It's been a common refrain, one that's morphed into an intense chorus in recent weeks as county officials ponder the possibility of easing shelter-in-place restrictions in an effort to get people back to work.

"It's really important we have robust testing in place so we know what's happening in the community and we can test, we can trace and we can isolate," said Deputy Health Officer Josh Ennis at a forum last week. "That is a huge piece of this that really needs to be in place."

A few days later, at an April 27 media availability, Public Health Officer Teresa Frankovich echoed the sentiment: "We want as much information as possible about how much of this virus is out there in the community and that will help inform everything we do."

The stakes of how Humboldt County navigates the coming weeks are dizzyingly high and Frankovich has been very direct in saying that easing shelter-in-place restrictions will lead to more illness. The virus is circulating in the local community and the more people interact and are in contact, the more it will spread. But she's also conceded the current situation — with most of the population sitting at home and economic losses mounting — is untenable long term.

"As we look forward, we know that we can't sit where we are forever," she said. "We're going to have to start moving out of shelter in place and we know that will bring with it some increase in community transmission, so we're working very hard to have all the underpinnings to make sure we can respond to new cases."

As Ennis indicated, the county's goal moving forward will be to aggressively test, trace and isolate new cases to prevent spread of the disease. Officials are planning accordingly. Where the county once had three communicable disease investigators — the folks tasked with finding everyone a COVID-19 patient has been in contact with so they can be assessed for symptoms and urged to self isolate — it has now trained 30 more with further reinforcements coming. But building up the county's testing capacity remains a daunting challenge and, by the metrics some infectious disease experts have outlined, we are no where close to where we need to be.

Testing is an essential component of preventing COVID-19 spread for a number of reasons. The disease manifests with a wide range of symptoms — the CDC recently broadened them to include muscle pain, chills, headache, sore throat and new loss of taste or smell — making it difficult to identify, especially in early stages. Studies have shown more than 25 percent of patients may never experience symptoms but will still be contagious carriers for 14 days.

To date, healthcare providers have almost exclusively been testing symptomatic patients. Due to a shortage of testing supplies, they've followed strict criteria for determining who gets tested and where those samples are sent. The highest risk patients — people being treated in a hospital, those with extreme symptoms, those with symptoms plus underlying health issues or people who are symptomatic and capable of spreading the disease widely, like healthcare workers — are tested, with their samples going to the Public Health Laboratory, which can process them in 48 to 72 hours. Samples from lower risk patients — like those who are mildly symptomatic and have been in contact with a confirmed case — have generally been sent to one of two out-of-area corporate laboratories, Quest and LabCorp, which have slower turnaround times. Mildly symptomatic people have generally just been told to stay home.

As this edition of the Journal went to press, 2,086 local residents had been tested — about 1.5 percent of the population, which puts us between national (1.69 percent) and state (1.39 percent) testing rates. But the rate at which locals have been tested has declined in recent weeks. According to the numbers released by Public Health, we've gone from seeing an average of almost 87 tests a day from March 25 through April 7 to an average of 50 daily tests since. The biggest decline has come from the corporate labs, which went from reporting an average of almost 45 tests a day in the first span to just eight in the second.

It's unclear exactly why that is. Mad River Community Hospital sends all its samples to the Public Health lab for testing, while St. Joseph Health and Open Door send to either a corporate lab — St. Joseph uses Quest while Open Door uses LabCorp — or Public Health based on the agency's testing priority criteria.

Spokespeople at Mad River and St. Joseph say providers at the hospital continue to send samples for testing at roughly the same rate they were weeks ago, but Open Door CEO Tory Starr said there has been a notable drop-off in the rate at which providers are ordering tests. Starr said that while Open Door sent 151 samples for testing the week of March 29, it only sent 90 samples the week of April 12.

"Our assumption is testing has declined because the number patients meeting the criteria for testing has declined," he said. "That means less people meeting the testing criteria have been seeking care from Open Door."

Frankovich recently suggested the decline may be due to Humboldt County moving out of cold and flu season, meaning fewer people are experiencing respiratory symptoms that make them worry they may have COVID-19. But Frankovich has also indicated that, as testing capacity continues to increase, she's less convinced Public Health is getting accurate numbers, noting that while labs are legally required to immediately notify Public Health of a positive test, neither providers nor labs are mandated to do so for a negative.

"Getting a good count on all the negatives is going to be increasingly difficult," she said, adding it's problematic because positive tests only tell part of the story of how prevalent the virus is in the community.

The Public Health Laboratory, one of only 29 in the state, wasn't designed to conduct high volume testing and can currently only process about 55 samples a day, though work is being done to increase that number. On April 28, Public Health announced a new community testing site has opened in Eureka.

