With delays, a ripple of impacts: How slow COVID-19 test results complicate life for public health workers and patients.
In mid-June, as Montana’s COVID-19 case count began its summer climb, the Missoula City-County Health Department announced it would begin testing asymptomatic frontline workers. The declaration seemed to signal progress on the path to expanded testing capability, fitting neatly into the hopeful picture painted by Gov. Steve Bullock when he set a goal in April of conducting 60,000 COVID tests statewide per month.
Within a week, however, Missoula health officials were inundated with people displaying symptoms of the disease. Cindy Farr, Missoula’s COVID-19 incident commander, estimates the county was doing 80 to 100 tests a day, all of them either symptomatic individuals or close contacts to a known case. On top of that, test results for asymptomatic individuals were taking as much as three weeks to come back. By early July, Missoula County halted its asymptomatic testing efforts.
“We’re still currently testing between 80 and 100 people a day, and they’re mostly people who are having symptoms,” Farr said. “The remaining slots have been used for people who are close contacts to a confirmed case.”
It’s a familiar enough story by now: Ramped-up testing goals, rampant outbreaks in certain corners of the country and thinly stretched supplies of critical testing materials have resulted in long delays. Social media feeds for Quest Diagnostics, one of several clinical lab companies scrambling to test patient samples from across the country, are rife with criticisms and complaints from people still awaiting results after five days, 10 days, even two weeks or more. A spokesperson for another company, LabCorp, told Montana Free Press last week it was working to increase its testing capability from 130,000 per day to 150,000, but that average turnaround times of four to six days are still expected. The only exceptions are those tests assigned the highest priority — swabs collected from the symptomatic and the hospitalized.
These delays have resulted in waves of calls from an understandably impatient public, and have put health care providers in a difficult situation when it comes to treating non-COVID ailments. Responding to this latest challenge, Bullock announced a plan Wednesday to expand surveillance testing for frontline health care workers and other essential personnel by partnering with Montana State University. Researchers at MSU will begin processing tests for as many as 500 people a day starting next week, with the Montana Department of Public Health and Human Services determining which populations will take surveillance testing priority.
Bullock also said in his press release he anticipates an additional 1,000 tests per day to be processed under a new contract with North Carolina-based Mako Medical, which went on a hiring spree in June with the goal of processing as many as 25,000 tests per day and is gaining increasing attention from other states looking for solutions. The contract was finalized even as Montana opted to drop Quest Diagnostics due to lengthening turnaround times.
Whether these new avenues will skirt the compounding issues of national demand and testing supply constraints, or will settle the question of feasibility of surveillance testing for counties such as Missoula, is another question. What’s clear is that the delays are an unsettling reality for individuals crossing their fingers for a clean bill of health.
And for those actively fighting the pandemic in Montana, the delays have delivered a host of challenging side-effects.
Trisha Gardner, health officer for the Cascade City-County Health Department, said the biggest impact on her staff has been an “onslaught” of calls from the public looking for their test results. Her office informs anyone getting tested to expect a wait of up to 10 days, yet each follow-up call necessitates an explanation about why the results aren’t yet available, an added investment of time for staff already working long hours. There’s little the department can do, Gardner said, beyond trying to spread awareness of the situation.
“Our approach is just to educate as much as we can about why those delays are happening,” she said, “and hopefully that will reduce the number of calls that we get in so we can focus on the other work that we need to do.”
According to Barbara Schneeman, public information officer for Riverstone Health in Billings, one of the primary factors dictating turnaround time is priority. The Montana Department of Public Health and Human Services developed a set of tiers for testing, with symptomatic people at the top. The state lab, with a current capacity of 9,000 tests per week, has kept pace with that first tier. But with some counties racking up nearly 1,000 close contacts, and with others conducting surveillance testing of asymptomatic community members, sample swabs from lower tiers are being shipped to out-of-state labs operated by Mayo Clinic, Lab Corp and, until recently, Quest, which may be backlogged with samples from higher-priority individuals in other states. In the case of LabCorp, samples may be forwarded to one of the company’s other labs, adding to the transport time.
Schneeman said one of her primary concerns stemming from the delays is the potential for unchecked community transmission. Symptomatic individuals are instructed to isolate until test results come back, but if an asymptomatic individual faces a 10-day wait for results, they may opt to continue with their usual routine in the meantime, socializing in public or returning to work, only to find out later that they carry the virus.
“It’s causing impacts on their workplaces,” Schneeman said. “It’s also causing impacts on the public health system in terms of trying to trace all those contacts and notify people in a timely manner so we can prevent the spread.”
