Like many people who are older, Palo Alto City Councilwoman Liz Kniss wanted to get tested for COVID-19. But though she tried, she wasn't eligible for one in Santa Clara County.
She went to one of Stanford Health Care's drive-thru coronavirus-test sites for help.
"I got fairly far. The governor said that (people like me) can get one because of my age, but they indicated that I did not have sufficient symptoms," said Kniss, who is over 60.
So on Wednesday, Kniss drove to Alameda County — to the Hayward COVID-19 Testing Center at California State University, East Bay, which tested her because she is in a high-risk group, regardless of her county of residency. Kniss didn't need an appointment, and the nasal swab procedure took about 20 minutes.
"It was easy," she said of the drive-up procedure. "I'll have the test results tomorrow morning."
By 9:30 a.m. on Thursday, she had her answer: Her test came back negative.
Kniss apparently is far from alone in leaving Santa Clara County to get assessed for the coronavirus. Another Alameda County city, Fremont, began a drive-thru testing program six weeks ago, spearheaded by the fire chief. As many as 40% of the people tested in Fremont have come from Santa Clara County, according to fire Chief Curtis Jacobson.
As Los Angeles County and, this week, Sacramento County announced coronavirus testing for all of their residents, including those exhibiting no symptoms, Santa Clara County has lagged behind — to the frustration of local leaders like Kniss.
The numbers show the shortfall.
The county needs to be able to test roughly 4,000 people per day before the stay-at-home order can be relaxed, County Executive Jeffrey Smith told the Board of Supervisors on Tuesday, May 5. As of last week, it had reached only about 1,000 tests per day.
The 4,000 tests per day are the minimum needed; the county's goal is to expand to 15,000 to 20,000 tests per day, he said.
Testing is crucial to getting the county's businesses, schools and other facilities reopened. Without testing, it's hard to identify who has the disease and to whom they are spreading it, Dr. Sara Cody, the county's public health officer, has said.
County Supervisor Joe Simitian voiced his frustration with the slow pace of testing.
"We've only gotten in the last week or so to 1,000 tests. Our current level is 25% of where it needs to be by the end of this month," when the shutdown order ends, he told this news organization.
At Tuesday's meeting, Simitian expressed urgency about testing at all long-term-care facilities, like skilled nursing homes. It's known that the virus has been introduced to residents of these facilities by employees, which highlights the importance of testing asymptomatic individuals, he said.
"This needs to happen now. Forty percent of the deaths are in long-term-care facilities," he said.
Kniss' and Simitian's concerns are widely shared among the county's 15 mayors, who joined together last week to try to spur the county to faster action and greater collaboration with its cities.
In an April 29 letter to county leaders, the mayors specifically requested that the county identify a clear goal "in unambiguous, quantitative terms" for testing frequency that would be sufficient to safely reopen schools and businesses; create a comprehensive list of testing sites; and identify how many people would be needed for contact tracing, the process of identifying — and isolating — people who may have been exposed to someone who tested positive.
The letter noted that Gov. Gavin Newsom's Testing Task Force has asked for partnerships and more testing sites but has not offered specific details. The mayors urged the county to form a county task force devoted to testing.
"Without dramatic scaling of testing from the current levels ... we cannot reopen our county," the letter states.
At the urging of Kniss, Palo Alto's council on May 4 unanimously agreed to hold a full discussion on Monday, May 11, about ways it can help expand testing. Councilman Greg Tanaka noted that Shenzhen, China, which was one of the first cities to experience the pandemic, has been able to reopen about 90% of its economy by offering widespread testing and contact tracing. He also pointed to the free testing run by the cities of Fremont and Hayward.
Testing "lets us know what the spread is," Tanaka said. "And that's what other places have done — Seoul, South Korea, and China. They've been able to reopen successfully and without a resurgence because of this kind of practice."
Yet council members also recognize that the city's ability to offer tests and reopen schools and businesses hinges on the county, given its charge of protecting public health. Mayor Adrian Fine said that anything the city does needs to be "additive to the county process" and not duplicative or counter to what the county is doing. The city would need the county's help to figure out what type of tests to do, how to report results and how to maintain residents' privacy, Fine said.
"We as a city are not professional in those areas," he said.
The problems with testing
County leaders have offered a variety of reasons for why testing in Santa Clara County continues to fall short of the need. On April 29, Smith told the Board of Supervisors' Health and Hospitals Committee that testing is "a priority we have very little control over, locally."
Smith cited the shortage of reagents (chemicals that are used for analysis of samples); the length of time to get approval for tests from the FDA, the CDC and CMS (Centers for Medicare & Medicaid Services); the ineffectiveness of the test developed by the CDC; and the fact that other parts of the nation are doing far worse than Santa Clara County and, as such, are "sucking up the capacity."
Ken Dueker, director of Palo Alto's Office of Emergency Services, similarly attributed the shortage of tests to inadequate supplies of test kits and uneven distribution of personal protective equipment for the health care workers implementing the tests. In some cases, he said, ability to test is limited by a shortage of the required nasopharyngeal swabs.
"Reagents and chemical components have been hit and miss in the supply chain. Even the medium to safely transport the samples has been in short supply," Dueker told the City Council on May 4.
He also noted that while the state has been funneling testing supplies to various parts of California and setting up new testing sites, these resources have not for the most part been directed to Santa Clara County.
"They've gone elsewhere," Dueker said.
All of these reasons do not entirely sit well with the county's supervisors, who instead — like the cities' mayors — point to a lack of coordination as significantly contributing to the problems with testing.
Simitian, who serves on the county's Health and Hospitals Committee, suggested on April 29 that the committee take the lead in coordinating the county's effort to ramp up testing.
