Covid-19 National Testing & Tracing Action Plan

We’ve gone from 1 million to 4.5 million tests per week in the U.S., but we’ll need to redouble our efforts to make it to 30 million tests per week and beyond in order to reopen communities and economies, and keep them open.

Foreword to National Covid-19 Testing & Tracing Action Plan

America faces an impending disaster. The extraordinary scale of the Covid-19 crisis is evident in the growing deaths and economic losses the pandemic has wrought in every state. Devastated minority and low-income families bore the brunt of those costs. As the virus tore across the country, it exposed the structural inequities that have underpinned and undermined our economy for decades. And it will only worsen during fall’s cold and flu season.

This terrifying tragedy was not and is not inevitable. America can function safely, even as we fight Covid-19. Other countries have shown that a better alternative is possible. But as we said in April – when we first released The Rockefeller Foundation’s National Covid-19 Testing Action Plan – testing is the only way out of our present disaster, and it will remain the case until a vaccine or effective therapeutics are widely available.

When we were barely a month into this pandemic, we brought together scientists, industry, technologists, economists, and Republicans and Democrats alike to formulate an action plan to expedite the development of our nation’s widespread testing and tracing system. We called for rapidly expanded diagnostic testing capacity from 1 million tests per week to 3 million tests per week by June, and to 30 million tests per week by October. Today we’re at 4.5 million tests per week, but unfortunately it’s taking far too long to get to 30 million tests per week, and communities that most need them – low-income families, minorities, and highly vulnerable essential workers – find it most difficult to gain access, while elite institutions, companies, and enterprises seem to be able to access them on the private market. We need to urgently fix clinical diagnostic testing and accelerate the introduction of faster, cheaper, point-of-care screening tests to prepare for next flu season. Some say it’s impossible. Some say America has already given up. But we know it can be done, and we present here a renewed national action plan to help get there.

Across the board, federal leadership and genuine public-private partnership will be essential to meeting three key needs identified in this updated plan. First, we need to massively scale up fast, cheap screening tests to identify asymptomatic Americans who are currently infected. Today the country conducts almost zero such tests, and we need at least 25 million per week for schools, health facilities, and essential workers to function safely. Teachers, healthcare workers, grocery store workers: these are the real heroes of this crisis, and they should be able to support our country without the all-consuming fear that they’re jeopardizing their lives or the lives of their loved ones.

Second, we need to dramatically reduce the processing time for diagnostic tests, from the current 5-14 days to a 48-hour standard turnaround time that every state and community should meet. Many businesses that are privately contracting with lab companies already meet this standard. We propose a public-private collaboration between government, lab companies, and scientists in order to alleviate the very basic constraints that are leading to these extraordinary delays.

Third, this reinvestment in testing must be tied to the basics of any pandemic response to really work: clear public health communications from trusted community leaders, and robust contact tracing and support for targeted isolation to reduce the contagion of the disease.

The Rockefeller Foundation will invest an additional $50 million toward realizing the emergency requirements we outline in this updated plan. But make no mistake: this crisis demands immediate federal funding. Congress took a first step by including $25 billion for testing in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. This plan requires another $75 billion as soon as possible, because tests should be free and accessible to all who need them – with extra effort to make sure low-income and minority communities, those who are more financially vulnerable and critical institutions like nursing homes, schools, and community centers are supported, and that we address the sharp racial injustices and inequities that plague our country. This represents the single best investment America could make in averting an even more tragic and pending disaster.

Today Covid-19 cases are spiking, and the trajectory in much of America is rising rapidly. In addition, we will soon enter a new cold and flu season with potentially 100 million cases of flu-like symptoms that stand to overwhelm our current testing capacity. Not only do we need to bend the curve of this epidemic; we need to provide America’s essential workers and children with a way to go about their work and lives more safely, so that critical institutions can survive and function during this period of time. The only alternative is more large-scale lockdowns. The price of that is too high to pay when we don’t have to, if we make smart, strategic, science-based investments now.

Dr. Rajiv J. Shah
President, The Rockefeller Foundation

Action Plan Summary

The United States is losing the battle against Covid-19, resulting in a national tragedy that will become far worse unless we all come together as a nation to care for one another.

We are entering now our most fraught stretch in the battle against Covid-19. Businesses are reopening, workers are returning to work, and schools will soon welcome back millions of students. And yet, the U.S. is again caught in a tense viral upswing, with the number of positive Covid-19 cases hitting record numbers and rising in well over half the states.

We have 4% of the world’s population but around a quarter of all cases and all deaths. The surges in Florida, Arizona, and Texas are not being contained and portend similar outbreaks in other states that have opened without having in place adequate testing, tracing and public safety measures. While deaths are down, they will increase as cases rise and healthcare facilities are overwhelmed. With the fall coming, we could face an even more devastating combination of Covid-19 and the seasonal flu.

