Tip sheet and resources for covering COVID-19 testing
By Bara Vaida
Testing in the U.S. has been challenging for myriad of reasons including lack of laboratory infrastructure, supply chain gaps, regulatory obstacles, lack of test production capacity and federal leadership attention. Public health experts say that for much of the pandemic, testing in the U.S. has been more about documenting cases than anticipating and altering the course of the pandemic.
Now that may be changing. By the end of January, millions more Americans will have access to rapid tests for detecting COVID-19 infections, raising numerous questions about how to use them and whether they will help the country move beyond the pandemic.
To help journalists cover this story, I compiled questions that have come up repeatedly over the past month including, why and how tests should be used, whether or not they work, how to obtain them and what they cost, resources for finding answers and experts to call.
Three reasons why testing matters
- Diagnosis: A test lets someone know if they have become infected with the SARS-CoV-2 virus (the pathogen that causes COVID-19) and the course of treatment. Antibody and antiviral treatments for COVID-19 are most successful when administered within a few days of infection. For example, the recently authorized medication Paxlovid (by Pfizer) can reduce hospitalization in high-risk adults by 90% if taken within the first five days of symptoms.
- Pandemic control: Someone infected with SARS-CoV-2 may be contagious for several days before showing symptoms. People who never develop symptoms but are infected may transmit the pathogen to others. COVID-19 testing triggers isolation and quarantine measures, important public health measures used to stop an outbreak. According to updated CDC guidelines, someone who tests positive for COVID-19 should isolate for five days and quarantine for another five if symptoms have resolved. Testing allows people to know whether they should quarantine or can travel and interact with others safely and fosters a return to normal activities of life. The CDC has also created a National Wastewater Surveillance System to test sewage in 37 states, four cities and two territories to detect rising cases and prepare hospitals for the potential of an influx of patients.
- Testing data: See this Johns Hopkins University & Medicine Coronavirus Resource Center site for the latest national and state testing data.
Who should be tested?
- Anyone with symptoms of COVID-19 such as fever, cough, congestion or runny nose, sore throat, new loss of smell or taste, shortness of breath, headache, nausea, diarrhea or fatigue should be tested. These symptoms also occur with other illnesses such as the flu, reinforcing why getting tested for treatment purposes is crucial. Treatment for the flu is different than for COVID-19.
- Anyone who has been in close contact with someone for 15 minutes or longer in the past five days who has tested positive for COVID-19 should get tested.
- People planning to be in close contact with someone who might be immunocompromised or at high risk of developing severe illness from COVID-19, such as an unvaccinated person or someone 65 and older should also be tested. Many public health experts also advise getting a test before gathering with friends and family indoors, even if you don’t have any symptoms, just to make sure you aren’t infectious.
- The CDC also created an easy-to-use coronavirus self-checker to help people decide if they should get tested or seek medical care.
- Testing guidelines for who should test differ for health care institutions, schools, and businesses. Check out the CDC's recommendations for health care workers and for K-12 and higher education institutions. The Occupational Safety and Health Administration has testing guidance for employers.
What kind of COVID-19 tests are available? How should they be used?
- There are diagnostic and antibody tests. Diagnostic tests (the CDC calls these viral tests) use samples from the nose or mouth to look for current COVID-19 infection. Antibody tests use a blood draw to determine whether a person was infected in the past. Here’s an FDA -produced video explaining COVID-19 testing.
- There are two kinds of diagnostic tests, a molecular test and an antigen test. Each detects a different part of the SARS-CoV-2 virus. Molecular tests search for pieces of the virus’s genetic material. This is done through a technique called polymerase chain reaction (PCR). These tests are highly accurate but it usually takes a day or longer to provide results. Antigen tests (more than a dozen have been approved by the FDA) search for viral proteins that cause the body to produce antibodies for specific pathogens, like SARS-CoV-2. They are less accurate in detecting infection at the earliest stages of illness, but provide results quickly, usually within 10 to 15 minutes.
- Most PCR tests are sent to a lab and are the test results states send to the CDC for case counts. COVID-19 PCR tests can be found through local public health departments, health care providers, public libraries, and community health centers. Two companies produce at-home molecular tests that provide faster results.
