National Covid-19 Testing & Tracing Action Plan - Update Report Time to Redouble Our Efforts on Covid-19 Testing - The ...

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National Covid-19 Testing & Tracing Action Plan - Update Report Time to Redouble Our Efforts on Covid-19 Testing - The ...
National Covid-19                                                            Update Report

Testing & Tracing                                                            Time to Redouble
                                                                             Our Efforts on
Action Plan                                                                  Covid-19 Testing

                                                                             Embargoed until 12:01am EDT,
                                                                             Thursday, July 16, 2020
THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                  1
National Covid-19 Testing & Tracing Action Plan - Update Report Time to Redouble Our Efforts on Covid-19 Testing - The ...
Foreword                                                                     This terrifying tragedy was not and is not inevi-
                                                                             table. America can function safely, even as we
                                                                             fight Covid-19. Other countries have shown that
                                                                             a better alternative is possible. But as we said in

America faces an impending disaster.                                         April – when we first released The Rockefeller
                                                                             Foundation’s National Covid-19 Testing Action
The extraordinary scale of the                                               Plan – testing is the only way out of our present

Covid-19 crisis is evident in the                                            disaster, and it will remain the case until a vaccine
                                                                             or effective therapeutics are widely available.

growing deaths and economic losses                                           When we were barely a month into this pan-
the pandemic has wrought in every                                            demic, we brought together scientists, industry,

state. Devastated minority and                                               technologists, economists, and Republicans
                                                                             and Democrats alike to formulate an action plan

low-income families bore the brunt of                                        to expedite the development of our nation’s
                                                                             widespread testing and tracing system. We
those costs. As the virus tore across                                        called for rapidly expanded diagnostic test-

the country, it exposed the structural                                       ing capacity from 1 million tests per week to 3
                                                                             million tests per week by June, and to 30 million

inequities that have underpinned                                             tests per week by October. Today we’re at 4.5
                                                                             million tests per week, but unfortunately it’s
and undermined our economy                                                   taking far too long to get to 30 million tests per

for decades. And it will only worsen                                         week, and communities that most need them –
                                                                             low-income families, minorities, and highly

during fall’s cold and flu season.                                           vulnerable essential workers – find it most
                                                                             difficult to gain access, while elite institutions,
                                                                             companies, and enterprises seem to be able to
                                                                             access them on the private market. We need
                                                                             to urgently fix clinical diagnostic testing and
                                                                             accelerate the introduction of faster, cheaper,
                                                                             point-of-care screening tests to prepare for
                                                                             next flu season. Some say it’s impossible. Some
                                                                             say America has already given up. But we know
                                                                             it can be done, and we present here a renewed
                                                                             national action plan to help get there.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                       2
Across the board, federal leadership and genu-           The Rockefeller Foundation will invest an
ine public-private partnership will be essential         additional $50 million toward realizing the emer-
to meeting three key needs identified in this            gency requirements we outline in this updated
updated plan. First, we need to massively                plan. But make no mistake: this crisis demands
scale up fast, cheap screening tests to identify         immediate federal funding. Congress took a
asymptomatic Americans who are currently                 first step by including $25 billion for testing
infected. Today the country conducts almost              in the Coronavirus Aid, Relief, and Economic
zero such tests, and we need at least 25 mil-            Security (CARES) Act. This plan requires another
lion per week for schools, health facilities, and        $75 billion as soon as possible, because tests
essential workers to function safely. Teachers,          should be free and accessible to all who need
healthcare workers, grocery store workers:               them – with extra effort to make sure low-income
these are the real heroes of this crisis, and they       and minority communities, those who are more
should be able to support our country without            financially vulnerable and critical institutions like
the all-consuming fear that they’re jeopardizing         nursing homes, schools, and community centers
their lives or the lives of their loved ones.            are supported, and that we address the sharp
                                                         racial injustices and inequities that plague our
Second, we need to dramatically reduce the               country. This represents the single best invest-
processing time for diagnostic tests, from the           ment America could make in averting an even
current 5-14 days to a 48-hour standard turn-            more tragic and pending disaster.
around time that every state and community
should meet. Many businesses that are privately          Today Covid-19 cases are spiking, and the
contracting with lab companies already meet              trajectory in much of America is rising rapidly.
this standard. We propose a public-private               In addition, we will soon enter a new cold and
collaboration between government, lab com-               flu season with potentially 100 million cases of
panies, and scientists in order to alleviate the         flu-like symptoms that stand to overwhelm our
very basic constraints that are leading to these         current testing capacity. Not only do we need
extraordinary delays.                                    to bend the curve of this epidemic; we need
                                                         to provide America’s essential workers and
Third, this reinvestment in testing must be tied         children with a way to go about their work and
to the basics of any pandemic response to                lives more safely, so that critical institutions can
really work: clear public health communications          survive and function during this period of time.
from trusted community leaders, and robust               The only alternative is more large-scale lock-
contact tracing and support for targeted isola-          downs. The price of that is too high to pay when
tion to reduce the contagion of the disease.             we don’t have to, if we make smart, strategic,          by Dr. Rajiv J. Shah,
                                                         science-based investments now.                          President of The Rockefeller Foundation

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                 3
Overview

The nation is clearly falling short of
the commitment, focus and initiative
needed to defeat Covid-19. Infection
rates are hitting record highs
nationally and in more than a dozen
southern and western states. Tests
are still perilously hard to come by
in regions where demand is surging.
Testing bottlenecks persist in many
of the nation’s labs. We lack central
coordinating authorities even at the
state level. In much of the country
essential contact tracing systems are
nascent at best. The public is still not
united in its response to the lethal
virus, with large numbers refusing to
take precautionary steps and dubious
over the need for more testing.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN   4
Our failures in the fight against Covid-19 have          We are now at nearly five times that level –
highlighted our national weaknesses and                  a notable improvement but still not nearly
vulnerabilities. We have 4% of the world's               enough. We need to be honest: We have in no
population but around a quarter of all global            way prevailed over Covid-19, and our original       WE HAVE 4% OF THE
cases and all deaths. Infections are down to a           plan underestimated the roadblocks to scaling       WORLD'S POPULATION BUT
                                                                                                             AROUND A QUARTER OF
mere trickle in most of Europe while surging to          testing, the role of asymptomatic spreaders,        ALL GLOBAL CASES AND
record highs across the United States.                   and the acceptance of contact tracing.              ALL DEATHS

