.

According to, which collects testing data from across the country, about 1 million tests per week have been conducted in the US in the past two weeks.

HRI’s analysis of some of the most populated and more rural states suggests that the capacity varies, with the hardest-hit states having more capacity. For example, New York, which accounts for over 60% of cases in the US, has an outsized capacity of 0.008. New Jersey, which has the second-highest number of cases in the US, has conducted over 44,000 tests per week in the past two weeks or about 0.005 tests per person. However, the state has reported a backlog in its ability to conduct tests and obtain the ancillary supplies needed for them.

California, the most populous state, has seen far fewer cases and has a capacity of 0.002 tests per person, which is the same as the most rural state, Wyoming.

To increase testing capacity in the US, CMS announced on April 14 that it would reimburse for high throughput testing at a higher rate of $100 per Medicare patient compared to $51 MACs are now paying COVID-19 tests.  “CMS has made a critical move to ensure adequate reimbursement for advanced technology that can process a large volume of COVID-19 tests rapidly and accurately,” said CMS Administrator Seema Verma in a statement announcing the new reimbursement rate.

Public health employees are also in short supply. According to ASTHO, the US public health workforce has been “sharply reduced” over the past 15 years.

As the cases plateau and testing continues to ramp up, contact tracing will be necessary to manage the COVID-19 epidemic, ASTHO said. The organization estimated that it would need 100,000 contact tracers deployed “to areas of greatest need and managed through state and local public health agencies.”

ASTHO estimated that $3.6 billion in emergency funding would be required.

Massachusetts has already announced plans to hire 1,000 people to do contact tracing, which ASTHO notes could serve as a model for other states. Additionally, tech companies have joined forces to develop an opt-in contact tracing app. The companies will start with apps from public health authorities in May and work toward Bluetooth-enabled tracing.

HRI impact analysis

Limited testing and contact tracing could hamstring the ability of states to hit the benchmarks outlined in the recent reports.

In the COVID-19 contact tracing report, ASTHO noted that during the Ebola outbreak in 2014-15, state and local health agencies conducted contact tracing and monitoring of nearly 30,000 people, which “stretched many local and state health departments to the maximum of their capacity.”

Earlier this month, the CDC reported that it had over 600 people in the field doing contact tracing for COVID-19 patients, while San Francisco said it had just 10 people in the city to do contact tracing with plans to add 100 more.

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Crystal Yednak

Senior Manager, Health Research Institute, PwC US

Erin McCallister

Senior Manager, Health Research Institute, PwC US

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