Leaving the fight up to individual states, cities, businesses and school systems is a patchwork approach that will not work. We are at war and need to unite nationally on a clear testing, tracing and communications strategy, bringing together public, private, minority communities, faith-based institutions, public health and scientists to agree on basic principles on diagnostic and asymptomatic testing, contact tracing, and safety measure that must be followed in order to keep our economy open.

Only through a unified and clear national plan can we beat this insidious virus, protect the most vulnerable in our communities, and preserve our economic and social vitality.

In April, The Rockefeller Foundation and a team of top scientists and medical experts released a 1-3-30 Action Plan calling for a bold but achievable goal of rapidly expanding diagnostic testing capacity to three million tests per week by June and 30 million tests by October, which along with contact tracing and supported isolation for those infected, could suppress the virus. This report chronicles the lack of progress made to date in several areas we believed vital and mandates a new set of important action steps that must be taken immediately to curb the rising death toll.

We need, above all, an effective national testing strategy – something the nation sorely lacks today. Millions who want and need testing can’t get access quickly. Overburdened clinical labs take days to return results that are accurate but too late to support informed decision-making and effective contact tracing. Businesses and schools that are trying to reopen, as well as many communities that are hard-hit, are trying to use screening tests – but have little practical guidance for who, how, and when to test. The cost of tests and concerns about the reliability of many tests adds to the failures of current testing approaches to achieve containment of the virus.

An effective testing strategy will require the country to ramp up to where it can administer at least five million diagnostic tests and 25 million screening tests a week within three months, with the acknowledgment that we will need still more than that. This must be combined with rigorous and extensive contact tracing and supported isolation. Getting to the goal of at least 30 million weekly tests, with the majority of those being screening tests, is the only way to beat back Covid-19.

If professional baseball and basketball players can get routine tests, so should our teachers, students, essential workers, nurses and bus drivers – every American, free of charge. Investing in the creation, delivery and administering of these tests will be far cheaper for the nation than the incalculable fiscal and social costs of another economic shutdown.

To hit these goals, the country will need at least another $75 billion in federal funding for testing. Insurers and government agencies must also clarify how the country will pay for this widespread screening program as it is put in place town by town, business by business and school by school. We must assure that sufficient support is flowing to the hardest hit communities, many of them Black and Hispanic, which have been disproportionally hit by Covid-19.

Money alone, however, will not be a sufficient catapult. The administration needs to invoke the Defense Production Act or a similar federal program to oversee and goad the production and distribution of mass quantities of fast, low-cost antigen tests. Simple, quick, easy and inexpensive tests are on the horizon. Getting them into the hands of everyone who needs them – schools, employers, health providers, public essential workers, vulnerable communities – will require the muscle that only the federal government can provide.

We need not just more tests but smarter testing. Timely access and processing for diagnostic laboratory Covid-19 tests – so-called “PCR” testing – is the most accurate way to decide whether someone with symptoms, or someone who has had a close exposure, has the virus and is infectious. The testing strategy that will contain the pandemic requires rapid access to diagnostic testing for people with symptoms and close contacts of Covid-19 cases – at least 5 million tests per week with turnaround time of less than 48 hours, and ideally less than 24 hours. We are approaching this level of testing, but with delays in access and processing that are far too long.

The testing strategy that will contain the pandemic also requires widescale onsite and home testing of Americans who are not showing symptoms. These screening tests for people who are asymptomatic – as contrasted with diagnostic testing done by clinical laboratories and some hospitals – requires tests that are reliable, simple, fast, and inexpensive.

Even with major improvements, including the use of pooled testing for screening, laboratory testing cannot come close to fulfilling the nation’s screening test needs. They aren’t convenient, simple, or inexpensive enough to use at the scale needed. Point of care tests, mostly antigen tests, must be ramped up and improved to provide the screening necessary to detect cases early and contain spread in our workplaces, schools, and communities.

In an ideal world, Americans would be able to test themselves at home or at the workplace at no cost several times a week and get the results within minutes or hours. We remain far from that ideal. But getting there is possible if we give this proper focus and commitment.

With this report, The Rockefeller Foundation has outlined the essential elements that testing protocols should include. Companies and organizations will need tailored risk assessments to set a transmission reduction goal and testing strategies to accomplish that goal and lay out how to respond to positive cases. The Rockefeller Foundation is committed to collaborating on protocol development and use. But it is imperative that the Centers for Disease Control and Prevention (CDC) play its rightful role in laying out explicit screening test protocols so that organizations know how to protect against outbreaks and keep the economy functioning.

