What the hell is going on with coronavirus testing in the US?

A couple of weeks ago I began to feel unwell. It started with a sore throat, then sinus pressure and a headache, and then a runny nose and cough. My body was overcome with fatigue, and I was struggling to push through nausea to eat.

In fact, I had many of the symptoms of Covid-19 (even the loss of taste and smell, which is increasingly looking like a sign of the illness) except one: a fever. But when I went to urgent care (twice), the doctors who saw me each time dismissed any concerns about coronavirus. They cited the lack of a clear fever plus the fact that I hadn’t been out of the country recently.

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Coronavirus symptoms share a very large overlap with what you’d expect from the common cold or the flu. So if you go to your doctor or the local clinic to get checked out, it would seem to make sense that health staff would want to test you for Covid-19.

“We have a simple message for all countries: test, test, test,” World Health Organization head Tedros Adhanom Ghebreyesus told reporters March 16. “Test every suspected case. If they test positive, isolate them and find out who they have been in close contact with two days before they developed symptoms, and test those people too.”

But even weeks after we’ve heard federal officials tell us the US is ramping up coronavirus testing, many people are still not getting checked. Many have been rejected because they showed no symptoms, even if they made it clear they had been in close proximity with someone who tested positive. Around the country there’s testimony after testimony from doctors and patients alike who have good reasons for wanting Covid-19 testing but cannot get it. Weeks after government officials said they had rectified the initial coronavirus testing problems that plagued the country last month, and after President Trump announced that anyone who wants to get tested would be able to, people around the country are still finding it impossible. (Unless, it seems, you’re a celebrity.)

This contrasts sharply with other countries that have tackled the outbreak with a strict regime of testing, contact tracing, and isolation of the infected and potentially infected.

South Korea, where the number of new cases has seemingly flatlined to a little over 9,000, is an example of how aggressive testing action (without the draconian measures used by China) can help flatten the curve effectively. The country is testing nearly 20,000 people a day, offering services like free “drive-through testing” where you can be swabbed for samples in minutes, with results texted to you the following day. Over 327,000 South Koreans have been tested so far—about 1 in 170 people.

Compare that with the US, which confirmed its first case of coronavirus the same day as South Korea (January 20). Ashish K. Jha, the director of the Global Health Institute at Harvard University, told the Associated Press the US ought to be testing up to 150,000 people a day. Instead, we are at a paltry 40,000 tests per day. As of March 24, just over 350,000 people have been tested in the US—about 1 in 943.

In other words, what we need to do to stop the spread of coronavirus—vigilantly test as many people as possible—is simply not happening.

“It’s very clear over there [South Korea] how people can get a test, very rapidly,” says Joshua Sharfstein, the vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health. “And that requires more than just test availability—it’s also about being better organized.” By comparison, he says, the US health-care system “is not built for something like this.”

This should frighten Americans. Italy was another country that began coronavirus testing very sluggishly, at about one-third the rate of South Korea. Sick individuals went about their normal activities, unaware they were spreading the virus until case numbers exploded. Nearly 70,000 people in Italy have now tested positive for Covid-19, and 6,820 have died according to Johns Hopkins University. The situation in the US could easily degrade into something similar if it’s not clear who is infected and how to track them.

The CDC’s official guidelines call for prioritized testing for any hospitalized patients who have “signs or symptoms compatible with Covid-19”; vulnerable individuals with symptoms (those over 65, those with chronic medical conditions, those with compromised immune systems); and anyone who shows symptoms within 14 days of being in contact with a confirmed Covid-19 patient or has a history of travel to affected geographic areas (such as China, Italy, Iran, and South Korea). According to Sharfstein, this would mean testing people who are at least “moderately” ill, with a fever and cough.

That’s far from what’s being practiced on the ground. Cities like New York City and Los Angeles, for example, are discouraging testing for anyone who isn’t severely ill.

And that’s a problem when you remember you don’t even need to be symptomatic to be contagious. Signs of the illness might not show up until up to 14 days after infection. Clearly it would be useful to get as many people as possible tested early so they self-isolate immediately and reduce transmission.

“There really should be criteria for each testing place,” says Sharfstein. “Obviously if hospitals get critically ill patients, they’re going to test them. But for the general public, there should be some set of instructions that says if you have symptoms, here’s what to do and here’s where to go to get tested. There are probably hundreds of thousands of people with symptoms walking around.”

Why aren’t we testing more people? Our lack of tests is the most immediate obstacle, but Sharfstein also points out that “we’re building this on top of a chaotic health system. We generally aren’t that organized with respect to health care, so this is following that trajectory.”

Last month, the CDC botched the rollout of the initial PCR-based tests it sent to state labs around the country. It was quickly discovered that many of those tests yielded false positives because of faulty reagents, rendering them useless and forcing those labs to ship their patients’ samples to the CDC itself for testing.

The FDA attempted to right the ship by lifting restrictions that previously prevented local and private labs from developing their own tests without an “emergency use authorization.” Many labs are now ramping up fast, especially in hard-hit areas like Seattle (where the University of Washington’s virology lab is processing 3,000 test kits a day, under capacity). Almost two weeks ago, the Trump administration issued new moves to accelerate test production and administration, including FDA approval of a new test. The changes were supposed to help make half a million additional tests available last week.

It’s not just the actual test kits we lack. Medical workers need to be protected from infection with masks and gowns, and they need basic tools like nasal swabs to collect samples. Shortages of those materials are contributing to bottlenecks.

In the face of this disorganization, health officials want to avoid making demands that sap time and resources away from patients who need immediate help. Local doctors and health officials are forced to decide who’s getting tested and who isn’t.

“The system is not really geared to what we need right now, what you are asking for,” Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, said in testimony to Congress on March 12. “It is failing. I mean, let’s admit it.”

Maybe I actually was sick with Covid-19, and maybe I wasn't. I don't know with certainty either way, and probably never will. It's troubling to think I might have had the virus and may have been unwittingly spreading it, and that there are countless others who are facing the same circumstances—all because US testing is in such a sorry state.