We can reverse this trend, and prevail over              We need to redouble our efforts to combat
Covid-19, only with a clear, concerted, national         Covid-19 and achieve the aims we set out in our
plan for testing, tracing and communications.            first action plan, while also adjusting to new
Leaving the fight up to a patchwork of indi-             realities.
vidual states, cities, businesses and school
systems will not work.                                   The national testing strategy we need will
                                                                                                             THE NATIONAL TESTING STRATEGY
                                                         require the country to ramp up to where it can      WILL REQUIRE THE COUNTRY TO RAMP
In late April, The Rockefeller Foundation and            administer at least five million diagnostic tests   UP TO AT LEAST FIVE MILLION
                                                                                                             DIAGNOSTIC TESTS AND 25 MILLION
its partners proposed the nation rally around            and 25 million screening tests a week within        SCREENING TESTS A WEEK WITHIN
a bold but achievable goal of expanding our              three months, with the acknowledgement that         THREE MONTHS
testing capacity from one to three million tests         we will need still more than that. This must be
per week by the middle of June and to 30 mil-            combined with rigorous and extensive contact
lion tests per week by the end of October. We            tracing and supported isolation.
also proposed a robust human-centric contact
tracing program to ensure that those exposed             Tests must be easily available to all our teach-
to the disease self-isolate to stop the spread           ers, students, essential workers, nurses and
and that data be on positive cases be collected          bus drivers – every American, free of charge.       TESTS MUST BE EASILY
                                                                                                             AVAILABLE TO ALL OUR
and shared across the country.                           Investing in the creation, delivery and adminis-    TEACHERS, STUDENTS,
                                                         tering of these tests will be far cheaper for the   ESSENTIAL WORKERS,
                                                                                                             NURSES AND BUS DRIVERS –
Successful implementation of this 1-3-30 Action          nation than the incalculable fiscal and social      EVERY AMERICAN, FREE OF
Plan would allow the country to reopen and               costs of another economic shutdown.                 CHARGE

equip businesses, schools and institutions to
detect and contain inevitable outbreaks so that
they could remain open. The country then was
administering an average of around 143,000
tests a day – or 1 million a week – with no appre-
ciable sign of an increase in those numbers.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                      5
We can hit these goals only with concerted               We have made progress in many areas since
national focus and attention. Congress needs             The Rockefeller Foundation put out its initial
to urgently approve the proposed additional              report in April.

                                                                                                                                           $
$75 billion for testing as part of the next stim-
ulus bill. Insurers and government agencies              The country has delivered over 39 million tests      CONGRESS NEEDS TO URGENTLY
must also clarify how the country will pay for           and is now averaging well over 600,000 tests         APPROVE THE PROPOSED
                                                                                                              ADDITIONAL $75 BILLION FOR
this widespread screening program as it is               a day – or roughly 4.5 million tests a week.         TESTING AS PART OF THE
put in place town by town, business by busi-             Success in exceeding the three-million-tests-        NEXT STIMULUS BILL

ness and school by school. We must assure                a-week goal reflects a surge in testing capacity
that sufficient support is flowing to the hard-          and noteworthy strides in overcoming some
est hit communities, many of them Black and              of the barriers to the production, supply and
Hispanic, which have been disproportionally hit          distribution of test kits. It also shows increased
by Covid-19.                                             resolve at the local and state level to prioritize
                                                         testing.                                             THE COUNTRY HAS
In addition, the administration needs to invoke                                                               DELIVERED OVER
                                                                                                              39 MILLION TESTS AND IS
the Defense Production Act or a similar federal          The progress so far is also the fruit of increased   NOW AVERAGING WELL OVER
program to oversee and goad the production               cooperation. The Rockefeller Foundation since        600,000 TESTS A DAY
and distribution of mass quantities of fast, low-        April has drawn together hundreds of data
cost antigen tests. What we need to implement            experts, medical professionals, epidemiolo-
a mass screening program are simple, quick,              gists, business executives, philanthropists and
easy and inexpensive tests. These sort of tests          government officials at both the federal, state
are on the horizon, but getting them into the            and local levels. We are in frequent contact
hands of everyone who needs them – schools,              with a number of governors’ offices. We have
employers, health providers, public essential            launched a pilot tracking and tracing system in      THE PROGRESS SO FAR IS
                                                                                                              THE FRUIT OF INCREASED
workers, vulnerable communities – will require           Baltimore that holds national promise.               COOPERATION
the muscle that only the federal government
can provide.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                     6
The result of all this is
a national network
of like-minded
specialists devoted to
these principal aims:

                                                                             A dramatic expansion of       The creation of local sys-
                                                                             our testing abilities, with   tems to track infections
                                                                             a focus on tests to screen    and alert those who may be
                                                                             asymptomatic individuals      exposed

                                                                             The development of            The need for better data
                                                                             reliable, simpler, faster     tracking and dissemination
                                                                             and cheaper tests

                                                                             The delivery of these         The launch of a national
                                                                             tests to the hardest-hit      education campaign to
                                                                             communities                   build support for testing
                                                                                                           and other safety measure

                                                                             The establishment of
                                                                             a standard set of proto-
                                                                             cols to assist employers
                                                                             and schools to reopen
                                                                             successfully

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                              7
But amid the promising signs – increased                                                                       Getting to three million tests a week was
testing, sharp declines in hospitalization and                               The inability of key federal      essentially a framing exercise. Ramping up to
fatality rates, the uptick in innovation and                                 institutions like the CDC to      a number 10 times that high and higher will
cooperation – we still see infection rates rising.                           keep pace with the scale of       require breakthroughs in testing technology;
Just as disturbing is the realization that asymp-                            the pandemic                      vast improvements in delivery and logistics;
tomatic people are spreading the disease at                                                                    firmer commitments to test among compa-
alarming rates – and perhaps at rates higher                                                                   nies, schools and government officials; and a
that currently understood. That, and the loom-                               Wavering resolve over             stronger conviction among Americans that a
ing specter of seasonal flu in the fall, mean we                             testing within many state         robust national testing and tracing program is
must strongly demand that we as a country                                    capitals                          vital to our vanquishing the virus and getting
come together to drastically scale up test-                                                                    fully back to work.
ing for the fall – especially for asymptomatic
people.
                                                                             Public confusion over the
                                                                                                               It is one thing
                                                                                                               to reopen.
Chief among our                                                              central role of effective test-
                                                                             ing and contact tracing

many concerns are:                                                                                             It is quite another
                                                                                                               to remain open.
                                                                             Multiple barriers to devel-
                                                                             oping fast, cheap and easily      Keeping America open and operating through
                                                                             administered tests                the fall will require vigilance, adherence to
                                                                                                               prevention practices, and a commitment to a
                                                                                                               vast screening program built around tests of
                                                                                                               asymptomatic individuals to spot new out-
                                                                             Equity issues in the              breaks in schools, factories, office, and at-risk
                                                                             distribution and availability     populations across the country. Over this
                                                                             of tests                          next phase, The Rockefeller Foundation and
                                                                                                               its partners believe it is vital that government
                                                                                                               and like-minded organizations pool efforts to
                                                                                                               accomplish a range of critical goals.
                                                                             The need for wide agree-
                                                                             ment on who should be
                                                                             tested, and how frequently

