Medical Examiner

Why America’s COVID Testing Is Trash

A medical worker holds a tube.
A worker holds a tube with a swab sample for a COVID-19 test in Bonn, Germany, on Monday. Andreas Rentz/2020 Getty Images

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The United States is still experiencing one of the worst COVID-19 outbreaks of anywhere in the world. And much of that is because many of our communities still haven’t been able to answer one fundamental question: Who has the virus? Efficient testing would have allowed us to identify superspreaders early on in the pandemic, but now, with so much community spread, it’s a little late to expect testing will help us get out in front of the virus. We still don’t have enough tests, but according to Robinson Meyer, who covers the pandemic for the Atlantic, there is a way we could fix our testing system on a mass scale that might help us get the pandemic under better control, even before a vaccine is made available. To figure out what it would take to have widespread, functional testing in the U.S., I spoke with Meyer for Tuesday’s episode of What Next. Our conversation has been edited and condensed for clarity.

Ray Suarez: Early on in the pandemic, the emphasis seemed to be on stopping the spread. So many of the public health messages centered around wash your hands, cover your face, keep your distance, since we didn’t know who had it and who didn’t. We were trying to stop people from handing the virus from one to another. Then testing came surging in. What does that look like now?

Robinson Meyer: Testing remains one of the key tools in the public health fight against this virus. And there are two reasons for that. It allows us to do the most basic task in disease control, which is figure out who’s sick and keep them away from susceptible people. That’s how you bring down a pandemic. The second reason testing is extremely important for this virus specifically is that there do seem to be some fraction of people who may never know they’re sick or may not experience symptoms any more severe than an allergy, so they don’t think they’re sick. It seems like those people may potentially be more infectious for longer than the people who eventually do develop symptoms. We have no way of knowing who those people are and keeping them away from susceptible people without testing.

There is a set of other behaviors about this virus we’re starting to understand that make testing even more important. It seems like a relatively small number of people drive a relatively large number of infections. Most people probably infect zero other people, but 1 out of every 10 cases or 1 out of every 20 cases infects 20 or 30 other people. This virus is driven by spiky, superspreading events.

Now, we definitely started testing too late. There’s no question about that. There’s another question, though: Do we even have the right tests? Do we have the right kind of tests? Nearly all the tests we run in this country are called PCR tests. They’re highly sensitive, very accurate molecular tests.

That’s the one with the long-stick nasal swab, where recipients feel like they’ve just gotten poked in the brain.

They need to be run in a lab by trained technicians, and they take a few hours to run. Because they require a special place, there are logistics involved, like getting a sample from the test site to the lab. In a good world, it can take one or two days for results to come back. In a world like ours, where the system is totally slogged and overwhelmed, it can take as much as five to seven days. I mean, Arizona tests are not coming back for 14 days. That is a useless test. There is no reason to do that because 14 days is the quarantine period for the coronavirus in the first place. What we need, in addition to those molecular tests—which are extremely useful and effective for medical context—are screening or diagnostic tests that let us test a lot of people quickly across the population.

How would that work? What would that look like?

First of all, the NIH has started to fund advanced forms of testing, which use genetic sequencing machines that would let us test, at a single facility, 250,000 or 300,000 samples a day—which is about a third of the country’s total capacity right now. What this epidemiologist at Harvard, Michael Mina, is calling for is the development and government-funded mass production of rapid tests, which exist right now. They don’t require special machinery; they’re just a paper strip. You would spit on it, put it in a cup, and wait 10 minutes. It would tell you whether you’re infectious right now, delivering a result within 15 minutes. What Mina says is we should produce these things in the billions at public expense and then make them freely available to anywhere in the country. And then, before you go into a public place like a movie theater, restaurant, school, or office, you take one of these tests. If it’s negative, you’re allowed to proceed. If it’s positive, you go home and wait. He argues that if we had a testing strategy on that scale, we’d be able to bring the virus to heel within three weeks.

That time estimate is debated among epidemiologists and economists, but what is not debated is that the federal government needs to invest a lot more in these rapid tests, because no private company can produce them on such a massive scale.

The government has powers to compel the manufacturing of materials for national security or the public good. It did this during the Korean War and World War II. The big law is the Defense Production Act, which the Trump administration only invoked once in the spring to make more respirators. What we haven’t seen in a broad sense, though, is the massive expenditure of billions of dollars to make testing a widespread, common, cheap, easy, and accurate part of American life. We’ve really only seen that money spent on vaccines, and I think there needs to be a similar effort for tests.

One thing we know about rapid tests is that they are less sensitive, less accurate, a cruder measure. Why are they still a useful tool?

I think those questions around accuracy are exactly why they’ve stayed off the market. So far, the FDA doesn’t allow any test on the market that’s not 80 percent as accurate at catching positive cases as the high-end, best-in-class PCR molecular diagnostic technique is. I think they’re still a useful tool because even if they’re only somewhat as accurate, they will still catch a lot of infections and catch people with the highest viral load. If you have a lot of virus in your system, then a slightly less sensitive test is more likely to give you a positive than if you only have a little bit of virus in your system. So both tests catch a lot of infections, but rapid tests are almost answering a different question than other kinds of COVID tests: What they’re really looking for is infectiousness. The way to think about these less sensitive tests is that they’re contagiousness tests. They don’t answer: “Am I infected with SARS-CoV-2?” They answer: “Do I have so much SARS-CoV-2 in my system that I’m contagious right now?” You actually get information that you can’t get from the PCR test we use right now.

One concern I have about these tests, honestly, is that because they are not as sensitive as these high-end PCR tests, there are going to be news stories that say, they’re not as accurate, they miss 20 percent of cases that PCR tests don’t. I’m worried people wouldn’t trust the results of these tests and then opt out of taking them, or not take the results seriously.

We live in a country where millions of people are refusing to wear a mask when it’s been offered as a cheap, low-threshold way to stop making other people sick. We live in a country where, depending on the poll, anywhere from 35 to 50 percent of people say they won’t take a vaccine once one is developed. Millions believe there are nefarious purposes behind the vaccine, that people want to put tracking chips into their bodies, that it’s part of a worldwide conspiracy, that the novel coronavirus was developed as a bioweapon. Are we really going to have people patiently waiting outside the front doors of restaurants to voluntarily give saliva samples in a country where that many people believe those things?

There are a few ways I would look at this. The first is that, in many, many states of this country, if this test existed in such quantities that we were able to give a rapid test to everyone who wanted to eat indoors, I’m not sure it would be voluntary. I think many states would immediately say, you have to take one of these before you go eat food, before you go into a store. I don’t see a reason that wouldn’t be within the legal power of the states. Plus, no public health intervention has 100 percent uptake. There are going to be people who doubt masks. There are going to be people who doubt the efficacy of social distancing. We should not let the perfect or the imagined imperfect be the enemy of the good here. If this technology were available, it might not do everything that we want to do in a perfect world, with 100 percent of people picking it up. But it would save a lot of lives and allow a lot of public space, a lot of public places, to reopen.

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