The site, which comes as part of Gov. Gavin Newsom's plan to increase testing capacity throughout the state, is operated by Optum, a multi-billion-dollar, multi-national healthcare company. Once fully up and running, it will have the capacity to test approximately 96 people per day, with the samples sent to one of the corporate labs for processing.

According to state Sen. Mike McGuire, the site is beginning by testing "frontline" local workers — doctors, nurses, skilled nursing facility staff and people who work in nursing homes — as a soft launch of local surveillance testing, or the practice of testing asymptomatic people in an effort to limit the virus' spread by identifying carriers. But Frankovich said the goal is open it up to the general public so mildly symptomatic — and eventually even asymptomatic — people can make an appointment and get tested.

But while any increase to testing capacity is welcome, it's hard to see this as much more than a baby step for a number of reasons.

First, there are approximately 1,500 nurses in Humboldt County, so testing them alone would take more than two weeks. And one of the challenges of surveillance testing is that a negative test just means the subject doesn't have COVID-19 at the moment they are tested. But there is, of course, the risk they may become infected tomorrow or the next day. So systematically ensuring frontline personnel aren't infected — and risking simultaneously hastening the virus' spread and diminishing local capacity to provide healthcare — means testing them regularly.

A variety of infectious disease specialists have said that nationally, to really contain the virus, we need to be testing 2 to 8 percent of the population daily. That would require 5 million to 20 million tests every day. (As the Journal went to press, about 5.6 million people had been tested nationally.)

"Even under the most optimistic scenarios, we need to be testing millions of people per day to allow a significant return to the workforce," reads a white paper report from Harvard University's Safra Center for Ethics. "Tens of million per day seems more likely and more than 100 million may be necessary in the worst case."

Testing 2 percent of Humboldt County's population daily would be 2,692 people — some 600 more than have been tested to date. Testing 8 percent daily would be 10,769 people.

At the moment, those numbers seem insurmountably high due to a variety of factors, from providers' capacities to take samples and labs' capacities to process them (again, the Public Health Laboratory simply wasn't built to process hundreds — let alone thousands — of tests a day) to supply chain issues.

What's generally referred to as a COVID-19 test is actually a complex series of steps, each of which requires specialized equipment. There's the deep nasal swab commonly used to obtain a sample from a patient at a hospital, clinic or testing site, specialized containers used to transport the samples to the lab, testing equipment in the lab and specific chemical reagents used to process the tests. All these items are in incredible demand as just about every laboratory in the country works to ramp up testing capacity to meet the incredible need.

Frankovich has said that Newsom's task force on testing has eased some supply chain issues, which has led her and state counterparts to ease testing criteria to allow the testing of mildly symptomatic people. But many have argued the only swift and definite way to address supply chain issues and allow the kind of rapid increase to testing capacity needed would be for President Trump to use the Defense Production Act to compel companies to manufacture the necessary testing components in huge quantities, which he has so far been loath to do, or for Congress to invest billions of dollars to fund a massive supply increase.

These are clearly issues way beyond local control, though Public Health staff scrambles daily to keep supplies flowing. The Safra Center white paper recommends a federal investment of potentially hundreds of billions of dollars to ramp up testing nationwide and "end a lockdown that is costing the U.S. economy tens of billions of dollars every day."

"Failing to make this investment would go down as one of the most extreme examples in history of being pennywise and pound foolish," the paper concludes. "A key impediment to scaling up the supply chain is the lack of demand and supply perceived at every step of the testing supply chain. Achieving common acceptance of the need for tens of millions of tests a day and coordinating efforts to hit this target is therefore critical to our ability to go outside again. We must communicate this message as clearly and as loudly as we can to as many leaders as possible, and as quickly as possible."

But Humboldt County is a long way from Washington, D.C. and, given the realities of testing capacity, officials are left to balance the ongoing negative impacts of shelter in place against the potential spread of a deadly disease. It's a slow dance of preparing and mitigating, building healthcare surge capacity and ordering people to wear facial coverings while also urging essential businesses and government offices to re-open.

At the forum last week, Ennis and Frankovich talked publicly for the first time about local modeling projections, unveiling two different scenarios. The first projected what might happen if the county kept all social distancing measures in place until the end of the year and estimated we might see 28 deaths by December, at which point 145 people would be hospitalized, including 64 under intensive care and 38 breathing through ventilators. The other projected what might happen if the county were to lift all social distancing requirements and resume life as normal May 1, and found we could see 188 deaths by July, at which point there could be almost 1,000 people hospitalized, including 408 in intensive care and 251 breathing with ventilators. That would be hundreds of ventilators and ICU beds we don't have.

The next day, a reporter asked Frankovich about the chasm that exists between the two models and what might happen if the county eased just some of its shelter-in-place order.

"It's the million-dollar question," she said. "We are going to have to be watching carefully to know what the impact is ... A lot of this is uncharted territory and [there is a] massive importance of being able to monitor our population through testing."