If testing is to be a foundational block of Maryland’s plan to begin reopening the state, as Gov. Larry Hogan has said it will be, then the tests themselves are just part of a complex supply chain management problem that needs to be solved.
Nearly 85,000 people have been tested in Maryland so far, but Gov. Larry Hogan hopes to get 10,000 people a day tested. To help, he acquired 500,000 tests from South Korea last weekend.
That may not be all the state needs.
“They don’t have everything that’s needed,” Hogan said Monday of acquired tests. “It’s a very complex set of things that goes into testing. You need the lab capability, you need the swabs, you need the reagents and they all need to work together.”
Almost every step of the testing process comes with its own supply and staffing issues. And these issues are made more complex because Maryland is not the only government trying to solve these problems.
After patients have been recommended for COVID-19 tests by their physician, they could receive an immediate test in high-priority cases, or go to one of the drive-through testing sites around the state.
Every test requires a nasal swab. Because health care workers take those swabs at close quarters, personal protective equipment — including masks, gloves, gowns and face shields — are required.
Swabs and protective equipment are particularly in short supply. The swabs, a special type with stiff bristles, have mostly been made at a factory in northern Italy, the epicenter of that nation’s COVID-19 outbreak.
Every country in the world, every state in the U.S. and most hospitals are all looking for these swabs.
“I think we already have a shortage of swabs, and it’s going to be more severe in the future because we try to broaden testing, especially when you are talking about people going back to work,” said Tinglong Dai, a professor in the Johns Hopkins University Carey Business School who studies the medical supply chain. “Everybody is trying to get the same supply, so that is causing a lot of problems.”
It may be easier to have a central body coordinating everything, Dai said.
“Everything depends on the weakest link,” he said. “You want someone who can have this global perspective and look at the separate parts, coordinate them properly and achieve the goal for us to go back to work.”
A different type of test could help solve the personal protective equipment issue, preserving some of that gear for hospitals. Rutgers University has created a saliva-based test for use in New Jersey. That type of test allows health care workers to collect samples without the intimate contact needed for a nasal swab.
A trip to the lab
After a sample is collected, it is placed in a viral transport media that allows its genomic information to remain intact while it is delivered to the lab. There, the virus’ ribonucleic acid, or RNA, is extracted and tested.
Typically, labs use one established test, said Kirstie Johnson, a professor of pathology at the University of Maryland School of Medicine. She is also the director of the Clinical Microbiology and Virology Laboratories at the University of Maryland Medical Center.
“In a normal situation with a normal disease that we are trying to detect in the lab, we normally pick one method and use that method. Normally we’re not battling supply issues with every hospital or every laboratory in the country,” she said.
On top of that, if a different test is changed or a different transport media is used, the lab has to make sure it will still get accurate results.
The pandemic has created a different situation where most tests are being used before full regulatory approval. There is no gold standard test for the virus yet, but tests are accurate enough for labs to use.
Most tests take about a day to return results. Some tests have promised quicker results, as fast as 15 minutes in some cases. But those tests can only run one at a time.
The University of Maryland School of Medicine is a key part of Hogan’s plan to ramp up testing in the state. Officials at the school are investing in robotics to run more tests at once.
But they will also need more people to help with that effort: people to log tests, run tests, ensure quality controls are in place and report results.
“No matter what you do, you need more people,” Johnson said. “We need people to make sure that the testing is working appropriately. And to get these numbers out, you need to do it 24/7. You really need to be able to perform the testing all day long.”
Testing the workforce
When eventually the state begins to loosen its restrictions and people start to move around a little more, taking the test will not be a guarantee of not getting the virus. It is only a glimpse into whether a person had the virus when they were tested.
A separate type of testing, serology, looks for antibodies of the virus in a person’s blood. If the antibodies are present, that means the person likely had the virus.
This type of testing could be important to learn more about COVID-19 and how it spread in the United States, particularly because it is believed that a lot of people who do not show symptoms of the disease are capable of transmitting the virus.
But serology will not reveal whether people who had the virus are protected against it because that is not known yet, Johnson said.
“We don’t know if this is long-lasting protection … or maybe you’re only protected for a couple of months,” she said. “This is the data that is needed before we could use a serology (to) release us back to work.”