Establish expanded testing strategies

Thomas Montine and Alison Kerr on establishing an expanded testing strategy

Establishing and providing testing for SARS-CoV-2 has been a cornerstone of the pandemic response. From the onset of the outbreak, Thomas Montine, MD, PhD, professor and chair of the Department of Pathology, and Alison Kerr, RN, MSN, chief administrative officer of clinical operations at Stanford Health Care, have been working with Stanford Medicine faculty to develop and scale testing for the Stanford community and beyond. Through deliberate strategies to diversify testing platforms, Kerr, Montine and many others helped boost Stanford Medicine’s testing capacity for the Stanford community and many others in California, making efforts to provide testing to those who reside in at-risk communities.

Outside of testing for current SARS-CoV-2 infection, other researchers have successfully developed a serology test, which detects whether someone has been infected in the past. Researchers are also devising tests to pinpoint specific types of immune responses elicited by SARS-CoV-2 in the body, such as a T cell response, as well as tools to screen for other viruses with “pandemic potential,” which can cross the animal-human barrier and can be easily transmitted from person to person.

Where was Stanford Medicine at the beginning of the pandemic in regard to testing?

Montine: As soon as the DNA sequence of the virus was released, Benjamin Pinsky, MD, PhD, associate professor of pathology and of medicine, began researching and developing a clinical test for the virus. It was really because of that foresight that he was ready by the end of February with a test. At that time, hospitals were allowed to test using only the CDC test, which was flawed. But as soon as the federal government allowed hospital laboratories to conduct independent testing, we were ready to leap into action. That tool was critical for our clinical colleagues to be able to diagnose and manage patients who had COVID-19, influenza or other respiratory illnesses. Stanford was, in my opinion, very fortunate to have it available from the start, and through the work of Alison Kerr and Christina Kong [MD, professor of pathology], we made that test available throughout the Bay Area to allied health entities. Then, in the second week of March, a group of researchers led by Scott Boyd [MD, PhD, associate professor of pathology] developed, quite frankly in record time, serologic tests to detect past exposure to SARS-CoV-2. He and his group did the research, development and validation all in just under a month. On April 6, we launched our serologic tests.

Scaling the COVID-19 test in the early days was truly a team sport

Kerr: Scaling the COVID-19 test in the early days was truly a team sport. It’s one thing for the excellence of one physician to translate into an invention; it’s another to be able to then scale that and offer it to the community. That’s what Stanford Medicine did incredibly beautifully. There was a period of time, for about four to six weeks, when we supported COVID testing for all of Northern California hospitals. When we were scaling the test, we bought every piece of available equipment we could think of — we had a very intentional strategy around diversifying our platforms. Think of it this way: If you’re making a Ford car, and you can’t get a Ford part, you can’t make a Ford car. So we said, “Let’s get several different platforms and all the associated pieces for them so we don’t find ourselves cornered by a lack of resources.”

Where are we today?

Kerr: A short while back, we opened up Occupational Health and let our Stanford Medicine colleagues know that whoever wanted to get tested could — regardless of whether you were a dietary worker or were a cardiac surgeon — you could come and get a PCR and serology test. That was intentional to not only make sure that our staff knew that they were healthy and their PPE was working, but also to demonstrate to the community that our hospitals are safe and that we’re taking all proper safety precautions. We’ve continued with that very liberal testing protocol, whether someone has been exposed or not, within Occupational Health according to both the county and California Department of Public Health testing guidelines.

We also recently held a town hall addressing some of the anxieties, concerns and stresses that employees at Stanford Medicine are experiencing. We know that this work is exhausting, and we have to acknowledge it and recognize that everyone’s human and you need a bit of a break sometimes.

What are the next steps as we continue to expand tests and testing strategies?

Montine: The testing that we offered through Occupational Health went a long way to reduce anxiety among hospital staff and clinicians. Recently, asymptomatic testing on campus has been the focus of a lot of discussions. Thanks to Alison and her team and many others, those programs are now rolling out, and there will be asymptomatic screening available on campus going forward. We’ll continue to monitor whether we need to ramp it up through the winter.

We’re also continually thinking about how to scale our testing to larger populations. There are a variety of strategies to do so: One way is to get more robotic equipment; the other is to pool samples, and we’re actively pursuing both of these options. I think one key, though, is what Alison and her team very wisely did in deciding to diversify testing equipment. That gives us a resilience that other large laboratories don’t have. Diversification allows us to continually build tests using different commercial platforms, which all have different needs and therefore put different pressures on the supply chains. By diversifying across platforms, we build in resilience. If we continue with the car analogy, we’re not just able to build Ford cars, we can build Fords, Buicks, Toyotas and Hondas. That has allowed us to increase our testing capacity. Today, we’re able to conduct 10,000 tests per day, and we’re working toward 20,000.

What kind of research is underway to inform and advance COVID-19 testing?

Montine: This won’t be the last pandemic we face, and we don’t want to get caught flat footed. Dr. Pinsky had an idea to develop a process within Stanford Medicine that would allow us to screen for emerging pandemics. Pandemics occur mostly through nasty viruses that cause serious illness and can be transmitted from person to person. We know that coronaviruses are poised to jump the species barrier to humans, and there are others, too, such as the viruses that cause Ebola and West Nile. Screening for them is relatively straightforward: We would run a surveillance screen of residual blood samples that come through the hospital laboratory, and that would allow us to determine whether these viruses are popping up in the communities that we serve.

The next one in the pipeline is research led by Niaz Banaei [MD, professor of pathology and medicine]. Dr. Banaei is developing a test to detect the T cell response to the virus. It turns out that some people who are infected with COVID-19 don’t have an antibody response. That immediately raises the question: If they have no immune response, how did they recover? It’s extremely unlikely that they had no immune response. Rather, it’s more likely that they had a different type of response that doesn’t generate antibodies — and that’s the T cell response.

How are you working to help the greater community?

Kerr: We continue to support testing in the broader community — anyone who has needed access to testing, we’ve tried to support them as much as we can. We’re even doing weekend testing events. For instance, a small group of physicians and health care professionals are going to test 300 farmworkers in Gilroy in an effort to provide resources to at-risk communities. Unsurprisingly, there has been this issue of health care disparities around access to testing; the virus spreads more readily and is more prevalent in areas of conjugate living and in places where people have less access to health care and less income. I think expanding testing to these areas is a really crucial way for us to involve our community stakeholders. Lately, Stanford Medicine has also put forth some options to support the testing of teachers in our communities to allow children to get back to the classrooms. There is no shortage of opportunities to serve others in a global pandemic. Stanford Medicine stands ready.