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How a tip exposed serious flaws in rapidly testing nursing home residents for COVID-19 Date: 09/08/20

Rachana Pradhan

By Rachana Pradhan

There’s been a staggering rate of COVID-19 infections at nursing homes since the start of the pandemic. Tens of thousands of residents have died, with countless others still at risk of infection or developing severe complications.

How much would the federal government’s push to increase rapid testing at long-term care facilities help? I began digging into the Department of Health and Human Services’ push to send millions of these tests to nursing homes after a source provided a recording of a call that senior Trump administration officials held with nursing home representatives in July.

One thing that struck me was the emphasis being put on the value of these antigen tests ― which rapidly detect viral proteins ― as almost a silver bullet. But my source warned that the way HHS wanted the tests to be used didn’t align with the actual instructions from the two manufacturers producing them: Quidel and BD.

After reading the manufacturers’ testing documentation on the FDA’s website, I confirmed that the tests are meant to be used on patients showing COVID-19 symptoms. That begged the question: how could HHS be saying these should be used for broad screening purposes, regardless of symptoms? We know from the Centers for Disease Control and Prevention that nearly half of current COVID-19 infections are asymptomatic.

I began calling state public health and nursing home officials in multiple states to see whether this was an issue. As turned out, this was turning into quite a notable one. It seemed to underscore again something that had repeatedly been the case for the U.S. government’s response to the pandemic ― that the national hype exceeded what was possible. BD later confirmed to me that its test should not be used on asymptomatic people, and Quidel deferred to FDA guidelines, which only allowed for limited use on such patients. 

Finding sources

For reporters, one difficulty in covering this pandemic has been the continually shifting guidance from both federal and state officials on COVID-19 testing methods and who should get tested. Nursing homes are regulated by both state health departments and the U.S. Centers for Medicare and Medicaid Services. I had to check a variety of sources, including:

  • State public health department guidance on testing within nursing homes. Many states in recent weeks have moved to mandate testing for nursing home staff or residents and both in some cases. They generally say what kinds of tests should or must be used to meet those requirements.

  • Nursing home testing recommendations and requirements from CMS. The federal health agency has moved slowly from recommending COVID-19 testing in nursing homes to now mandating it in certain scenarios.

  • CDC guidance on the general use of antigen tests because that agency granted the emergency use authorizations allowing them to be used during the pandemic.

  • CDC COVID-19 testing recommendations for antigen tests, as well as testing guidelines at nursing homes.

One problem that I discovered along the way is each federal agency often would have slightly different criteria for how antigen tests should be used. Adding to the problem was that the misaligned federal guidance sometimes would conflict with what state health departments would say. That discrepancy became a significant part of the story, but it isn’t unique to nursing homes ― this issue can crop up in other COVID-19 testing stories, too.

Questions to ask

It took roughly two weeks from the time that I began reporting the story for it to be published. For health journalists trying to cover nursing homes during the pandemic, it can be dizzying to understand all the moving parts. Keep in mind which agencies determine nursing home testing rules in your state or county. Federal and state mandates may complement or conflict with each other. When interviewing nursing home administrators, here are some questions to explore:

  • What kinds of COVID-19 tests are being used on residents and staff? Are they PCR tests (which generally rely on a lab for results), antigen tests, or a combination?

  • How quickly are test results coming back? How has this changed over time?

  • Is the nursing home doing routine testing to screen for infections? If yes, is the testing performed on residents, staff, or both?

  • How frequently are nursing home staff being tested? How frequently are residents?

  • What percentage of residents are opting out of being tested?

  • If nursing homes are required to perform baseline testing at their facilities, what kinds of tests are allowed to be used to meet those requirements?

  • What infection control protocols are in place at the facility?

  • What happens if there is a confirmed positive COVID-19 case ― who else gets tested, and with what kind of test?

  • What has the facility’s testing positivity rate been over the last two weeks?

  • Have they had issues of antigen tests giving false positive results (e.g., saying someone is infected but actually isn’t)? Are antigen tests providing false negative results?

Rachana Pradhan, a Kaiser Health News correspondent, reports on a broad array of national health policy decisions and their effect on everyday Americans. She came to KHN from Politico, where for five years she covered health care policy and politics on national and state levels. Pradhan has been involved in several high-impact projects in her time as a health care reporter, including an investigation into former HHS Secretary Tom Price’s extensive use of private jets at taxpayers’ expense. The investigation, which resulted in Price’s resignation, was a 2018 finalist for the American Society of News Editors’ O’Brien Fellowship Award and earned an honorable mention in the White House Correspondents’ Association’s Edgar A. Poe award.