The first failure of the United States when it comes to addressing the outbreak of the 2019 novel coronavirus was the failure to quickly develop and deploy an accurate test. The primary failure of Donald Trump in his most basic role of protecting the nation came when he deliberately decided not to roll out a national testing strategy because he thought that there was a political advantage in allowing COVID-19 to rage unchecked. And 10 months into the epidemic in the United States, the biggest problem is still the lack of adequate testing and associated contact tracing.

On Thursday, six states had rates of positive results over 30{1b1a587643a9e9b1244ae3f96d242e13c62224c25ebdf73114e48122c41a7985}—more than 10 times the rate that indicates an adequate level of testing. In fact, only three states had positive rates that were below the suggested maximum. Some of that ugly disparity is due to the simple explosion in cases. With over 210,000 cases on Thursday, many states have not built up testing capacity to handle the number of cases now flooding into test centers, resulting in images of hundreds of cars lined up in areas like Los Angeles or Chicago. However, there are some locations that are simply refusing to make an attempt at conducting anything approaching a necessary level of testing. States like Iowa, Idaho, and Alabama continue to report both some of the lowest rates of testing and the highest levels of positive tests. Their testing rates have actually dropped even as their positivity rates have continued to increase week after week. But there are still two different forms of testing that can play a vital role in putting the brakes on the pandemic.

Early in the pandemic, researchers began using the technique of searching for SARS-CoV-2 RNA and antigens in wastewater. This type of system is good for general surveillance of a neighborhood or district, allowing governments to monitor both presence of the virus and increases in the level of infection. However, it’s not very good for determining how many people are actually infected, and attempts to determine those values from wastewater have often resulted in large overestimates.

But increasingly researchers are seeing an advantage in another form of mass testing, often called “pooled” testing. As the BBC reported on Tuesday, this kind of testing requires a very high level of participation. In fact, it ideally means that everyone in a community, whether or not they have symptoms or believe they have been exposed, contributes to the test. But this isn’t just a call to ramp up testing to the Nth degree; while everyone contributes to the sample, the number of tests is drastically reduced.

For example, say there is a group of 100 people in a nursing home. All contribute saliva or mucus toward a single test. If that test comes back positive, the group might be broken into cohorts of 25 representing different wings of the home, and the same samples tested again. If two of those came back positive, results on smaller groups could be tested again. Testing can be continued until individuals are identified. This kind of testing can protect a community by allowing inexpensive and quick monitoring of a group rather than requiring 100 tests at each pass. This kind of mass testing can be implemented to protect areas of hospitals that are supposedly isolated from COVID-19 cases, military vessels or bases, or almost any community.

The other type of test that can play an enormous role in helping to cut the rapid growth of coronavirus infections is home testing. Home tests of both the nasal swab and saliva variety have been available for some time. However, when ordered by individuals these tests generally cost over $100 and are not covered by insurance. There are some tests that promise to be fast, cheap, and fairly accurate … but they’ve yet to hit the marketplace in the kind of numbers that would allow, for example, testing of everyone who might visit for Christmas dinner.

But that doesn’t mean that self-administered testing isn’t becoming more important. As The New York Times reports, several communities are using economies of scale to conduct widespread testing using these at home tests. In November, Minnesota began offering at-home testing using saliva for all residents. The state promises results of those tests within three days of their being mailed back, but it’s unclear how many residents have requested these tests so far. Orange County, California, is taking a more active approach by distributing half a million tests to residents of Anaheim and Santa Ana. If participation and results work out, the other 3 million county residents could be close behind. Though early saliva tests gained a reputation for being less accurate, the gap between those tests and the PCR tests administered using nasal swabs has closed with the rapid iteration of new generations of tests. 

At a time when over 200,000 people a day are already testing positive and America is reaching a fresh 9/11 per day’s worth of deaths, hearing the phrase “we need more testing” may sound like a lament that belongs back in March (or the Middle Ages, which now feels like the same thing), but the impact of these two testing techniques could be tremendous. Even more so when the kind of test that gives results in minutes really are available, at home, in quantity.

As WBUR reports, these tests alone could help transform the state of the pandemic in a remarkably short time. “Unlike a mask which has become politicized in many ways,” says epidemiologist Michael Mina, “these tests take less than one minute to perform and you do that twice a week.” Because they’re done simply, quickly, and privately, these tests could really turn what has been until now a mythical corner on the coronavirus. 

Writing three weeks ago in Time, Mina said that “if we act today, could allow us to see our loved ones, go back to school and work, and travel—all before Christmas.” However, that was three weeks ago. And Trump did not act on this proposal any more than he has on any other. After all, he has a coup to stage. As with so many other reasonable actions, it will likely require the installation of Joe Biden in the White House before there can be the kind of testing necessary to throttle the raging pandemic.

The good news is that these tests are more available, less expensive, and easier to administer than ever. It makes absolute sense to deploy them in advance of vaccines—and even to use the results of this kind of testing, along with mass tests, to determine where vaccines are most needed.

Refusing to put in place a program of national testing was Trump’s original, and largest, crime when it comes to handling the COVID-19 pandemic. His continued refusal only compounds that damage every day. Biden can’t restore the 300,000 families who will be mourning lost loved ones before he takes office, or restore to health the millions who will suffer long-term damage from COVID-19 infection. But he can use both mass testing and at-home testing to do what any reasonable leader would have already accomplished: drastically slow the spread of COVID-19 while waiting for vaccines, and keep on testing after those vaccines to prevent the disease from making a comeback.

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