"I know for public health purposes that the incremental growth in testing that we've been able to achieve has significance, but in terms of charting a course back (to normal life), these numbers are pretty modest," Simitian said at the meeting. "That's the kindest way I can put it."
Supervisor Susan Ellenberg, who also serves on the committee, agreed.
"There is such discrepancy in what is happening from state to state and from county to county that I fully believe there is more that we could be and must be doing to move this along," Ellenberg said.
That lack of coordination has been evidenced in Kniss' experience of trying to get tested for COVID-19 in her home county — one in which she both worked as a public health nurse and served as a county supervisor. Even as Los Angeles and Sacramento counties have partnered with nonprofit groups to provide COVID-19 tests to all their residents, Santa Clara County's testing network resembles a collection of disparate systems, each with its own rules and objectives.
Most health care systems — Kaiser Permanente, El Camino Health, Palo Alto Medical Foundation — will test only their own patients provided they have symptoms that meet the CDC guidelines and receive a doctor's referral. Stanford Health Care initiated testing with similar restrictions in March, although now the organization allows non-Stanford patients with symptoms or exposure risks to be screened for a possible test. (Stanford Health Care has also focused on testing its 14,000-member workforce and its patients.)
Beyond the private and nonprofit health care networks, there has been no clear route to getting tested unless you fit certain limited criteria. Wonder how you can get tested? Find out through this graphic.
The Palo Alto VA Health Care System is testing military veterans with symptoms. The County Health System is testing those who don't have insurance.
Verily Life Sciences — a research subsidiary of Mountain View's Alphabet — has been testing persons who are either symptomatic or working in frontline professions, such as first responders or health care or prison employees.
And through a new public-private partnership between the state of California and health-services company OptumServe, two sites in south county will offer COVID testing to all, but with the caveat that priority will be given to a range of groups, including high-risk workers, the elderly, the chronically ill, those referred by public health, people living or working in group-care facilities and those with symptoms. Those who are asymptomatic are at the bottom of the list.
Where do we go from here?
Even as local leaders have urged swifter action, the county has made some progress on boosting its testing numbers. And this week, officials announced new plans to ramp up testing capacity and create a new group to improve coordination.
Between April 1 and April 15, the county reported an average of 511 tests per day, according to Public Health Department statistics; in the period between April 16 and May 4, the average number of tests rose to 844; and in the past 10 days, the county reported an average of 1,040 tests per day, with a peak on May 1, when there were 1,383 tests.
The county also formed a new COVID-19 testing task force, to be headed by former county public health officer Dr. Marty Fenstersheib, to move the county toward adequate testing and its longer-term goal of complete contact tracing, which Smith said could require a workforce of 600.
Smith told the Board of Supervisors on May 5 that in order for the county to get closer to testing capacity of 4,000 per day, the tests will come from outside sources.
Stanford Health Care has the capacity to do 2,800 tests per day, Kaiser Permanente 1,500 tests, and Valley Medical Center can 2,000, although it currently can test only 300 a day. It expects to receive new reagent and new machinery at the end of this week.
"We can quickly approach capacity," he said.
Dr. Scott Boyd, associate professor of pathology at Stanford School of Medicine, who created a serology test to identify antibodies to COVID-19 in blood samples, said there are plans to increase the capacity for the PCR swab tests, which identify the virus by its RNA, and the serology test.
Stanford has tested a mix of patients, including some individuals who were asymptomatic, and it has tested samples sent by other medical centers on a small scale. So far, Stanford has had enough supplies for the testing, but shortages have been an ongoing issue in general with tests.
"It's a moving target all of the time," he said.
The county also has loosened its criteria a bit for who can be tested by any organization. Depending on test availability, other health care workers, first responders and essential employees such as grocery clerks, utility workers, food supply workers and others who have close contact with the public can be tested. People who are hospitalized and undergoing elective procedures can also be tested, as can all residents of congregate living facilities, such as senior-care centers. Anyone older than 60 years of age or individuals with chronic medical conditions that increase their risk of severe COVID-19 symptoms can also be tested.
There is now more testing capacity than there are people being tested, Smith said. Private laboratories, including the Verily site, are underutilized. Smith said he has been told people make appointments but don't show up. He said he doesn't know if they have trouble getting to the site or if they aren't being referred there.
Just about everyone agrees that the county's communication on testing has been a problem. When Simitian asked on May 5 whether the county should make the criteria for who can get tests less rigorous, Smith pointed to the recent loosening of the county's guidance and the recent boost in testing capacity.
"Since we currently have capacity for selection, I think for the most part that means anybody," Smith responded. "But that just points out the fact that we're still having trouble communicating that message effectively, because private doctors and institutions aren't necessarily doing it as on call, or as needed."
That said, the official guidelines that are posted on the Santa Clara County website continue to restrict who can get tested, forcing residents to go to other counties. This includes even residents like Kniss, who fit the county's recently expanded criteria. Smith acknowledged this week that the county needs "to communicate that (testing) is available, that it can be done here."
Cody said the challenge is matching the capacity to the need and understanding the barriers to getting people to where they need to be tested.
"We are successful in driving down the infection," she said on May 5 of the nearly 2-month-old public health effort.
In areas where there are more infections, the county needs to do intensive testing and make them priority areas, she said.
"I'm an eternal optimist," Cody said. "I feel we can do this."
Symptoms of COVID-19
The U.S. Centers for Disease Control and Prevention currently lists the common symptoms of COVID-19 as:
• Shortness of breath.
• Muscle pain.
• New loss of taste or smell.
• Vomiting or diarrhea.
• Sore throat.
Editorial Assistant Lloyd Lee contributed to this article.
Find comprehensive coverage of the Midpeninsula's response to the new coronavirus by Palo Alto Online, the Mountain View Voice and the Almanac here.