Spotting a spike in new cases in the midst of an epidemic isn’t as simple as looking at the numbers for the day. For example, Louisiana reported 295 new cases on Monday, but with over 27,000 cases already reported, this was both a significant decrease over previous days and a fairly low value overall—just a 1% increase in known cases. Those new cases were also backed up by 4,000 new tests. Meaning that the testing on that day resulting in 7% positive cases. That’s not great, but it’s definitely an improvement.
On the other hand, Nebraska reported 330 new cases on Monday. On the surface, that seems like a very similar number. Only that number came on top of just 2,732 previous cases, making the new cases an 11% increase for the day. Also, Nebraska only performed 1,100 new tests on that day. So positive tests were 26% of the total. That’s an absolute sign that the testing was grossly inadequate, likely restricted to people entering the hospital, and was sure to miss a great number of cases. That day wasn’t the only such day in Nebraska. It followed a whole series of days just like it: rapidly rising cases, woefully inadequate testing. Cases in Nebraska have doubled in a week, and it’s not the only state showing this kind of spike.
When cases in New York state first began explosive growth, the answer was straightforward: They were already there, but no one was looking. It was clear even then, and definitely established now, that cases had been expanding across New York throughout February, even as the CDC fumbled and failed to produce tests. It wasn’t until March 4 that the first tests—44 of them—were available in New York. As late as March 14, the number of tests being conducted in New York in a single day was just 103. Whole generations of virus had expanded across the city at that point. Testing wasn’t describing an outbreak, it was searching for the boundaries of an epidemic already underway. Even as testing became a priority and the rate increase enormously (hitting a peak rate of 46,000 tests last Saturday) the already massive size of the outbreak still defied description. On Monday, the rate of positive tests in New York City was 19%. Horrible … but down from 45% two weeks ago.
The problem with states like Nebraska is that testing has never become a priority. The state has just reached 1,000 tests a day in the last four days, and across those days the rate of positive tests has been 25%, 22%, 25%, and 26%. There is COVID-19 in Nebraska. It is expanding rapidly. No one in the state government headed by Republican Gov. Pete Ricketts seems particularly interested in finding it.
Neighboring Iowa has a similar problem. Though the state made it fairly deep into the crisis without reporting a significant number of cases, in part that was because it barely conducted any testing before mid-March, and when those tests were 10%-20% positive, Republican Gov. Kim Reynolds apparently took this as permission to continue snoozing. This resulted in darkly amusing situations like the one on March 26 where Iowa conducted just 34 tests. All positive. This is not exactly the best indicator that everything is under control.
In the last week, Iowa has increased its rate of testing, hitting 2,000 tests a day for three days out of the last four. But it’s clearly done so in response to a sharp increase in confirmed cases. The rate of positives over that period has been over 20%, showing that like Nebraska, Iowa isn’t testing at a rate sufficient to describe the outbreak that already exists, much less get ahead of it and halt it short of disaster.
There are other states that stand out for low levels of testing. Arizona has tested at barely half the national average. Despite the high number of elderly residents, the state seems to have largely gotten away with this so far. But then, unlike the governors of Iowa and Nebraska, Republican Gov. Doug Ducey did order a fairly comprehensive shutdown—which expires on April 30. Which means that Arizona is about to get an answer to whether it has tested sufficiently to support relaxing those guidelines. (It hasn’t.)
Of course, there is a state under a Democratic governor that’s testing at a genuinely shocking rate. Under Gov. Jay Inslee, Washington state conducted only 37 tests on Monday and fewer than 700 over the last three days. But then, the rate of positives on those tests was 0%. COVID-19 is far from defeated in Washington. Over the last week, the state has uncovered 1,100 new cases while carrying out 21,000 new tests, and that 5% positive rate is still way too high. (Washington also had at least 165 cases on Tuesday, but the number of total tests conducted on that date hasn’t yet been made available.)
Across the country, there are states that are doing fairly well with testing, but not well on distancing guidelines (see Utah), states that are doing well on guidelines, but under testing (check out Virginia), and states that are really not doing well at either (Kansas is a stand out and not standing out). None of these states is ready to step back to anything approaching “normal.” Some of them, like Iowa and Nebraska, aren’t just facing possible spikes in cases if they reopen—they’re already in the middle of spikes. Others have tested at such low levels that opening wide to save the economy is only going to raise the stock price of companies that rent refrigerated trucks. Too many of them are about to discover that the virus may be too small to see, but its effects are not.