The country also needs to make swift progress in establishing better contact tracing programs within the states and within individual organizations. We urge states with high infection rates to require masks, establish strict social distancing rules in public places, and demand that people who are infected or were in contact with someone who tested positive to self-isolate, with support from their state or locality for food and basic expenses. More unified and systematic data collection will also assist greatly in spotting outbreaks early, thus improving distribution of PPE and vital hospital supplies, improving the quality of care and protecting overburdened healthcare workers.

Lastly, a divided and misinformed nation cannot prevail in this fight. To build unity and resolve, we are calling for a coalition of major employers, non-profits, universities, government agencies, media companies and others to participate in the mass screening program and support unified, fact-based public education on how we, as a nation, can stay open and stay safe. This campaign, powered by foundations and corporations, would articulate the reasons that testing can and will save lives. This campaign will inspire Americans to feel that they have the power to save their life and their loved ones by adhering to safety measures.

In summary, why are we testing? We are not testing to just tally the impact of the virus. We are testing to stop the spread, take back control, and safely open our workplaces, schools, and communities.

Action Steps

This Update Report examines the current state of Covid-19 testing, contact tracing, data accumulation and communications. It calls for a series of vital steps to be taken across each of these pillars over the coming weeks and months.

Resolve diagnostic testing shortages and implement protocols for widespread screening testing

The Rockefeller Foundation is committed promoting and supporting public, private, and community efforts to implement the following series of urgently needed actions to ramp up clinical diagnostic and introduce widespread asymptomatic screening testing to contain the accelerating pandemic, address its disproportionate impact on vulnerable and minority populations, and prepare for the potential of a combined Covid-19 and fall influenza season:

1. Ensure diagnostic and screening testing is free and available to all Americans.

Public and private health insurance are already mandated to cover diagnostic testing, but action is required to cover protocol-based screening tests zby employers along with further mandates for public and private insurance coverage.

We need an additional $75 billion in federal funds to cover testing costs into next year as well as to incentivize test development and production.

The federal government should commit explicit aid to the communities of color worst hit by the contagion.

The benefits of the resulting reduction in illness, deaths, and economic disruption from preventable outbreaks will far outweigh the costs of smart testing or the burden on labs to increase their turnaround times.


2. Address the current crisis in lab-based diagnostic testing through urgent action by the federal and state governments, manufacturers, laboratories, and others. 

Urgent, collective action is needed to break the existing testing “log jam” of tests so that results of diagnostics testing is reduced from the current 2+ days to less than 2 days nationwide.

The Federal government should throw its full weight behind expediting the production and distribution of diagnostic and screening tests, including, if necessary, through the Defense Production Act or other appropriate authorities.


3. Create and implement protocols for widespread screening testing of asymptomatic people to keep our schools, workplaces and communities open and safe.

Screening tests are essential to detect and rapidly contain local Covid-19 outbreaks.

National testing capacity should expand to at least 30 million tests a week by November, including at least 25 million screening tests and 5 million diagnostic tests a week.

We urge the CDC, in partnership with the public health community, to put forth riskbased specific protocols for screening tests for K-12 schools, universities, workplaces, nursing homes, vulnerable communities, and other settings based on their individual levels of risk and exposure.

The development and implementation of effective protocols should prioritize impact vulnerable populations, low-income populations, and Black Americans and People of Color that have been disproportionately impacted by Covid-19.

The Rockefeller Foundation is partnering with state and local leaders in under-served communities across the US to introduce screening test protocols for schools, nursing homes, and vulnerable groups.


4. Support the development and deployment of appropriate, convenient, accurate, affordable and rapid antigen required for implementing screening test protocols.

Screening tests should be point-of-service/ point-of-care tests costing $5 to $10 per test, with same-day turnaround for schools and workplaces, and even faster turnaround for mobile testing in communities. They should be easily collected via nasal swab, saliva, breathalyzer-type, or another convenient device. On-site analysis would greatly facilitate immediate counseling on self-isolation, contact tracing, and availability of supportive services.

The NIH National Institutes of Health (NIH) Rapid Acceleration of Diagnostics (RADx), test developers, and other partners should work together to bring to market robust and fast antigen screening tests.

The U.S. Biomedical Advanced Research and Development Authority (BARDA) should make large-scale advance purchase commitments to accelerate the scaled manufacturing and introduction of antigen tests.

The FDA must work closely with test developers to fast-track approval of such tests and promote data sharing and analysis to improve understanding of test performance in actual use.