- Antigen tests can be purchased at pharmacies and other retailers for at-home use. ECRI published a January 2022 report evaluating the ease of use of seven of the tests, which found On/Go to be the easiest to use.
- Many infectious disease specialists recommend people use rapid antigen tests on day five after testing positive for COVID-19 to determine whether or not they should remain in isolation. PCR tests will have positive results for weeks after someone is no longer contagious. NPR has a helpful round-up of how tests should be used.
- Epidemiologist Katelyn Jetelina has a good explainer on how to use rapid tests that you can use in your reporting.
Do rapid antigen tests work?
When writing about whether rapid tests work, keep in mind that at-home rapid tests were meant to detect COVID-19 cases for medical and public health quarantining purposes not to determine whether someone is contagious before a social gathering like a family dinner or a party.
“Remember, testing all along had a purpose,” Michael Osterholm, Ph.D., M.P.H., director of the Center for Infectious Disease Research and Policy said on his Jan. 6 podcast. “What was that purpose? It was to find out who is infected [and now] we're trying to ask these tests to potentially do things that they were never intended to do.”
Over the holidays, the question of whether rapid tests work and whether an infected person should use one to determine if they can leave isolation or quarantine was hotly debated. Some data show they don’t work as well with omicron, missing positive cases that were found with a PCR test. On Dec.28, the FDA also said that with omicron, some rapid tests may be less sensitive in detecting the virus, without providing any further detail as it continues evaluating rapid tests. Another study showed that rapid tests can provide false-positive results, though it is rare.
Before omicron, data indicated rapid tests are reliable if the viral load is high enough in the nose and the person has symptoms of COVID-19. Most at-home rapid tests use nasal swabs to identify virus antigens. Data show rapid tests reliably detected a COVID-19 infection once someone has symptoms. At that point, people usually have enough virus in their nose to be contagious to others through coughs, sneezes, or respiratory droplets. But the data on whether a rapid test can detect whether someone is contagious without COVID-19 symptoms is sparse, says Osterholm.
Further, with the omicron variant, the rapid data indicate the virus replicates more quickly in the throat and may not reach the nose until later in the infection and therefore a rapid test may not detect the virus quite as early as a PCR test and provide a false negative result. Infectious disease experts also say that vaccinated people with a COVID-19 infection may show symptoms of disease like a runny nose but never become contagious because the immune system has minimized replication of the virus, according to Dr. Michael Mina, an epidemiologist and chief science officer at eMed, a digital at-home testing company. The result is that a person may have a positive result with a PCR test, but not a positive with a rapid test.
A Jan. 10 pre-print study of Abbott Labs BinaxNOW rapid tests concluded that it was 95% effective in detecting the omicron variant in someone with a high viral load. Further, Bruce Tromberg, Ph.D., director of the National Institute of Biomedical Imaging and Bioengineering, who is overseeing the rapid test evaluations in partnership with the FDA said rapid tests work and should still be used by people if they have COVID-19 symptoms.
In other countries, rapid tests are designed for throat swabs and a South Africa study showed these tests caught omicron faster than tests using nasal swabs, which has spawned recommendations on social media for Americans to swab both their nose and throat if they are using at-home rapid tests. FDA Commissioner Jane Woodcock said people shouldn’t swab their throats because the tests and swabs aren’t designed for this purpose and there is no data from rapid-test makers showing that it works.
Where to find rapid tests? What do they cost, and will it be enough?
You can find rapid tests at pharmacies and retailers online and now through the mail. The New York Times Wirecutter published a Jan. 7 evaluation of tests and where to buy them here. The average cost of a test in the U.S. is $12, putting them out of reach for many Americans, according to Axios. Beginning Jan. 15, private health insurers were required to cover up to eight at-home rapid tests a month or reimburse beneficiaries up to $12 for a test. However, those who have Medicare coverage cannot get reimbursed. Community health centers will have free tests for those who are uninsured.
