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L.A.'s coronavirus testing has been a failure on all levels. He’s trying to fix it

Clayton Kazan, an ER physician and medical director at the L.A. County Fire Department, at his office in Monterey Park. He is coordinating testing in the county.
(Gabriella Angotti-Jones / Los Angeles Times)

Clayton Kazan, Los Angeles County’s new coronavirus testing coordinator, has no shortage of opinions on how management of the crisis has gone so far.

It’s been a failure at all levels of government, he says, and testing capacity in Los Angeles County remains “grossly inadequate” — a fact that should frustrate residents here.

He also believes that the tests, even if widely available, can be unreliable — and effectively useless to people without symptoms or those who test negative, because they can face exposure moments after getting the results.

With the pandemic growing exponentially, and with the test availability still lagging, the county’s Board of Supervisors announced Kazan this week as the new coordinator on the testing issue. His job is to wrangle the network of health officials — both private and public — and help solve the problem.

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Kazan is the medical director at the Los Angeles County Fire Department and an emergency room physician in Torrance. The Rancho Palos Verdes native, 45, talked with The Times about his frustration with the system’s slow adaptation to the need for testing — and whether it’s too late now to limit the strain on hospitals.

What follows is a transcript of that conversation, lightly edited for clarity and brevity.

Q. It seems like getting to widespread testing might be the defining challenge so far in tackling this crisis. Would you agree?

I would .… When you ask countries that have been successful, that is one thing that they point to. When you ask countries that have been especially challenged, like Italy and now the United States, one of the big limiters to them in the initial phase has been a lack of access to rapid, widespread testing.

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Q. And you’re now coordinating that effort for Los Angeles County, one of the most populous and complex municipalities in the nation. That seems like a job most people wouldn’t want.

[Laughs]

I’m one of the physician leaders of the county, so when asked to step forward, of course, I did. This is all in addition to my duties at the L.A. County Fire Department. But I can recognize as a clinician that there’s a desperate need to get this access. Let me give you an example. In the hospital where I work in the emergency department, I had a patient who appeared really ill. She didn’t meet any classic definitions of COVID, but I had no explanations for why she was ill .… We put her in isolation. We took all the precautions, and we sent off the test. The patient did better, was sent home and after she got home, the test result came back six days later positive.

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Q. The public is looking at this, and they’re asking: Were we not prepared?

It is hard to prepare a lab to receive specimens for a novel virus …. There was some initial denial that it could do in Los Angeles what it has done in Wuhan, because our healthcare system is so good. But unfortunately, we’re realizing that there are definite cracks in our armor that we hadn’t anticipated. We’re trying to spool up our labs to handle not just this unique test that we need but also on a scale that we’ve never done before. That takes time.

Q. What have been the main roadblocks for the county and its healthcare system related to testing? Internal equipment? Staff? Delays in getting test kits? Reagents to process the kits? Private lab capacity?

It really is all of the above. The number one shortage item that the labs talk to me about is swabs. Number two is reagent and materials for running the tests. So, on the existing machines where they can do it, they’re lacking some of the different raw materials that they need. But number one is swabs: the simplest piece.

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Q. How many tests are we able to perform per day now, roughly, in L.A. County?

It’s so rapidly changing from day to day. I would say we’re able to run a few thousand a day, if everything is operating at capacity and has all the raw materials in all of the labs.

Q. The turnaround for those tests could still be days, or many days, depending on where they’re sent?

The range that I’ve heard from those who are doing best, those who are doing it on-site, is about four to six hours. The long end of the range [is] running four to six days. If you’re sick enough to have it done in the hospital, and the hospital can do the test in their own lab, the turnaround can be just a few hours. But unfortunately, not a lot of hospitals in our region are able to do that. A lot of them send it out.

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Q. Are you and the policymakers you’re talking to happy with that turnaround time? If not, how can we speed it up?

No, I’m not at all happy about that turnaround time. As a clinician and as an ER physician, by nature I am an impatient person. In the ER we get turnaround times of 30 to 60 minutes for the tests that really matter for us. The acceptable time on this one for me should be measured in no more than hours. Anything beyond that becomes relatively useless to us. What do we need to do to get there? We need a massive scaling locally. As long as we’re having to ship our labs out of state, and we’re having to compete with all the other states that are struggling with their own outbreaks, then we’re going to be struggling.