Increase the use, speed, public trust, and support services for contact tracing

Public health officials have widely cited contact tracing as an essential tool in the fight against Covid-19, noting that it is a proven, effective method of general epidemic management used in past outbreaks such as HIV, Ebola and SARS. Contact tracing consists of identifying and then reaching out to those who may have interacted with infected patients to determine if they are also at risk. It helps to both contain the spread of a virus and helps potentially infected individuals through supported isolation. But it has never worked well in the United States where people conflate giving essential information that will protect others with an invasion of privacy, and it is proving no different with Covid. Therefore, The Rockefeller Foundation urges that public, private and non-profit leaders:

5. Increase the use and speed of contact tracing.
Because Covid-19 is fast-moving, timing is of the essence, especially as communities reopen. Several steps must be taken to increase speedy action:

Linking both diagnostic and screening testing to contact tracing, whereby people with symptoms are immediately asked for contacts as are those with positive point-of-care tests, even before a positive diagnostic test result is back.

Mandating contact tracers complete all possible exposure notifications within 24 hours after lab results are in before moving on to other cases.


6. Heighten public trust through linking tracers to the community.
Contact tracing won’t work if exposed citizens don’t answer their phone or don’t act when warned of possible exposure. As much as possible, contact tracers should be hyper-local. They must be trained in how to relay news of possible exposure and how to follow up with support systems for those who are asked to self-isolate. We also recommend:

Employing (either as hires or as volunteers) contact tracers who come directly from the communities they will work with, and have strong cultural awareness, linguistic abilities and community connections.

Using the existing public health workforce around the country, consisting of about 60,000 individuals prior to the onset of the current Covid-19 crisis.

Encouraging PSAs about contact tracing from trusted messengers, including community and spiritual leaders, and influencers such as performers and sports celebrities. Sharing the PSAs on both traditional and social media.

Repeatedly communicating strong commitment to protecting confidentiality and privacy rights, and that the data being collected will not be used against the patient’s wishes.


7. Expand support services for self-isolation.
Support services for those who must self-isolate are the cornerstone of disease management. A wide range of concerns people have must be addressed from the initial outreach, and many who have to isolate may require help with essential needs such as:

Access to food and prescriptions.

Financial assistance to cover lost wages.

Childcare or elderly and disability accommodations for themselves or those whom they care for.

Strengthen the data infrastructure and use data to drive testing and tracing performance

Collecting accurate and reliable data about the spread of Covid-19 has been the foundation of effective response efforts around the world. Across the United States, however, data collection has been stymied by fragmented data systems and a lack of federal leadership on data standards. Getting to at least 30 million tests-per-week and acting on the test results and contacts traced will require continued effort to improve data infrastructure and reporting and expand the use of data to drive performance and improve decision making.

8. Strengthen Data Infrastructure and Reporting.
This can happen only if we take the following steps:

Support under-resourced states, cities, and labs as they work to meet the August 1 deadline for compliance with HHS testing data guidelines.

Improve public trust in testing data by being clear and open about methodology while also building—or re-building—clear firewalls between political and public health processes.

Speed integration of testing and tracing data systems.

Consistently collect and act on racial equity data

Plan for the arrival of home and employer testing. We’ll need these technologies to get to 30 million tests per week, but many states do not have a robust approach to integrating these results into their public health surveillance systems.


9. Expand Use of Data to Drive Performance and Improve Decision Making.
This will require:

A behavioral intervention toolkit to improve testing and tracing participation and adherence. As testing and tracing capacity ramps up and new technologies are built, human behavior will increasingly become the limiting factor in the efficacy of these systems.

Moving from descriptive analytics to predictive analytics and policy modeling. Most states and cities have been able to stand up basic dashboards to inform decision making. Managing the next phase of the crisis will require these entities to use and present new models to support health and economic policy decisions.

Coordinate and focus public communications on the value of personal safety measures, testing, and contact tracing

The past two months have dramatically underscored the necessity for a strategic approach to broad public communications. Without clear messaging, health officials will fall short in convincing a sufficient number of Americans to support testing, contact tracing, the use of masks and other precautionary measures.

10. The Rockefeller Foundation calls for the formation of a broad-based national Covid-19 Communications Coalition to:

Develop and implement ways to promote safety measures such as masks and social distancing. The coalition should include non-profits, community organizers and alliances of faith leaders as well as governmental leadership at the federal, state and city levels. Communication should be localized to ensure culturally appropriate messaging and allow for linguistic adaptation.

Combat rumors and misinformation by working directly with media and social media to encourage direct and \ speedy correction of mistakes or falsehoods—and to counter the flood of bad information with a steady stream of stories about communities and individuals taking positive action, which promotes wider adoption of those behaviors.

Educate the public about smart tests, treatments and a vaccine as they become available as way of building awareness, self-efficacy and trust.