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                         8
To effectively
combat Covid-19
and keep
our economy
running,
policy makers,
foundations                               Ensure diagnostic and screening       Address the current crisis in       plan, of which $25 billion was

and the private                           testing is free and available to      lab-based diagnostic testing        appropriated in the CARES Act
                                          all Americans. Public and private     through wartime like mea-           for testing. At least another $2
sector must:                              health insurance are already man-     sures by the federal and state      billion is necessary to incentivize
                                          dated to cover diagnostic testing,    governments, manufactur-            test development and produc-
                                          but action is required to cover       ers, laboratories, and others.      tion, similar to the amounts being
                                          protocol-based screening tests        Collective action is needed to      spent on vaccine development.
                                          by employers along with further       break the existing testing “log
                                          mandates for public and private       jam” of tests so that results of
                                          insurance coverage. Congress          diagnostics testing is reduced
                                          needs to approve the proposed         from the current 2+days to less
                                          $75 billion in additional federal     than two days nationwide. The
                                          funds to cover testing costs into     Federal government should
                                          next year as well as to incentivize   throw its full weight and massive
                                          test development and produc-          funding behind expediting the
                                          tion. The benefits of the resulting   production and distribution of
                                          reduction in illness, deaths, and     diagnostic and screening tests,
                                          economic disruption from prevent-     including, if necessary, through
                                          able outbreaks will far outweigh      the Defense Production Act or
                                          the costs of widespread screen-       other appropriate authorities. We
                                          ing tests or the burden on labs to    proposed $100 billion for testing
                                          increase their turnaround times.      through April 2021 in our initial

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                            9
24H

Create and implement test pro-            Support the development and            Create a broad-based national            Improve the speed and effec-
tocols for widespread screening           deployment of appropriate,             Covid-19 Communications                  tiveness of contact tracing at the
testing of asymptomatic people            convenient, accurate, affordable       Coalition to develop and imple-          local level and make self-isolation
to keep our schools, workplaces           and rapid antigen tests required       ment ways to promote testing,            and quarantining more practical
and communities open. Screening           for implementing screening test        tracing and safety measures such         with proper public support for
tests are essential to detect and         protocols. Screening tests should      as masks and social distancing.          lost wages and other necessary
rapidly contain local Covid-19            point-of-service/point-of-care tests   The coalition should include             services.
outbreaks. We urge the CDC, in            costing $5 to $10 per test, with       non-profits, community organizers
partnership with the public health        same-day turnaround for schools        and alliances of faith leaders as
community, to put forth risk-based        and workplaces, and even faster        well as governmental leadership
specific protocols for screening          turnaround for mobile testing in       at the federal, state and city levels.
tests for K-12 schools, universi-         communities.                           Communication should be local-
ties, workplaces, nursing homes,                                                 ized to for cultural awareness and
vulnerable communities, and other                                                linguistic adaptation.
settings based on their individ-
ual levels of risk and exposure.
National testing capacity should
expand to at least 30 million tests
a week by November, including at
least 25 million screening tests and                                                                                      Improve data infrastructure and
5 million diagnostic tests a week.                                                                                        reporting and expand the utiliza-
                                                                                                                          tion of data to drive performance
                                                                                                                          and improve decision-making.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                 10
1
                                                         The virus has pivoted.                              of symptomatic individuals and contacts to get
                                                         It is now more contagious and appears to be         to this level.
                                                         spreading more aggressively across large
                                                         swaths of the country.                              Outbreaks across states will continue to get
                                                         We must pivot as well.                              worse if we don't increase testing to suppress
                                                                                                             the virus and open safely. As of July 11, only

Covid-19 Testing                                         Since early April, when U.S. Covid-19 viral test-   14 states are doing enough testing to sup-
                                                         ing had plateaued at 1.0 million tests per week,    press the spread of the virus, while 26 states
                                                         considerable progress has been made in test-        are achieving mitigation. 12 states have such
Resolve diagnostic                                       ing but clearly not enough given the spread.        significant testing shortfalls that the outbreak

testing shortages and                                    By the end of June testing had reached 3.5
                                                         million tests per week, and by mid-July, over
                                                                                                             is growing.

implement widespread                                     4.5 million tests a week. Flattening the curve      We are also seeing huge disparity among the

screening testing                                        will require going to at least 7 million tests
                                                         per week just to reach mitigation. But bend-
                                                                                                             states, with some states moving fairly aggres-
                                                                                                             sively on testing, while entire regions lag far
                                                         ing the curve for new cases to a much lower         behind. Some outbreak states are increasing
                                                         suppression level, which must be our focus,         testing, just not nearly enough to keep up with
                                                         will require at least 30 million tests per week,    the epidemic growth. Many states are seek-
                                                         including 25 million weekly screening tests of      ing to ramp up testing but are constrained by
                                                         asymptomatic individuals.1 Even higher levels       commercial lab capacity and/or limited lab
                                                         of testing may be needed to keep our work-          availability of testing supplies.
                                                         places, our schools, and our communities
                                                         open.                                               As of July 12, Massachusetts, New Jersey and
                                                                                                             New York – all states that had achieved dra-
                                                         This can only be done through a concerted           matic decreases in new cases – all had positive
                                                         national effort.                                    rates under 3%. At the same time states experi-
                                                                                                             encing overwhelming surges had positivity
                            COVID-19                     Canada, Australia, Germany, France and South        levels well over 10%, including Arizona, Florida,
                                                         Korea – countries that have most successfully       and Texas, just to name a few.
                                                         combated the coronavirus scourge – each
                                                         achieved positivity rates less than 1.5%. 2
                                                         Positivity rates must be under 10% just to flat-    1   https://www.npr.org/sections/health-
                                                         ten the curve and less than 1-3 % to bend the           shots/2020/06/30/883703403/
                                                                                                                 as-coronavirus-surges-how-much-testing-does-your-
                                                         curve toward suppression. With much higher              state-need-to-subdue-the-virus
                                                         outbreak rates, we need a lot more testing just     2   https://ourworldindata.org/coronavirus-testing

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                      11
At least 30 million tests per week nation wide are required
to safely open and keep open our workplaces and communities
                                                            3,4,5

              Arizona
               Florida
           Mississippi
      South Carolina
                 Texas
                 Idaho
              Georgia
             Alabama
              Nevada
            Arkansas
                   Utah
               Kansas
            Louisiana
                   Iowa
           Oklahoma
           Tennessee
            California
       South Dakota
      North Carolina
              Indiana
           Wisconsin
            Nebraska                                                                   Growth: More than 10% positivity indicates the
             Missouri
            Kentucky
                                                                                       pandemic is not being contained
            Colorado
         Washington
                   Ohio                                                                Mitigation: Less than 10% positives based on
              Oregon
              Virginia                                                                 at least 8 million tests a week indicates the
        Pennsylvania
            Maryland                                                                   pandemic is staying about the same
            Delaware
       North Dakota
            Wyoming
         New Mexico
                                                                                       Suppression: Less than 3% positives based
        West Virginia                                                                  on at least 30 million tests a week indicates most
           Minnesota
             Montana                                                                   communities should be able to safely stay open
        Rhode Island
                Illinois
            Michigan
      Massachusetts
                                                                                   3   https://coronavirus.jhu.edu/testing/testing-positivity
          Puerto Rico
               Hawaii
                                                                                   4   https://www.npr.org/sections/health-
    New Hampshire                                                                      shots/2020/06/30/883703403/
District of Columbia                                                                   as-coronavirus-surges-how-much-testing-does-your-state-
          New Jersey                                                                   need-to-subdue-the-virus
               Alaska
                                                                                   5   https://globalepidemics.org/wp-content/uploads/2020/06/
            New York
         Connecticut
                                                                                       key_metrics_and_indicators_v4.pdf
                Maine
             Vermont

