Why is it so difficult to get tested for coronavirus in the United States?

As the coronavirus started to spread across the U.S., there was (and still is) a Catch-22 with testing: Many couldn’t get tested if they hadn’t come in contact with someone who tested positive, but so few people were being tested that it was difficult to know who did and did not have the virus.

That’s still the case in many parts of the U.S. “Not everyone who thinks they should get tested is getting tested,” Dr. Jennifer Kates, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation, told Digital Trends.

Now the country is playing catch-up with testing, even as states start trying to reopen their economies.

Why is testing important?

So much depends on the numbers. Experts haven’t agreed on a benchmark for how many tests the U.S. needs to perform weekly before it can safely reopen parts of the country — only that we need many more than we have right now. At the end of March, Michael Ryan, executive director of the World Health Organization Health Emergencies Program said countries with widespread testing were reporting about 12% of the results were positive. The rates are higher in places that are limiting their testing to people showing symptoms.

But testing people without symptoms is important. They might still have the virus, even if they don’t have a cough or fever. But if their test comes back positive, then anyone they’ve come into contact with should also be monitored and quarantined, and ideally, tested. A country’s ability to test even those who appear healthy is a sign that their testing capabilities are robust and not being confined to certain groups, like the elderly or those who are hospitalized. Less restrictive testing gives researchers and health experts a better idea of how many people actually have the virus. Also, it should allow them to catch infections earlier, before individuals have more time to spread it.

Both WHO and the Trump administration have guidelines for reopening the country. They include only sporadic new cases or a continual decline in new cases for 14 days. The Rockefeller Foundation put out a plan for increasing testing from 1 million to 3 million to 30 million a week, in order to get a better picture of where the declines are happening. The White House didn’t give definitive numbers for the drop in new cases; it’s been largely left up to governors.

One important reason public health officials want to stave off a second wave in new COVID-19 patients is so that hospitals don’t become overwhelmed. There is still no approved cure, treatment, or vaccine for the virus.

Why is the U.S. so behind on testing?

On January 21, the first Washington state case of COVID-19 was announced, one day after South Korea’s first case. In the U.S., testing was much slower to ramp up, and the virus was spreading undetected. While South Korea had tested about 250,000 people by March 13, Washington state had only tested 17,105 by March 18. As of April 27, Washington had performed more than 175,000 tests, according to the COVID Tracking Project.

“This will be a question that will be studied for years: ‘Why couldn’t the U.S. get ahead of testing for this virus as quickly as other countries could?’” Dr. Mark Cameron, an immunology professor at Case Western Reserve University, told Digital Trends in an interview. “And that is going to be a multi-faceted question to answer because the supply chain for the test failed at several different levels.”

The tracking site puts the overall number of tests, nationwide, at 5,434,943. Since March, the U.S. has vastly improved its number of tests per capita. The U.S. has a population of around 330 million, while South Korea’s is under 52 million. The slow start to widespread testing helped spread the virus in the U.S., and it now accounts for almost a quarter of all the deaths worldwide, according to Johns Hopkins University.

“We need to significantly ramp up not only the number of tests, but the capacity to perform them, so that you don’t have a situation where you have a test but it can’t be done because there isn’t a swab, or because there isn’t extraction media, or not the right vial,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, recently told Time. “I am not overly confident right now at all that we have what it takes to do that. We are doing better, and I think we are going to get there, but we are not there yet.”

There are several reasons the U.S.’s ramp-up in testing was slow. In the early days of the virus reaching the country, the only approved tests for COVID-19, delivered by the Centers for Disease Control and Prevention, were faulty. It took several weeks to correct the issue.

Labs, like the University of Washington’s virology department, that wanted to create their own tests, had to go through a convoluted procedure that, at the time, required them to mail in paperwork. On February 29, the CDC and public health labs had tested only 3,999 people nationwide. The same day, the Food and Drug Administration agreed to let hospital laboratories develop their own tests. The Emergency Use Authorization lets such facilities create tests without undergoing the usual, rigorous testing of efficacy.

“In order to have a perfect test, you want to validate,” said Dr. Laila Woc-Colburn, an infectious diseases professor at Baylor College of Medicine. But, she added that tests for other viruses also went through similar issues, it’s just researchers have had decades to study them. This is a new version of the coronavirus.

As of late April, there are dozens of kits being used to test for COVID-19, created by a variety of commercial and university labs.  The increased number of kits is an important piece of testing a larger portion of the population, but it’s not sufficient in and of itself.

Labs also need more machines, with higher capacities, to test the samples. There have been shortages of kit components, especially the swabs needed to gather cells from patients’ noses or throats. Because of the nature of the tests, the health care workers taking the sample need to wear personal protective equipment (PPE), which is also in high demand. There’s been concern, due to the process for preparing the swabs for testing, that those testing the samples should also be wearing PPE. Some labs have also had to hire more staff to meet the demand.

Are things going to improve?

The latest coronavirus relief bill provides $25 billion for testing. That includes $1 billion to the CDC for “for surveillance, epidemiology, laboratory capacity expansion, contact tracing, public health data surveillance and analytics infrastructure modernization, disseminating information about testing, and workforce support necessary to expand and improve COVID–19 testing.” It’s not yet clear whether that money will help the U.S. better coordinate its testing country-wide.

“There’s no national coordinated plan for testing scale up or roll out,” said KFF’s Kates. “There’s not a system for understanding the supply and demand issues across the country right now.” The U.S.’s testing capacity is a hodgepodge of public and private labs with many types of tests, varying capacities, and differing levels of supplies. With a lack of federal oversight to track and distribute the supplies where they’re needed, states and hospitals have been competing against one another for them.

Between April 15 and 27, the U.S. averaged nearly 192,000 tests a day, according to the COVID Tracking Project. In order to reach even one of the lowest benchmarks for weekly testing , 2.6 million, the U.S. needs to find a way to coordinate a million more tests a week.

What countries are doing testing well?

“In a few countries, the use of diagnostic testing on a massive scale has been a cornerstone of successful containment strategies,” according to the authors of a recent study on COVID-19 testing in The Annals of Internal Medicine. “In contrast, the United States, hampered by limited testing capacity, has prioritized testing for specific groups of persons.” South Korea is one successful country mentioned due to its amount of testing.

South Korea had its first COVID-19 case on January 20, 2020. By early March, it had already set up drive-thru testing sites, which were free and available to almost anyone who had a fever or who had come in contact with someone who tested positive. The country was testing around 15,000 people a day by mid-March. Germany also had a quick, widespread response and is testing around 120,000 people a day, according to NPR.

Germany is also conducting antibody testing, to try and find out how many people in the country have recovered from the virus. While this type of testing reveals the presence of antibodies in a person’s blood, not all are accurate enough to distinguish between COVID-19 and other types of coronavirus, including some common colds. That could mean some false positives, with tests showing someone has antibodies even if they’ve never been infected with this particular virus. In addition, WHO said there’s “no evidence” that someone who’s been previously infected is protected from a second infection. It’s too early to tell whether easing stay-at-home restrictions and opening some shops in Germany will create a second wave of COVID-19 cases in the country.

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