Setting sights on a coordinated testing strategy

Improving local response is one step, but only one. Beyond state borders lies the federal response. Here, too, more (or any) would have been helpful—more knowledge, more communication, more transparency.

“Just from a communications standpoint,” Dr. Sossaman says, “you want to understand what the plan was as far as allocation of resources. Or if there was an ability to coordinate resources where they were most needed, or coordinate testing.”

Louisiana was inordinately affected early in the pandemic, driven, Dr. Sossaman suspects, by the superspreader event of Mardi Gras. Perhaps laboratories in less hard-hit states—in the Midwest, say—could have stepped in. Compass Group calls last year, he recalls, were filled with discussions about capacity and underutilization. “People had rushed to bring up tests, did a whole bunch of tests, for a while, then didn’t have a lot of testing directed their way. Whereas other areas of the country were inundated.” Capacity was incapacitated, in other words.

The conversation failed in another way, Dr. Sossaman says. Vendors told laboratories that the federal government was sequestering and redirecting supplies. “But then you heard something different—when you did hear about it—from the federal agencies: No, we’re not doing that. We’re not redirecting supplies.

“It was very confusing,” Dr. Sossaman says, “because we’re hearing the opposite from vendors.”

That led to the fierce and wrenching competition between states, and between systems, for supplies. “Maybe that would have happened anyway,” Dr. Sossaman says. “But when you have something that’s affecting the entire country, it seems like a more concerted response would have been more appropriate, where you put more resources to where they were most needed at different times.”

Vendors, he stresses, know their own inventory and where it’s heading; health systems don’t have similar lines of sight. “And the government had a direct line to large vendors.”

Dr. Sossaman speaks without bitterness. Indeed, he counts himself as one of the better-resourced systems throughout the pandemic. From the start, he says, his laboratory chose a single-source strategy, relying exclusively on Abbott. “We didn’t try to purchase multiple types of instruments,” he says. “We put a lot of stock in our relationship with Abbott, and we told them that: We’re going all in with you, but you need to work with us.”

Because Louisiana was blitzed early, Abbott told him, the government was letting the company allocate more supplies to the state. “So I benefited from being in a state that was harder hit—unluckily lucky,” he says. “But I wouldn’t have gotten what I got if I hadn’t had that relationship.” Without that flowing pipeline, other strategies, including hoarding, would have been viable, he says. “That’s what people were forced to do because they didn’t know when they were going to be getting their next shipments, or what their allocations would be.”

Knowing that the larger vendors were communicating with the federal government was another reason for sticking with one vendor, he says. He did not want hearsay to be part of his own system’s strategy. “I was fearful the government was going to allocate resources away from us and to large commercial entities. Frankly, there were lots of rumors out there, for a long time, and it was hard to know what to believe.”

In the future, facile communications might also help laboratories in another critical role: deciding who should be tested.

At Ochsner, a tight-knit relationship between the laboratory and ID colleagues has sprung up, including daily phone calls for months on end. “I can’t say we have absolute input into who gets tested,” Dr. Sossaman says, “but we’re very, very connected to all plans coming up and being considered about testing. We’re involved in all of the decisions.”

Nevertheless, the laboratory was under enormous pressure to provide testing, much of it driven by promises and pronouncements from national leaders that seemed to be uttered more in hope than reality, unmoored from any strategy.

Moreover, “There was a lot of ambiguity” in the directives from agencies such as the CDC, he says.

Even as the lab worked closely with ID colleagues to develop a systemwide testing plan, Dr. Sossaman had to incorporate ever-ripening, sometimes murky, sometimes conflicting information. While that’s always been the lab’s role, Dr. Sossaman says, a pandemic is a pressure cooker. “The lab has to be on top of it all, not only talking to vendors and understanding capacities, and vetting new technology and talking to ID colleagues, but following regular FDA and CDC calls, listening to the information as it evolves.” Added to that was the guidance being issued by professional societies “and a million people trying to publish,” along with tracking all the tests coming out—the good, the bad, and the cockeyed.

A pandemic waits for no laboratory. “Things were moving so quickly, I followed most of what I needed to on Twitter and podcasts.”

In the future, however, he sees “a place for a clearinghouse for information from a lab standpoint,” he says. “Even if it’s not federally coordinated.” In fact, he applauds the webinars put out by the FDA and CDC. “Those are great sources of information, and they do as much as they can as federal entities. There are just some things they can’t do or say. The lab community could have helped out. There was no one laboratory group putting out information.”

Dr. Sossaman joins many of his colleagues in calling for laboratory representation as part of any future federal response. Labs know what they can do and, just as importantly, what they can’t. Linking payment to turnaround times, for example, may seem, from the outside, like a useful nudge to expand testing. “But that just ignores the realities of things like transportation and other issues that a lot of labs face,” he says. Likewise, federal leaders may fail to see the harm being caused by the current technologist shortage. “We’re short hundreds of people in our system,” Dr. Sossaman says, including phlebotomists and medical technologists. “We can’t do this testing without the technologists, even if the supply lines are intact.”

“That’s why we need to be a voice at the table,” he says. Even the rollout of vaccines shouldn’t dim that voice. “Who knows how long it’s going to take to vaccinate everyone?” he asks. “Maybe with this virus we don’t get herd immunity.” Testing was the only tool available at the pandemic’s start. “And it could be what we continue to rely on for a couple years. Who knows? We need to have that voice at the federal level, probably even more so in the future as things begin to shift away from the urgent pandemic response.”

Evolution of the pandemic will force laboratorians to consider alternative testing strategies and platforms, Dr. Sossaman says. PCR, rapid antigen, and antibody testing have an integral role when deployed to the appropriate population. Laboratorians and public health experts should be “the government’s guiding voice,” he says, “on how to test the most people quickly and in the most clinically relevant way.”

Testing for diagnosis, screening, and surveillance all have their place, as well as different challenges and requirements, he adds. “We will likely continue to have limitations with PCR testing, so the focus may shift to more screening with antigen tests, something we may have already seen in the new administration’s response.”

“This could be the moment,” he says, “to take advantage of the view of the lab and the people in it.” And, one hopes, to avoid any future disappearing acts.

Karen Titus is CAP TODAY contributing editor and co-managing editor.