Why so hard to be tested for coronavirus? Not enough swabs and confusing government guidelines

Patients hoping to learn if they are infected with coronavirus continue to be stymied by bottlenecks before they can learn the truth about their health.

Lab delays, mask and swab shortages, and changing guidelines have created a chokepoint, even as epidemiologists urge much broader testing to slow the spread of the coronavirus that has already turned life upside down in the Seattle area and much of the world.

Mask, gown and testing swab shortages

COVID-19 testing is brief and straightforward: A nurse sticks a six-inch cotton swab up a patient’s nostrils, then twirls it.

But the test depends on specialized equipment, from the swabs themselves to chemical reagents used in the lab to the all-enveloping clothing that nurses wear to administer the test.

Medical providers have been struggling to get their hands on personal protective gear and swabs. Collection drives have popped up and those with sewing chops are sewing masks for doctors and nurses.

Medical workers testing people for coronavirus require the “intensive” use of personal protective equipment, said Keith Jerome, head of the University of Washington’s virology department. “There's lots of masks and gowns and extra gloves and things that really get used very fast and very intensively in that situation.”

Jerome said he has worked with colleagues to identify additional swab types that would work for COVID-19 testing and give nurses the ability to use other options once they run out of the primary swab. The U.S. Food and Drug Administration has provided guidance on alternative swab types, he said.

Dr. Aileen Mickey, chief medical officer at EvergreenHealth, said her hospital has been able to keep up with demand for tests and, for now, is able to ramp up supplies as the number of cases rises.

“At some point, though, the limiting factor will be the test kits, the number of swabs we have and the ability of the lab to be able to perform the tests,” she said.

Lab turnaround time

Jerome, the virologist, said his department was one of first few places that could test for COVID-19. Demand exploded about a week ago.

Soon, there were more requests than the lab was able to handle. Turnaround time sat at 36 hours.

Commercial labs began to offer their own testing, alleviating some of the strain felt by the lab, but not the strain felt by those waiting on their test results.

The lab urged health care providers to send their tests to commercial labs, which they did--so much so that the UW lab’s output dropped to just over 1,000 tests on Sunday, from 3,000 tests on Friday.

“We've sort of overshot where we needed to be, and some of the local hospitals have been sending things, again, to some of these commercial labs, when we could be doing them here,” Jerome said.

He said university officials spent the weekend calling local hospitals to let them know that its lab did have the capacity to do more tests and return results in as little as 12 hours.

“The last thing you want to do is have the capacity to do testing that’s not being useful,” he said.

Increased demand for drive-through testing at EvergreenHealth swelled the turnaround time there from a three-day wait to five to seven days, said pulmonologist Aileen Mickey, chief medical officer for the medical group in Kirkland.

James Martin, chief medical officer for Swedish Medical Group, echoed this sentiment.

“[Turnaround time has] been not as good as we would like,” Martin said. “And that's been for a variety of reasons, but LabCorp has really stepped up and is trying to address that.”

The North Carolina-based firm announced last week that it would double its nationwide testing capacity by the end of the week to 20,000 tests a day.

Swabs that were being sent to North Carolina from Seattle for testing are now being directed to LabCorp’s Arizona location instead, shortening the travel time.

Testing delays are more than just an inconvenience: Some patients can’t leave hospitals until they get their results, so the wait can worsen the crunch on hospital beds as the COVID-19 pandemic worsens.

“Right now, if you're in a nursing home and you've got respiratory illness, they're sending you to the hospital, and you might really just have a cold,” Cassie Sauer with the Washington State Hospital Association said. “And we're waiting for multiple days to get those tests back in many cases, so you can't discharge those folks.”

“As long as we have a patient in the hospital, and we're not sure of their status, caring for that patient is extremely intensive in terms of the use of personal protective equipment,” Jerome said.

Of the 34,000 people tested for COVID-19 in Washington state as of Monday afternoon, 93 percent have tested negative.

Confusing government guidelines

Health officials say there are no restrictions on who can get a coronavirus test. But the reality is that mostly patients meeting certain criteria are getting tested.

“There's still not an unlimited supply of testing, of course, so we do still want to focus on people who are in higher-risk groups,” Jerome said. “People clearly who are hospitalized or showing symptoms [and] potentially, people who are exposed, although I know it's hard for folks to find providers who will do that.”

“We're only testing patients who are symptomatic, and that's fever greater than 100.4,” said Swedish Medical Group’s James Martin. “That's the CDC and DOH's guidelines.”

Each test means increased use of protective gear and increased exposure of staff at a time when hospitals already face staffing shortages.

“We also need to be careful and conserve resources because this is something that's going to last for months,” EvergreenHealth’s Mickey said.

The Washington Department of Health’s COVID-19 testing information, updated on March 17, says providers may test any patient with coronavirus symptoms (fever, cough, shortness of breath), but “until testing supplies and laboratory capacity are widely available,” it asks that providers follow narrower guidelines.

The document says providers should test symptomatic patients who: are hospitalized with severe respiratory illness; work in a setting where healthcare services are provided; are emergency responders; work at nursing homes or homeless shelters; or work at grocery stores, restaurants, gas stations and at public utilities.

Testing is not necessary for people under 60 years of age with mild illness, the guidelines state, and not recommended for people who are asymptomatic, the department of health says. Martin said Swedish isn’t testing people who have been exposed but are not showing symptoms: Many of those patients won’t have enough of the virus in their system to show up on a test.

A “negative” result in someone carrying the virus would offer a false sense of security, he said.

“That's really an important thing for folks to understand,” Martin said. “Not that we don't want to test people, we want to test them at the right time so we get a reliable answer.”

However, Jerome said even asymptomatic carriers have enough of the virus to test positive on a polymerase chain reaction test.

Broader testing could help providers slow the spread of the virus and keep hospitals from filling beyond capacity -- otherwise known as “flattening the curve.”

“If you look at the countries that have actually dealt with this problem well, they've certainly all had extremely robust testing systems,” Jerome said, adding that these countries were able to identify cases quickly and ensure isolation was happening.

“We also continue to need to track this infection, understand what the true positivity rates are in the community so that we can plan, and the only way to do that is to get a broad net of tests out there -- ideally from people who are not, you know, all needing to be hospitalized before they get a test,” Jerome said.

But Jerome said it’s “surprisingly controversial” among public health experts how to strike the right balance between testing as widely as possible and taking a more focused approach to make sure tests reach the people who need it the most.