Montana’s hospitals are also contending with their own delay-spawned challenges. Larger hospitals have the ability to conduct much of their testing on site. Bozeman Health can currently process 115 tests per day, with priority given to patients set to be hospitalized and those preparing for surgical procedures, as well as symptomatic staff and first responders. In a written statement, Bozeman Health said the turnaround time for in-house testing is between five and 24 hours. Other tests are sent to Mayo Clinic, with a turnaround time of five to seven days. Though having an in-house lab makes for faster results, every testing site in the nation is competing for supplies, and Bozeman Health is in constant communication with manufacturers to keep abreast of supply-chain issues.
“As is the case with many of our peer health systems, we are unable to order and receive many of the rapid COVID test kits and reagents that are available on the market as they are being prioritized to the areas of highest demand across the country,” Bozeman Health’s statement said. “All major reference labs are experiencing delays.”
Rich Rasmussen, president and CEO of the Montana Hospital Association, noted that Montana hospitals have another priority tier to consider: patients undergoing elective surgeries. Hospitals voluntarily suspended such procedures during the coronavirus response this spring, but resumed them in May. Whether it’s as simple as a colonoscopy or as invasive as a joint replacement, Rasmussen said, a COVID-19 test result is required before any procedure to ensure the safety of both the patient and the medical staff. A delay of even a few days can raise serious problems.
“Imagine if you drove from Terry to Billings Clinic, how many hours is that? Two and a half hours I’m guessing?” Rasmussen said. “You come there, you’re expecting your procedure, you take your test and you spend the night planning to have the results next-day. Four days later, five days later, seven days later, you don’t have the results back? That is a disruption to the patient, and it also creates an opportunity too where the patient’s condition, depending on the severity, could deteriorate over that period.”
One segment of the state’s health care community that has largely managed to sidestep testing delay complications is the Montana VA Health Care System. According to a spokesperson for Sen. Jon Tester, the VA established the capacity to run the bulk of its own testing this spring, boasting a turnaround time of 24 to 48 hours and presently revving up capacity to meet a potential new wave. Montana VA congressional liaison Christina Lundstrom said the lab at Fort Harrison in Helena has processed 1,600 COVID-19 tests of veterans and employees to date, as well as an additional 1,350 veterans and employees through its participation in Bullock’s statewide surveillance project.
Dr. J.P. Maganito, the Montana VA’s chief of staff, added that the system was “way ahead of the ballgame” in preparing to handle its role in the pandemic, and opted to utilize the gold-standard PCR testing over rapid-result testing due to the latter’s high false-positive rate. Save for one slight delay of a few days, Maganito said the Montana VA has had no trouble getting the 120 to 150 test kits per week it contracted for. He expects that capacity to double within the next two weeks, and has secured a second PCR testing machine that should be up and running in the Billings area by early August.
“I can tell you that the VA is prioritized by the company,” Maganito said. “A huge part of that is because of the population we have and the co-morbidities they have. So in a way we haven’t had that issue, because companies know what to do in order for us to get those reagents on time.”
Yet even the Montana VA has hit obstacles. After experiencing delays with some of the tests it sent to LabCorp’s East Coast lab, Maganito said, his agency began to tap less-inundated LabCorp locations in the western U.S. He’s taken steps to avoid burning out his lab staff, planned contingencies for if a lab team is compromised by the virus, and is even reserving some testing capacity as cushion in case demand spikes. As with Rasmussen, timeliness of test results is a particular priority when Maganito considers veterans coming to the Montana VA for non-COVID-related procedures.
“It’s important for me to stay within a window of, ideally, one to three days prior to the procedure,” Maganito said. “Days three to seven is acceptable. Seven to ten, now you’re like, how are you going to be able to instruct a patient to quarantine for seven to ten days?”
In general, though, local officials and health care professionals in Montana are mostly powerless to resolve the core problem driving these challenges. They can prepare, they can plan, and they can message, but they can’t control national demand or supply shortages.
Even a recent initiative by the Trump administration and the U.S. Department of Health and Human Services to steer more rapid diagnostic testing equipment to nursing homes doesn’t give Rasmussen much hope. What good are the machines, he said, if there aren’t enough test kits to go around? What Montana and the nation really need, he said, is a cohesive federal strategy specific to testing.
“We’ve been in this thing now for several months, we haven’t gotten it right yet,” Rasmussen said. “So states and providers are really looking to the federal government to take the lead on this, and for whatever reason we continue to struggle in being able to respond to this appropriately.”