                           0%             5%                        10%      15%                   20%                          25%

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                   12
The differences in testing                                                       In Arizona, the number                            New Jersey tells a very
and outcomes are stark                                                           of positive cases more                            different story. One of
across the country.                                                              than tripled over the                             the hardest hit states
                                                                                 month of June, a span                             early on, with a total
                                                                                 in which the number                               of more than 12,600
                                                                                 of tests administered                             deaths, New Jersey has
                                                                                 weekly nearly doubled.                            seen a sharp decline in
                                                                                 Arizona is now seeing                             new positive cases. The
                                                         more than 3,500 new Covid-19 cases every           state’s governor, Phil Murphy, has adhered to
                                                         day on average, by far its highest numbers         a phased plan for reopening built around a
                                                         since the start of the pandemic. The state         sharp increase in testing. The state was testing
                                                         is also seeing a rise in the share of positive     around 7,000 people a day on average in late
                                                         cases, from 12.3% of tests at the start of June    April, compared to around 20,000 a day by
                                                         to 26.9% by mid-July – the highest rate in the     mid-June. The state has resumed outdoor
                                                         country. Health officials on June 9 reactivated    dining while retaining sharp restrictions on
                                                         the state’s hospital emergency plan to brace       indoor dining.
                                                         for a possible shortage of emergency beds.
                                                         By the end of the month, the state’s inten-        The rate of positive cases in New Jersey now
                                                         sive-care capacity was at 90%.6 That makes         hovers around 1.26, among the lowest in the
                                                         Arizona one of the fastest growing hotspots in     country, while its rate of testing, at nearly
                                                         the country.                                       17,000 tests per 100,000 residents, puts it
                                                                                                            5th highest in the country.8
                                                         The increase in positive cases in Arizona
                                                         comes after Gov. Doug Ducey ended the              The disparity by region in terms of the actual
                                                         state’s stay-at-home restrictions in mid-May       spread of Covid-19 is also striking. In the
                                                         and loosened most restrictions on gyms, pools      South, the percentage of tests coming back
                                                         and restaurants. The famous hotels along           positive – at just over 10% in late June – dou-
                                                         the Grand Canyon’s South Rim are open and          bled in just two weeks. By comparison, the
                                                         accepting tourists.                                positive rate in the Northeast was at 1.7%, in
                                                                                                            the Midwest 3.8% and in the West 7.9%. The
6   https://www.newsweek.com/                            Arizona has administered just 9,331 tests per      sharp uptick in both the South and the West
    arizona-icu-91-percent-capacity-1-4-coronavirus-
    cases-positive-1515436
                                                         100,000 residents as of July 12, putting it        has raised alarms over whether states are
7   https://coronavirus.jhu.edu/testing/                 near the bottom of the list of states on testing   reopening too swiftly without proper protocols
    states-comparison
8   https://coronavirus.jhu.edu/testing/
                                                         metrics.7                                          in place.
    states-comparison

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                  13
Pay reasonably now or                                    Diagnostic testing for Covid-19 is generally
                                                                                                            Equitable Testing Funding Recommendation
pay exorbitantly later                                   covered through public and private health
                                                         insurance. But recent guidance from the
                                                         Department of Health and Human Services
                                                                                                            People across the U.S. are being unequally
                                                         and other federal agencies suggests that
Providing the level of testing needed to keep                                                               exposed to the Covid-19. Latino and African
                                                         screening testing may not be covered.9
our schools, workplaces, and communities                                                                    American residents are three times as likely as
                                                         Combined with the millions of Americans still
safe from recurrent Covid-19 outbreaks will be                                                              their White counterparts to be infected with
                                                         uninsured or underinsured, this lack of cov-
costly, even with more affordable screening                                                                 Covid-19 and almost two times as likely to
                                                         erage will only prolong our battle against the
tests. But the human, social, and economic                                                                  die.10 These disparities are the result of struc-
                                                         virus. Already people of color, the elderly, and
costs of lockdowns, school closures, and                                                                    tural racism that have overtly and covertly
                                                         other vulnerable populations are suffering the
recurrent surges will be far, far greater.                                                                  placed essential services, like quality health
                                                         greatest loss of life, disability, and economic
                                                                                                            care, beyond the reach of our Black and Brown
                                                         hardship; the magnitude of these disparities
Given the continued threat of Covid-19                                                                      communities.
                                                         and impacts will only increase if we don’t have
diagnostic and screening testing should be
                                                         adequate testing to catch recurrent outbreaks
available to everyone in the U.S. without cost                                                              The Rockefeller Foundation strongly recom-
                                                         early.
to the person receiving the test. Governments,                                                              mends that an additional $75 billion in federal
health insurers and employers can pay a                                                                     funds to cover the additional costs of test-
reasonable price today by covering the cost                                                                 ing and tracing as well as to incentivize test
of both diagnostic and screening testing – or                                                               development and production. Federal funding
over the coming months and years pay a far                                                                  for testing and supportive services should be
more exorbitant price as a result of a sluggish                                                             allocated in proportion to the burden of illness
economy, excess healthcare costs, and the                                                                   and disease that communities experience. In
potential need for additional bailouts. The cost                                                            short, this funding should be used to prioritize
of inadequate testing has already been vividly                                                              testing for racial and ethnic minorities who
proven by the preventable loss of life and the                                                              are more likely to get sick and die of Covid-19
tremendous economic cost of the first pan-                                                                  because of underlying conditions, jobs and
demic wave.                                                                                                 living situations with higher exposure risk, and
                                                                                                            inequitable access to quality healthcare.

                                                                                                            9    https://www.cms.gov/files/document/FFCRA-Part-
                                                                                                                 43-FAQs.pdf
                                                                                                            10   https://www.nytimes.com/interactive/2020/07/05/
                                                                                                                 us/coronavirus-latinos-african-americans-cdc-data.
                                                                                                                 html

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                        14
Screening Tests to keep our                              The pandemic coronavirus was deadly and            Implementing large-scale screening will
schools, workplaces, and                                 debilitating to begin with but now appears         require national commitment and resolve, as
communities open                                         even more contagious, thanks to a recent           well as substantial added funding. The fed-
                                                         mutation. More than 90% of Americans thus          eral government should invoke the Defense
                                                         far have avoided infection and remain vulner-      Production Act or some similar authority to
                                                         able. The virus is in nearly every part of the     speed production. We will also need at least
                                                         country, so recurrent outbreaks are inevitable     $75 billion in additional funding to pay for
                                                         without further steps to contain the virus. How    the ramped-up testing. Implementation will
                                                         many, how big and where these outbreaks            require a standard set of protocols, a delinea-
                                                         occur depends on what we do – or do not do –       tion of use cases for specific testing settings,
                                                         to protect ourselves from infection and rapidly    and viral tests appropriate to the large variety
                                                         detect new flare ups. Our solutions must be        of different screening programs.
                                                         more aggressive if we are going to prevail
                                                         against this pandemic.