Q. Does that mean that hospitals and local testing outfits need more equipment? What can be done locally to speed up or improve our capacity locally?

Having spoken to our Department of Health Services county hospital labs, they have acquired the equipment that they need. The equipment has to be set up, and they are actively doing that right now. And then it has to be calibrated before it can be used. So it takes about five to seven days from the time they received the equipment until it can be used. Up until now, they are not able to run any specimens in the county hospitals at all. They are all sent out, either to the county Department of Public Health labs or those national labs like Quest [Diagnostics] or LabCorp.

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Q. When will normal folks be able to get a test, either at a drive-through site or from their primary care doctor? And how long will they have to wait to get it turned around?

With the testing that we do, and with widespread community spread of the disease, there is no benefit to people without symptoms being tested, because the meaning of a negative test is pretty much zero. The tests still have a pretty high false negative rate that can approach 30%. Secondly, even if I can test you at a moment in time, until you get the results, you are being exposed every day, whether you go to the supermarket or go home. So when that test finally comes back as negative, we don’t want people to let their guard down and go back and resume their previous lives. They may well have an early infection that the test missed, or since that test was taken, they may have gone and exposed themselves to the virus.

Q. Can you describe the enormity of the challenge we face to get to where we want to be?

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When we talk about announcing 20,000 tests from Seegene [the South Korean company that was innovative in helping that country establish a reliable testing system early in the crisis], it sounds like a huge number. And yet that’s only enough tests for one in every 500 people in the county. What sounds like a big number quickly erodes to something approaching insignificant when you look at the size of our population and the scope of our need. In terms of lab capacity, the issue with that is that the level of sophistication of this test should not be underestimated. To bring something like that on a novel virus to a massive scale in a short period of time is a truly monumental worldwide effort. Right now we are deeply challenged by it.

Q. We had weeks of people moving around before social distancing measures, we still don’t have widespread testing and we’ve given up really on any chance of meaningful contact tracing — even if we could do it at scale at this point. Should we be frustrated about that?

I think it’s right to be a bit frustrated. The problem with contact tracing is it depends on widespread testing and rapid turnaround. In order for you to start tracing back people’s contacts, you first have to know who’s positive with some degree of reliability. With the level that we were testing a couple of weeks ago, or a month ago, the kind of critical juncture where we started to get our exponential rise, we had only a tiny percentage of the capacity that we even have now, and what we have now is still grossly inadequate.

Q. It seems obvious now that, for whatever reason, we were just late to a proper testing regime. As someone asked now to coordinate this for the county, how do you feel about that, in terms of what kind of a challenge that presents?

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There is certainly truth in that, and reason to be frustrated. It’s something that was vital to South Korea’s response, and we had time to develop it for ourselves, and yet we failed. That failure was federal, state and local. We all failed. I think we all, myself included, had some level of denial that it would ever reach our shores as it is now .… But, yes, we unfortunately missed an opportunity. If we could go back to January, when we saw what was happening in Wuhan, if we had taken that opportunity to scale ourselves up in anticipation, we could have been more prepared than we are now. We still would be facing an enormous challenge.

Q. What’s your sense for how long this might continue, this major adaptation in the way we live — weeks, months, into the fall or until we get some sort of vaccine?

So, it’s anyone’s guess. Because what we are seeing is unprecedented. Right now I would suggest that it is most likely going to follow the Italian model, where we’re going to see an exponential rise, and we’re going to have weeks or months of very, very big healthcare challenges. What we’ve been saying from the beginning is that COVID is not just a problem of acuity but [one] of capacity. Most of the people who get the coronavirus have a relatively mild syndrome. At least 80% have a pretty mild course. The problem is that the 20% who have mild to severe courses can be very needy for healthcare. It can very quickly overwhelm our already saturated emergency and critical care resources.

Q. How worried are you about what those weeks and months are going to look like?

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Extremely. But this is unprecedented. If it follows the 1918 flu epidemic, we could see it drop off suddenly. We could see a very long peak that could last for many months. There really is no telling. We’re preparing for a very long peak — at least, as a county, we’re preparing for up to six months. If we get surprised, and cases drop off, that’s outstanding. We will take every opportunity to prepare for another surge. No one really knows what the future is going to hold with this. There are only models.


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