In two months, the novel coronavirus has ripped through Malheur County, 10,000 square miles of cattle ranches, onion farms and small towns on the border with Idaho.
On July 1, the Malheur County Health Department offered drive-thru testing at the county fairgrounds for people showing symptoms of the virus, with a promise they should get their results back in about five days.
For many in Malheur County, the drive-thru event was the only easy way to get tested. The local hospital is reserving its testing capacity — which returns results quickly — for admitted inpatients only.
But five days proved to be an optimistic estimate. The county’s public health department sent its swabs by FedEx to Quest Diagnostics, a national lab Oregon has partnered with to increase testing capacity statewide. It took 14 days for the county to get the last of its results back from Quest.
Making the problem worse, about 16% of the samples collected during the testing drive came back positive for COVID-19. The county’s public health staff had to call people to let them know they had the coronavirus. In some cases, the calls came days after people’s symptoms had disappeared and after the Centers for Disease Control’s recommended 10-day isolation period had already elapsed.
“It was almost pointless. It takes so much of our staff time, PPE and capacity,” said Sarah Poe, the Malheur public health director. "That definitely is not meeting the need and purpose of testing in the first place.”
Almost five months into the pandemic, the coronavirus is spreading, often undetected — and certainly under-detected — in every community in Oregon.
Testing is supposed to be the cornerstone of the state's effort to suppress the virus.
But local and national supply shortages, delays processing results at out-of-state labs, and competing demand from hard-hit states like Arizona and Texas are undermining Oregon’s efforts to track the virus and to find and isolate the close contacts of people who test positive before they unwittingly spread the virus to even more Oregonians.
Public health clinics in Multnomah County have also been using Quest Diagnostics for testing and experiencing long delays.
With a virus as fast-moving and transmissible as COVID-19, the lag time in testing may be contributing to community spread, according to Dr. Jennifer Vines, Multnomah County health officer.
“There’s a big prevention window opportunity missed,” she said. “It makes contact tracing much more difficult and much less effective.”
A national problem with major Oregon impact
In Oregon, getting a COVID-19 test generally requires a doctor’s order. Many of the state’s hospital systems including Kaiser, Legacy and Providence have their own laboratories that can quickly process tests.
The Oregon State Public Health Laboratory can process coronavirus tests too, but due to limited capacity, the state lab focuses on rapid testing for people living or working in especially vulnerable settings, such as nursing homes, prisons and day cares.
The state has contracted with two of the nation’s largest commercial labs, Quest Diagnostics and LabCorp, to provide testing for places like Malheur County — communities that have significant outbreaks and limited hospital lab capacity.
Quest has been warning for the past month that demand for coronavirus testing nationally was once again outstripping supply.
“Despite our rapid scaling up of capacity, soaring demand for COVID-19 molecular diagnostic tests across the United States is slowing the time in which we can provide test results,” reads a July 20 statement on the company’s website.
The company cites limits involving the capacity of its testing machines and availability of chemicals.
According to Quest, the average processing time for the highest-priority patients — including people who are hospitalized and symptomatic health care workers — is now over two days, double what it was a month ago. For all other patients, Quest says processing results can take seven to 14 days.
The delays at commercial labs like Quest have led many counties to reimpose stricter limits on who clinicians can test for COVID-19.
In Multnomah County, some health systems had been providing tests for workers headed to Alaska, which requires a negative test for travelers from the lower 48 states.
Some local workplaces have also asked employees to provide a negative COVID-19 test result before returning to work.
Dr. Vines said Multnomah County is de-prioritizing testing for travelers and asking employers not to require a negative test for people returning to the office, both responses to slow turnaround times for tests.
“For now, just thinking collectively, it’s not the best use of our testing resources,” she said.
A test too late
With tests in short supply, confusion around who is eligible for testing is also causing delays with serious consequences.
Cottage Grove resident Steve Liu tried to get a test for COVID-19 when he developed a fever after a family vacation in Montana.
Liu registered as a patient with Nova Health, which runs drive-thru testing centers in Lane County. It took him about 48 hours to complete the paperwork and get a telehealth appointment.
He was told to wait five days before getting a test, so that it would be “more accurate.”
While Liu waited, he worried: He called his parents to let them know they might have been exposed to COVID-19. When he called his children’s mother to notify her, he learned that his 15-year-old son had developed a cough, too. Both children and their mother, who works at a long-term care facility, eventually tested positive.