                                                         Widespread testing to detect asymptom-
                                                         atic individuals11 is crucial. This sort of mass
                                                         screening enables early detection and rapid
                                                         response to both individual cases and local
                                                         outbreaks. The virus is already doing wide-
                                                         spread damage if the first sign of trouble is an
                                                         overflowing emergency room or a third of a
                                                         warehouse’s or meat packer’s workforce out
                                                         sick with coronavirus.

                                                                                                            11   In this report the term “asymptomatic” is used to
                                                                                                                 refer any individual who does not have symptoms
                                                                                                                 or show signs of Covid-19 infection at the time of
                                                                                                                 testing. This includes individuals who have not
                                                                                                                 become infected with Covid-19, individuals who have
                                                                                                                 become infected but will show symptoms during
                                                                                                                 the course of their infections, and “pre-symptomatic
                                                                                                                 individuals who are infected and will eventually
                                                                                                                 experience Covid-19 symptoms.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                         15
A Risk-Based Approach to                                 Mitigation measures like masking, distancing,       an effective screening test strategy in diverse
Protocols for Workplace and                              and monitoring for symptoms help but have           contexts around the country and considering
Community Testing                                        not been able to fully contain the spread of        the limits of laboratory testing and the chang-
                                                         the disease in the US, particularly among           ing threat of the virus.
                                                         essential workers and vulnerable populations.
                                                         Timely testing of people with symptoms and          A standardized set of protocols for testing is
                                                         close contacts is a key part of the contain-        needed to guide employers, schools, and other
                                                         ment strategy. Laboratory (PCR) tests are the       institutions as they reopen. Five months into
                                                         gold standard for determining whether people        the pandemic, the U.S. has not yet developed
                                                         with symptoms that could be Covid-19 have           specific enough guidelines that states and
                                                         been infected with the virus, which triggers        municipalities might emulate. This is also the
                                                         the need for continued isolation and contact        case for large-scale employers, public service
                                                         tracing. Because close contacts are also at         workers, schools, leading colleges and universi-
                                                         high risk of infection, timely laboratory testing   ties, nursing homes, and other at-risk settings.
                                                         is needed for these individuals as well.
                                                                                                             In the absence of such guidance, large orga-
                                                         In addition, significant Covid-19 spread has        nizations are moving ahead with a dizzying
                                                         occurred through people with no or minimal          array of different reopening protocols, some
                                                         symptoms; actual cases are estimated to be          of which emphasize frequent testing, but
                                                         ten times higher than reported cases, and the       many others that don’t. Uniformity of stan-
                                                         virus is increasingly present in communities        dards is impossible, but a data-driven set
                                                         across the nation. Consequently, screening          of risk-based protocols would greatly assist
                                                         tests among people who are asymptomatic             administrators and managers establish prac-
                                                         can help detect cases and contain the spread        tices to spot potential outbreaks and keep
                                                         of the pandemic in workplaces, schools, and         organizations open.
                                                         communities. For screening, point-of-care
                                                         tests like antigen tests are needed, potentially    Protocols are needed to use available tests
                                                         along with pooled laboratory tests, to provide      effectively in a wide range of employment,
                                                         much greater testing capacity, speed, and           school and community settings. The protocols
                                                         convenience than can be achieved through            should be easy to understand and imple-
                                                         laboratory testing alone. To date, there has        ment. They should reflect evidence-based
                                                         been limited guidance on how to accomplish          risk assessments of the characteristics of that
                                                         this in a risk-based way that balances accu-        setting, the capabilities of available tests, and
                                                         racy, timing, and costs. Consequently, there is     the actions required based on the tests. They
                                                         little guidance available on how to implement       should allow customization and should be

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                  16
updated as newer tests come onto the market              PROTOCOLS SHOULD CONSIDER
and relevant evidence on disease transmission            THE FOLLOWING:
becomes available. Public policy should work                Risk level of the setting (high, medium, low)
to support these initiatives, including financial            to set a transmission reduction goal
and technical support, particularly at the local
                                                            Testing strategies to accomplish
level as hotspots develop.
                                                             transmission reduction goals

                                                            Processes for acting on the testing results

RISK ASSESSMENT                                          TESTING STRATEGY                                    ACTIONABLE RESULTS

Likelihood of infection                                  Test Choice                                         Confirmation
                                                             > Accuracy
Likelihood of onward transmission                            > Convenience                                   Individual response
                                                             > Time to results
Consequences of transmission                                 > Cost                                          Environmental response

                                                         Who and how often to test                           Public health notification

                                                         Advanced strategies

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                17
Risk Assessment                                          Testing Strategy                                   Actionable Results

Symptomatic individuals or people who have               The goal of a testing strategy is to identify      Protocols should also address how to support
been in close contact with a person that has             infected individuals to reduce onward trans-       individuals during testing and how to act on
tested positive should always follow CDC                 mission. Any strategy should include a choice      results. Testing strategies that use less accu-
guidance to isolate until they have been tested          of a test or tests, and how to use them. Key       rate tests may need to confirm positive results
with a highly reliable test and been confirmed           factors in test choice include accuracy of the     with repeat testing or a more accurate test.
negative. For asymptomatic screening, risks              test and the time it takes to get the results,     Procedures will also need to be in place to
should be assessed over categories of people             as Figure 2 illustrates, as well as cost and       alert public health authorities about confirmed
and workflows in a workplace, school, com-               feasibility.                                       cases, with mechanisms for notification and
munity, or other setting, as shown in Figure 1.                                                             testing of close contacts. Supports may be
This includes considering the risk of infection          While clinical laboratory tests (rtRNA-PCR)        required to help people quarantine until confir-
in those coming in and out of the setting,               are most accurate, they take time to send out      matory test results are received, and to isolate
which in turn depends on the risk level in               and for the laboratories to run, and the clin-     if they are infected. Communication and trust
their communities. It also includes the risk of          ical laboratory capacity available is far short    are critical: protocols should be designed to
transmission of the virus given the mitigation           of that needed to support large-scale testing,     be respectful and supportive of individual
steps that are feasible and the severity of              although pooled laboratory testing may be an       concerns and should be clear about why the
consequences of infection transmission in that           option in some settings if sufficient capacity     actions based on the test are important, to
setting. More intensive testing will generally           is available. Some emerging laboratory tests,      maintain engagement in implementing the
be optimal in settings that are high-risk; some          for example based on CRISPR technology, may        protocols effectively. This includes clear com-
testing in settings that are medium risk; and no         provide a broader option for screening tests in    munication about isolation, cleaning and other
testing in settings that are low risk.                   the months ahead in settings that can support      mitigation procedures that are implemented
                                                         rapid access to these laboratory tests, will       when cases are detected.
                                                         affect how fast an individual and their contacts
                                                         are isolated from the rest of the population.
                                                         While less sensitive (that is, they miss some
                                                         cases), point-of-care tests have the advantage
                                                         of convenience, speed, and potentially cost so
                                                         support large-scale and timely testing. With
                                                         broader use and faster time to results, this can
                                                         lead to earlier detection and better contain-
                                                         ment12 of outbreaks.
                                                                                                            12   https://www.medrxiv.org/
                                                                                                                 content/10.1101/2020.06.22.20136309v2