The Biden administration has begun sending 500 million tests to Americans for free through the mail, which may or may not reduce the price of at-home tests. On Jan. 13, the administration said it plans to purchase an additional 500 million tests for the coming months. For those who aren’t insured or don’t want to or can’t pay for a test, many communities offer PCR and antigen tests for free, but people have had to wait in long lines to get the tests, as demand has swelled for tests during the omicron surge. The Biden administration is also planning to send 10 million tests for schools to use to regularly test students.
Manufacturers have significantly increased the monthly supply of rapid tests to 300 million in January 2022, up from 46 million in October 2021 and about 25 million to 28 million in August 2021, according to CNN. The Biden administration has projected that the supply will increase from 350 million to 400 million by the end of February. Whether or not it will be enough remains to be seen as some public health experts say more than 750 million a month are needed to implement a testing strategy that will enable the U.S. to move beyond the pandemic.
Further, manufacturers may not have the supplies to meet the demand for so many tests. The American Clinical Laboratory Association warned on Jan.12 that a sustained increase in demand “could lead to shortages, particularly in consumables such as specimen collection tubes and pipette tips.”
More tips for covering rapid testing
Poynter’s Al Thompkins offers the following tips for covering COVID-19 testing:
- Journalists have to stay alert to scams. Some people will try to hoard tests and offer them fraudulently.
- Spend some time explaining how to make the best use of these kits, when to use them and how to correctly apply the swabs.
- Explain why some experts say it may be useful to swab the throat and not just the nose.
- Explain that one negative test may not be enough since people may not show up as positive if they are infected but take the test too early. Experts say people who are symptomatic should test “right away.”
Experts to call about testing
- Mara Aspinall is managing director of the Health Catalysts Group and professor of practice biomedical diagnostics at Arizona State University, email@example.com. She co-authors an excellent state of U.S. testing newsletter which can be found here.
- Carlos del Rio, Ph.D., is executive associate dean at the Emory School of Medicine & Grady Health System and professor of infectious diseases and global health at the Emory University School of Medicine and the Rollins School of Public Health, firstname.lastname@example.org.
- Celine Gounder, M.D., is a clinical assistant professor of medicine and infectious diseases at NYU’s Grossman School of Medicine, Celine.Gounder@nyulangone.org.
- Scott Gottlieb, M.D., is a senior fellow at the American Enterprise Institute and former FDA commissioner for former President Trump. Contact him via Twitter: @ScottGottliebMD.
- Dr. Gigi Gronvall is a senior scholar at the Johns Hopkins Center for Health Security and an associate professor at the Johns Hopkins Hopkins Bloomberg School of Public Health, email@example.com
- David N. Louis, M.D., is a pathologist-in-chief at the Massachusetts General Hospital.
- Benjamin Castleman is a professor of pathology at Harvard Medical School, DLOUIS@mgh.harvard.edu.
- Michael Mina, M.D., Ph.D. is an epidemiologist and chief science officer at eMed, a digital at-home testing company. You can contact him via Twitter: @michaelmina_lab.
- Nira Pollock, M.D., F.I.D.S.A., Associate Medical Director Infectious Diseases Diagnostic Laboratory at Boston Children’s Hospital, Nira.Pollock@childrens.harvard.edu
- Angela Rasmussen, Ph.D., is a virologist and research scientist at the Vaccine and Infectious Disease Organization-International Vaccine Centre in Saskatchewan, Canada, and a non-resident affiliate at Georgetown University’s Center for Global Health Security, firstname.lastname@example.org (new window).
- Elitza S. Theel, Ph.D., is the director of the Infectious Disease Serology Laboratory, and associate professor of laboratory medicine and pathology at the Mayo Clinic, email@example.com.
- E. John Wherry, Ph.D., is director of the Institute for Immunology at the University of Pennsylvania Perelman School of Medicine, reach him via his schedule Sam Halter: firstname.lastname@example.org.
- Scott Whitaker, is president and CEO of the Advanced Medical Technology Association, can be reached via media affairs: Cody Uhing, Director, Communications & Media Relations, 202-316-1423.
- Kelly Wroblewski is director of infectious disease programs at the Association of Public Health Laboratories. Contact her via Michelle Forman, manager of media, 240.485.2793, michelle. email@example.com.