By the time Liu got his results, his wife had tested positive too.
Dr. Marc Schnapper, the medical director at Nova Urgent Care, said Liu shouldn’t have been told to wait at all.
“If you have had an exposure to a known contact, and do not have symptoms, the best time to get tested is four to seven days after exposure. But if you have symptoms, you should come in right away,” he said.
Counties with robust hospital networks that often do their own in-house testing are not immune to testing delays.
Some of those delays, like Steve Liu’s, are due to miscommunications.
“As a medical director, we put out protocols. But things are changing so fast, and we’re getting inundated with phone calls,” Schnapper said.
Testing delays mean tracing delays
Lane County is now seeing two- to seven-day delays on most COVID-19 tests.
“That delay can have a real personal impact, it’s so frustrating to not know. But there’s also a larger public health impact,” said Jason Davis, public information officer for Lane County.
Delays make a contact tracer’s job harder, because with each day that goes by, the virus spreads exponentially. It’s not just the sick person’s contacts, but their contacts' contacts, and so on.
Public health leaders in rural parts of Oregon say their communities are particularly vulnerable to delays and other problems with testing.
“We don’t get the volume of supplies. We don’t have access to the labs. We’re at the mercy of someone else,” said Lesley Odgen, CEO of Samaritan North Lincoln Hospital and Samaritan Pacific Communities Hospital in coastal Lincoln County.
Lincoln County, like Malheur, is in the midst of a significant COVID-19 outbreak, including 181 workers at seafood processing plants in Newport.
Ogden said access to rapid, reliable testing has remained a challenge for her hospitals and Lincoln County residents since the start of the pandemic. “It’s this mad scramble,” Ogden said, “to try to figure out how are we going to do more, how are we going to help our patients.”
Odgen said Samaritan has repeatedly run into problems with the labs with which initially contracted to process COVID-19 tests. The hospitals were sending samples to Quest Diagnostics, but switched after the turnaround times were too long. The second lab it worked with, Legacy, started experiencing equipment failures and supply shortages, so the hospital is now working with a third lab, Willamette Toxicology.
Samaritan, like a lot of hospital systems, also developed in-house capacity to process COVID-19 testing, by repurposing an Abbot brand diagnostic machine the hospital had to test for other pathogens. But according to Ogden, the hospitals are running into the same supply chain issues that have slowed down commercial labs.
Nasal swabs, diagnostic machine parts, and chemical solutions used to preserve samples are all in short supply.
“Even after you set up your own equipment, you are rationed about how much testing supplies you can get,” she said.
The Oregon State Public Health Laboratory monitors the capacity of in-state laboratories to test for COVID-19.
The state’s most recent weekly report on testing, published July 20, warns that hospital labs may soon face even more serious shortages and rationing of testing supplies.
Several manufacturers have notified the state that they may have to cut back on supply allocations for Oregon labs, including the Oregon State Public Health Laboratory, according to the report.
“These shortages could impact Oregon at a critical time, when we have seen a significant increase in infections in urban and rural Oregon,” said Charles Boyle, deputy communications director for Gov. Kate Brown.
Boyle said the state has requested additional testing supplies from the federal government, but received a “lukewarm” response.
“We will continue to look for contingencies and other ways to expand our testing capacity, including working with private testing vendors, but additional testing supplies from the federal government will be essential in the face of renewed national supply chain shortages,” he said.
For her part, Ogden says the only way out of what she calls the “testing nightmares” her hospital has experienced is stronger leadership at the national level.
“Someone needs to have a vision to say, we’re going to get on top of this,” she said.
“We have none of that. It is essentially free market in every way. The free market is not cooperative. The free market is not getting us where we need to be.”
State help is needed
Malheur County’s Sarah Poe said her community needs help from the state, either arranging a new contract with a different commercial testing lab, or assistance getting a rapid testing machine directly into the hands of health care providers in the county.
“Where a lot of other counties would have multiple testing sites, recognizing that rural counties don’t and would need additional support,” she said.
In the meantime, Poe said, the most important thing Malheur County residents can do is stay home if they suspect they might be sick.
"If you needed a test in the first place, it’s really important that you just be patient and stay home, in case that is a positive,” she said.
The CDC recommends that people who think they may have COVID-19 stay home until at least 10 days after the onset of their symptoms, and at least 24 hours after symptoms have improved.
“This is what you can do, to protect your community,” she said.