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                18
Advancing the Use of                             the Federal, state, and local governments,
                                                         Effective Testing Protocols                      where employer action alone is likely to be
                                                                                                          insufficient. Early priority areas for protocol
                                                                                                          development include higher-risk and vulnera-
                                                         The Rockefeller Foundation is committed to       ble communities, nursing homes, and public
                                                         advancing the use of effective testing pro-      schools.
                                                         tocols, including by increasing awareness,
                                                         sharing, and collaboration on protocols in       Especially in areas where Covid-19 has been
                                                         use and in development To connect employ-        prevalent and the risk of transmission and
                                                         ers around the globe as they grapple with        health consequences are high, communities
                                                         the virus, The Rockefeller Foundation is part-   need effective testing protocols to quickly
                                                         nering with Arizona State University and the     detect where outbreaks are emerging, with
                                                         World Economic Forum to launch Covid-19          special strategies to work with high-risk
                                                         Workplace Commons, an interactive website        populations. This includes those living in
                                                         that will 1) enable employer networking within   low-income groups, small multigenerational
                                                         and across industries around the globe and       housing, and neighborhoods with many
                                                         2) support the implementation of best prac-      essential workers. This also includes commu-
                                                         tices in testing for workplace reopening. The    nities of color as death rates among Black and
                                                         website will include an interactive back-to-     Hispanic/Latino people are much higher than
                                                         work data dashboard that employers, policy       for white people across all age categories.
                                                         makers and the public can use to learn about     Typical settings for community testing centers
                                                         the types of testing and other safety proto-     include shelters, housing complex, churches,
                                                         cols employers are using to reopen and where     community centers, and firehouses. Such
                                                         these strategies are being deployed. The back-   testing protocols should be fully aligned with
                                                         to-work data dashboard will be populated with    civil liberties, due process, non-discrimina-
                                                         data from a global employer survey, admin-       tion, data and health privacy protections, and
                                                         istered to over 10,000 employers at multiple     health ethics.
                                                         timepoints over the coming year.
                                                                                                          Public agencies and community outreach
                                                         Working with its Testing Strategy Group,         groups are already using innovative strat-
                                                         the Duke-Margolis Center for Health Policy,      egies and key partnerships to improve
                                                         and other expert advisors and partners, the      testing for high risk communities. Dr. Jennifer
                                                         Rockefeller Foundation will also support         Avegno Director of the New Orleans Health
                                                         awareness and development of protocols           Department and the Community Organized
                                                         in high-need areas from the standpoint of        Relief Effort (CORE) are focusing on

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                              19
hyper-mobile pop-up testing.13 Their approach       undertaken and how it can be implemented
                                                    PCR     is designed to meet people where they are           effectively. CDC recommends one-time “base-
                                                            and reduce barriers to access particularly for      line” laboratory testing of all nursing home
                                                            people of color, low-income, first responders,      residents, and CMS has further “strongly
                                                            and essential workers. Dr. Jill Jim, Executive      recommended” weekly testing for staff, plus
                                                            Director of the Navajo Department of Health,        testing of symptomatic workers and residents,
                                                            and Dr. Laura Hammitt, Director of Infectious       and close contacts of cases. Additional test-
                                                            Disease Prevention Programs, at the at the          ing of asymptomatic individuals may not only
                                                            Johns Hopkins Center for American Indian            help facilities detect and contain outbreaks
                                             ANTIGEN        Health, with support from CORE, are increas-        earlier, but also could support at least limited
                                                            ing testing and contract tracing efforts linked     relaxation of the “no visitor” policies that are
                                                            to wrap-around services needed during isola-        challenging for families and the well-being of
                                                            tion for the Navajo population as they wait for     residents. However, such laboratory testing is
                                                            testing results or if they are confirmed to be      very costly and thus hard to sustain for facili-
                                                            infected.14 Eric Garcetti, Mayor of Los Angeles,    ties that rely substantially on public funding for
                                                            the LA Fire Department, CORE, and other col-        their low-income residents, and the large num-
                                                            laborators are scaling large testing sites and      ber of laboratory tests required for nursing
                                            ANTIBODY        maximizing testing capacity for the diverse Los     home screening has strained testing capacity
                                                            Angeles population, and are developing plans        and contributed to overall testing delays.
                                                            for access to testing of asymptomatic individu-
                                                            als in high-risk neighborhoods.15                   As a result of these challenges, there is sub-
                                                                                                                stantial variation in testing protocols among
                                                            The impact of the pandemic in skilled nursing       the states. New York state guidelines fea-
                                                            facilities demonstrates that nursing homes          ture stronger testing requirements: biweekly
                                                            need effective testing protocols. Under 1%          testing of all residents, staff, and others
                                                            of the adult population lives in a skilled nurs-    in contact with residents twice per week.
                                                            ing facility over 40% of deaths in the United       Nursing facilities have a range of options to
                                                            States through June 2020 have been linked           comply, including referring workers to local
                                                            to these settings.16 These vulnerable popula-       or state-sponsored testing sites or to contract
13   https://ready.nola.gov/incident/coronavirus/
     city-partners-with-core-on-mobile-testing-site-in/
                                                            tions are served by staff that systemically face    with a third party. Workers who test positive
14   https://www.jhsph.edu/Covid-19/articles/partners-in-   disproportionate risks in their communities.        must isolate for two weeks and are entitled to
     fighting-coronavirus-among-native-americans.html
15   https://www.businessinsider.com/
                                                            While there is clear agreement that ongoing         paid sick leave. Nursing facilities that do not
     sean-penn-nonprofit-core-provides-coronavirus-         testing is needed as an integral part of miti-      comply can be fined up to $2000 per day.
     testing-in-los-angeles-2020-4
16   https://www.nytimes.com/interactive/2020/us/
                                                            gation strategies for skilled nursing facilities,   The state of North Carolina, supported by CVS
     coronavirus-nursing-homes.html                         there is less clarity on what testing should be     Health, has begun testing all residents and

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                      20
Performance and cost characteristics: 108 Emergency Use Approved (EUA) viral RNA and Antigen tests

                  70%                           85%                                 100%

                         0
staff, and is developing strategies for ongoing          infections, and while evidence is limited on the
testing. NCDHHS will also act as payer of last           extent to which children without symptoms
resort for all screening tests for those without         spread the virus, the school environment cre-
symptoms, removing a key barrier to such                 ates significant opportunities for spread. Thus,
testing. This baseline testing is in addition to         especially in communities where Covid-19 is
screening tests in facilities where there is at          prevalent, schools are potentially at high risk
least one confirmed case of Covid. Rhode                 for experiencing significant clusters of cases
Island has also prioritized testing all residents        before detection occurs based on symptoms.
and staff at all nursing homes in the state.             Timely testing of asymptomatic or mini-
Samples from residents were collected on                 mally staff and students could address these
site while staff were sampled off-site. Nursing          potentially large risks and help provide much-
homes with active infections have been tested            needed evidence to guide further protocol
more frequently. Testing is occurring every              development. But there are significant oper-
four to seven days to minimize the possibility           ational and cost challenges to implementing
that pre-symptomatic and asymptomatic indi-              testing in the school setting, and as a result,
viduals can infect other individuals.                    the CDC’s general guidance on school reopen-
                                                         ing recommends against universal screening
Finally, effective testing protocols to support          of all students. Given the high stakes of sus-
schools have not been developed, even as                 tainable school reopening, The Rockefeller
reopening dates approach and decisions                   Foundation is prioritizing collaborations with
about whether and how to reopen schools                  leaders in education to address the role of
are generating controversy and concern.                  testing in enabling safer and more confident
Teachers, students, parents, and policymakers            reopening.
want reopening to occur not only because of
the critical importance of education, but also
because of the support that schools provide
beyond classes, and the impact of school
closure on work. At the same time, they are
understandably concerned about the potential
for undetected spread in schools, which could
significantly worsen existing epidemic growth
around the country and lead to school re-clos-
ing and even more disruption. Most children
with Covid-19 have asymptomatic or mild

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                  22
MOST COUNTRIES THAT HAVE                                 Protocols for schools, nursing homes,
SUPPRESSED THE DISEASE AND ARE                           and vulnerable groups.
REOPENING SCHOOLS HAVE INSTITUTED
SCHOOL PROTOCOLS THAT INCLUDE:                           The Rockefeller Foundation is co-developing
                                                         and supporting the implementation of data
                                                         driven risk-based protocols on who to test,
Reducing class size and increasing the
                                                         with what frequency, under what conditions,
physical distance between students in
                                                         and with what type of test. While these pro-
defined groups
                                                         tocols are under development, and in lieu of
                                                         other guidance, we recommend the follow-
Staggered starts, stop, and
                                                         ing interim measures. For nursing homes, we
break times within the school
                                                         endorse the CMS recommendation, includ-
                                                         ing one-time “baseline” testing of all nursing
Opened more for younger versus older students
                                                         home residents as well as weekly screening
                                                         tests for staff and workers, including employ-
Required face masks for students and/or staff
                                                         ees, contract staff, medical staff, operators
in schools, with variability for lower ages
                                                         and administrators. We suggest PCR-based
                                                         diagnostic testing for symptomatic individuals
Implemented systemic school-based
                                                         and, particularly if timely PCR testing capac-
testing at some level
                                                         ity is limited, screening tests using pooled
                                                         PCR tests or FDA-approved antigen tests for
                                                         asymptomatic individuals. For K-12, we suggest
                                                         at a minimum schools require students and
                                                         staff to get tested as soon as possible after
                                                         they develop one or more Covid-19 symp-
                                                         toms or if one of their household members or
                                                         non-household close contacts tested positive
                                                         for Covid-19. Additional guidance is in devel-
                                                         opment. These testing approaches should be
                                                         paired with isolation and quarantine.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                23
WAITING                           CONSIDERING A RANGE
  What colleges are doing                                                                     2.7%     6%
                                                                             TO DECIDE                         OF SCENARIOS

  By September, some 20 million college stu-
                                                                                                                      8%     PLANNING FOR ONLINE
  dents will either return to campus or be ready
  for another term of distance learning. As of early
  July, the vast majority of higher-ed institutes – just
  over 60% – are planning to resume with in-person                                                                                          PROPOSING A
                                                                                                                                    22% HYBRID MODEL
  classes, with another 22% using a hybrid course
  model in which students can either take courses
  in person or online.17

  Schools sticking with in-person classes are
  implementing detailed plans with the standard
  social distancing, wearing of masks, etc., com-
  bined with various apps that can track symptoms.
  But many also plan to rely on a robust test-
  ing and contact tracing network on campus.
  Ambitious plans have been set forth by institu-
  tions such as Purdue University, Notre Dame
  University, Indiana University, University of
  Florida, University of Texas at Austin and Boston
                                                                                                                                   PLANNING FOR
  University. All are calling for a comprehensive                                                                          61% IN-PERSON
  testing and tracing system to protect students
  and faculty. These systems will screen students
  upon their return and offer continual Covid-19
  testing throughout the semester to guard against
  outbreaks. These schools, however, remain the
  outlier rather than the norm. Many other institu-
  tions appear reluctant to engage in large-scale
  testing due to cost concerns. Further, these
  schools might not be prepared for the signifi-
  cant number of positive student cases they may
  encounter at the outset of the semester.
                                                                             17   https://www.chronicle.com/article/Here-s-a-List-of-Colleges-/248626?cid=wcontentgrid_hp_1b

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                                24
What Companies Are Doing

                                                            Delta Air Lines                                 UnitedHealth Group & Microsoft
                                                            Plans to test employees for active Covid-19     Both companies are utilizing a coronavirus
                                                            and antibodies in partnership with the Mayo     screening app, dubbed ProtectWell, with a
                                                            Clinic and Quest Diagnostics. Will phase to     daily symptom screener to clear employees
                                                            cover all employees over time.                  to return to work or direct them to be tested
                                                                                                            for the virus.
                                                            Amazon
                                                            Will begin with a self-administered pilot       Smithfield Foods Inc.
                                                            testing program with an aim of testing all      Offers free tests to all of its workers on a con-
                                                            employees every two weeks. Plans to spend       tinuing, voluntary basis
                                                            $4 billion on Covid-19 -related expenses,
                                                            including developing its own diagnostic labs.   10X Genomics Inc.
                                                                                                            Administering weekly diagnostic tests for
                                                            Apple                                           about 180 research, manufacturing, and
                                                            Mandating temperate checks and providing        other employees. They self-report results,
                                                            optional nasal-swab tests to its employees.     which arrive two to three days later.

                                                            Walmart                                         Wynn Resorts
                                                            Considering diagnostic and antibody testing     Partnering with University Medical Center of
                                                            for its employees.                              Southern Nevada to provide free testing to all
                                                                                                            its Las Vegas employees, either at the work-
                                                            General Motors                                  place or a designated hospital
                                                            Any employee who shows symptoms of
                                                            Covid-19 at work will get a nose swab, which
                                                            will then be sent to a nearby medial lab for
                                                            rapid processing.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                      25
Risk-based protocols need fast
and affordable tests to prevail                                 24H
against Covid-19

                                                         RAPID                                            CONVENIENT
The development and deployment of
                                                         For screening testing to work effectively in     Easily administered and analyzed outside of a
simpler tests for employers, healthcare
                                                         many situations, the speed of reporting, or      clinical setting using a self-administered nasal
providers, schools, at-risk settings like nursing
                                                         turnaround time, may be more important than      swab, toaster-sized analytic device, saliva,
homes, hard-hit communities of color.
                                                         sensitivity. Faster turnaround time means        breathalyzer-type devices, antigen test strips,
                                                         positive individuals can be removed imme-        or other collection and analytic systems.
The tests needed for mass screening must be:
                                                         diately from a setting where transmission to
                                                         others may occur. Thus, results should ideally
                                                         be returned within 60 minutes but certainly
                                                         within 12- 24 hours, for schools and work-
                                                         places, and 30-60 minutes for mobile testing
                                                         in communities.
                                                                                                          ACCURATE
                                                                                                          Medium (>70%) sensitivity with frequent testing
                                                                                                          (at least weekly)

                                                         APPROPRIATE
                                                         Rapid results mean earlier isolation, less
                                                         spread while awaiting results, reduction in
                                                         positive cases lost to follow-up and enable      AFFORDABLE
                                                         on-the-spot counseling and contact tracing       Less than $5 to $10 per test.
                                                         interviews.

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                               26
The development of clear evidence on exist-         FDA sensitivity requirements for approved
                                                          ing tests and tests imminently coming to            screening tests, making sure the perfect is not
                                                          market to enable employers, school leaders,         the enemy of the good.
                                                          policymakers and others to make informed
                                                          decisions about screening tests in asymptom-        For viruses like SARS-CoV-2, speed of report-
                                                          atic populations, to help contain and avoid         ing has proven more significant than very
                                                          outbreaks.                                          high sensitivity in reducing spread – though
                                                                                                              both are important.18 For Covid-19, the two
                                                          We need a paradigm shift that differentiates        days before and after symptoms appear are
                                                          screening testing from diagnostic test-             the days of peak infectivity. Individuals often
                                                          ing. Screening testing of large swaths of the       do not self-quarantine unless symptoms
                                                          asymptomatic population should be viewed            become severe. The three to five-day turn-
                                                          with a pandemic-control lens, rather than a         arounds often experienced with rtPCR testing
                                                          clinical healthcare lens. Clinical diagnostic       means that results arrive after most of the
                                                          testing is focused on the appropriate diagnosis     infectivity period has passed.
                                                          and treatment for a specific presenting indi-
                                                          vidual. Today, the best of these tests are highly   Point of care (POC) or point of services (POS)
                                                          accurate rtPCR based with sensitivity of more       tests suitable for large-scale screening are
                                                          than 98%. They are performed mostly in a lab-       beginning to come onto the market. New tests
                                                          oratory setting and may take two days or more       and collection methods often meet initial
                                                          for results. Symptomatic patients are expected      skepticism, as did saliva testing. Saliva was an
                                                          to isolate pending test results so that delay in    unconventional but desirable alternate to the
                                                          test results does not lead to more infections.      dreaded nasopharyngeal swab. Initially con-
                                                                                                              sidered unreliable, the saliva test is showing
                                                          Key Principles and Considerations for Effective     increased reliability and may be superior to
                                                          Asymptomatic Screening Strategies                   the nasal swab, especially in the early stages
                                                                                                              of the disease.19 As more saliva tests are devel-
                                                                                                              oped and validated, it may be an ideal test for
                                                          To best reduce transmission, screening test-        hospitality and other settings where non-inva-
                                                          ing must value speed over sensitivity and be        sive DIY tests are needed.
                                                          conducted frequently. Achieving high fre-
                                                          quency of testing requires a massive increase
18   https://www.medrxiv.org/                             in test availability, ease of administration, and
     content/10.1101/2020.06.22.20136309v2
19   https://www.sciencedirect.com/science/article/pii/
                                                          a significant decrease in per test costs. If this
     S0163445320302139                                    model holds up, then we need to re-think the

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                   27
What got us to                                           Endorsement of asymptomatic screening
                                                         testing by public health officials, insurers
                                                                                                            Despite this progress, the U.S. is far from
                                                                                                            being on track to reach the 30 million-plus
3 million won’t get                                      and healthcare providers, along with more          tests it needs by fall. Shortages in test kits,

us to 30 million                                         rapid FDA authorization of the needed tests,
                                                         will be vital to encourage their development,
                                                                                                            reagents and collective devices continue in
                                                                                                            many areas. The average cost of a test is too
tests per week                                           to secure reimbursement for screening tests,       expensive – still around $100 apiece. Results
                                                         and to protect schools, employers, and other       can still take days to come in. The tests remain
                                                         organizations from potential legal concerns.       uncomfortable, and inconvenient.
                                                         This includes clear regulatory pathways to
                                                         authorize such screening tests during the pub-     Resolving the crisis in lab-based diagnos-
                                                         lic health emergency, and reliable mechanisms      tic testing capacity of manufacturers now
                                                         for payment for appropriate testing, through       appears to outstrip the capacity of labs to
                                                         employers, health insurers, or government          process the tests. The combined capacity of
                                                         subsidies for priority populations.                manufacturers of diagnostic platforms, test
                                                                                                            kits, and reagents is estimated at well over 50
                                                         Testing capacity has more than tripled since       million Covid-19 diagnostic tests per week. 20
                                                         the nationwide clamor for testing in late April.   Based on Department of Health and Human
                                                         Walk-in, drive-through, and mobile testing         services estimates, however, the combined
                                                         facilities are becoming increasingly common        capacity of commercial reference labs, public
                                                         across the country. Increased federal funding,     health labs, hospital and academic labs, and
                                                         action by many states to increase testing, and     point-of-care (e.g., CVS, Walgreens) to process
                                                         ramped up production by established diag-          or administer Covid-19 tests is believed to be
                                                         nostics manufacturers have all contributed to      around 7.5 million tests per week. 21 Pooled or
                                                         substantial increases in testing.                  batch testing22 can enable commercial, hospi-
                                                                                                            tals and university labs to increase their testing
20 Based on HHS May 26th Report to Congress, https://
   www.democrats.senate.gov/imo/media/doc/
                                                         That’s the good news. Remember when the            capacity. But the vast majority of current tests,
   COVID%20National%20Diagnostics%20Strategy%20          nation doubted whether we could go from one        nearly 90%, remain lab-based at a time when
   05%2024%202020%20v%20FINAL.pdf (assumes
   100% utilization of diagnostic platforms for COVID
                                                         million a week to two or three times that level?   the market is expected to swing heavily toward
   tests, includes EUA commercially authorized           We accomplished that goal, but we now must         on-site point-of-care and at-home testing.
   diagnostic tests only, and publicly available
   information provided by Deloitte.)
                                                         turn to the next critical threshold. Test sam-
21 Estimated from HHS May 26th Report to Congress,       ple collection has also progressed, with many
   https://www.democrats.senate.gov/imo/media/doc/
   COVID%20National%20Diagnostics%20Strategy%20
                                                         tests now collecting samples in easier ways,
   05%2024%202020%20v%20FINAL.pdf,CDC, and               including saliva-based tests and more easily
   independent resources provided by Deloitte.
22 http://ctbergstrom.com/publications/
                                                         administered nasal swabs.
   pdfs/2020CHE_full.pdf

THE ROCKEFELLER FOUNDATION NATIONAL COVID-19 TESTING & TRACING ACTION PLAN                                                                                  28
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