How Is COVID Testing Still This Confusing?

Upgraded at 12:44 p.m. ET on November, 23 2021

In a world with best coronavirus tests, individuals might swab their nose or spit in a tube and get near-instant responses about their SARS-CoV-2 status. The items would be complimentary, quickly, and entirely trustworthy. Positives would right away shuttle bus individuals out of public areas and, if required, into treatment; negatives might green-light entry into every shop, school, and workplace, and spring individuals out of seclusion with no reservation. Tests would ensure whether somebody is infectious, or simply contaminated, or neither. Which status would apply till everyone had the opportunity to evaluate once again.

Sadly, that is not the truth we reside in—nor will it ever be. “No such test exists,” K. C. Coffey, an infectious-disease doctor and diagnostics specialist at the University of Maryland, informed me. Not for this infection, and “not for any disease that I know of.” And practically 2 years into this pandemic, flaw isn’t the only screening issue we have. For numerous Americans, screening stays unattainable, unaffordable, and still—still!—unbelievably puzzling.

Inconsistent outcomes, for example, are an all-too-common quandary. Cole Shacochis Edwards, a nurse in Maryland, found at the end of August that her child, Alden, had actually been exposed to the infection while masked at volley ball practice. Shacochis Edwards rapid-tested her household of 4 in the house, while the high school ran a lab PCR on Alden. One week, 11 quick antigen tests, 3 PCRs, and $125 later on, their home was knee-deep in a confusing range of clashing outcomes: Alden evaluated unfavorable, then favorable, then unfavorable once again, then favorable once again, then unfavorable once again; her daddy evaluated unfavorable, then favorable, then favorable, then unfavorable; Shacochis Edwards, who evaluated 3 times, and her boy, who evaluated two times, remained unfavorable throughout. “None of it was clear,” she informed me. Months after their screening legend, Shacochis Edwards is quite sure the positives were incorrect—however there’s just no other way to understand for sure.

Some conflicting outcomes are simply bothersome. Others, however, can be a huge issue when individuals misguidedly act upon them—unwittingly triggering break outs, hindering treatment, and wasting time and resources. And the confusion doesn’t stop there. The tests can be found in a ridiculous variety of tastes and plans, with subtle distinctions in between brand names. They’re released in a disorienting range of settings: medical professionals’ workplaces, neighborhood screening websites, apartment or condo living-room, and more. They’re being asked to serve numerous really various functions, consisting of medical diagnosis of ill clients and screening of individuals who feel completely symptom-free.

Our tests are imperfect—that’s not going to alter. The technique, then, is finding out to deal with their constraints; to count on them, however likewise not ask excessive.

Tests can inform us just whether they discovered little bits of the infection, at a single time.

Tests are infection hunters. The very best ones have the ability to achieve 2 things: properly determining the pathogen in an individual who’s absolutely contaminated—a metric called level of sensitivity—and dismissing its presence in somebody who’s absolutely not, or uniqueness. Tests with terrific level of sensitivity will practically never ever error a contaminated individual for a virus-free one—an incorrect unfavorable. High uniqueness, on the other hand, implies dependably skirting incorrect positives.

Our tests achieve this in 2 broad methods. They look for particular bits of the infection’s hereditary product, putting them in the classification of molecular tests, or discover hunks of pathogen protein, which is the job of antigen tests. (The majority of the quick tests you can discover in shops are antigen, while PCR tests are molecular.) Both types will make errors, however whereas molecular tests consistently copy viral hereditary product till it’s noticeable, making it simpler to root out the pathogen when it’s rather limited, antigen tests simply study samples for SARS-CoV-2 proteins that are currently there. That implies they’re likelier to miss out on infections, specifically in individuals with no signs.

Even super-sensitive, super-specific tests can spit out more mistakes when they’re mishandled, or when individuals swab themselves sloppily. That can be quite simple to do when directions vary a lot amongst brand names, as they provide for quick antigen tests. (Wait 24 hr in between tests! No, 36! Swivel it in your nose 4 times! No, 5! Dip a strip in liquid! No, drop the liquid into a plastic strip! Wait 10 minutes for your outcome! No, 15!)

Random compounds can likewise fool particular tests: Soda, fruit juice, catsup, and a lot of other home liquids have actually produced rapid-antigen incorrect positives, an oopsie that some kids in the UK have actually obviously been happily making use of to recuse themselves from school. Production snafus can likewise set off incorrect positives, as just recently taken place with Ellume, a business that offers quick antigen tests and needed to remember some 2 countless them in the United States. (Sean Parsons, Ellume’s CEO, informed me that the problem is now under control which his business is “already producing and shipping new product to the U.S.”)

Even when they’re completely released, tests can spot little bits of the infection just at the minute a sample is taken. Evaluating “negative” for the infection isn’t some sort of long-term identity; it doesn’t even ensure that the pathogen isn’t there. Infections are constantly increasing, and a test that can’t discover the infection in somebody’s nose in the early morning may choose it up come afternoon. Individuals can likewise contract the infection in between the tests they take, making an unfavorable, then a favorable, another completely possible circumstance. That implies a test that’s taken 2 days prior to a Thanksgiving event won’t have any bearing on an individual’s status throughout the occasion itself. “People want tests to be prospective,” Gigi Kwik Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, informed me. “None are.”

Tests can serve a lots of various functions.

Just recently, I asked more than 2 lots individuals—colleagues, member of the family, professionals, complete strangers on Twitter—what they visualized the “perfect” coronavirus test to be. The responses I got were all over the location.

Individuals desired tests that were inexpensive and available (which they’re presently not), preferably something that might provide a lightning-fast response in the house. They likewise, unsurprisingly, desired completely precise outcomes. However what they desired those outcomes to achieve varied exceptionally. Some said they’d test only if they were feeling unwell, while others were way more interested in using the tests as routine checks in the absence of symptoms or exposures, a tactic called screening, to reassure them that they weren’t infectious to others.

At least for now, certain tests will be better suited to some situations than others. “The best test to use depends on the question you’re asking of it,” Coffey told me. When someone’s sick or getting admitted into a hospital, for instance, health-care workers will generally reach first for the most precise, sensitive test they can get their hands on. A missed infection here is high-stakes: Someone could be excluded from a sorely needed treatment, or put other people at risk. But lab tests are inconvenient for the people who take them, and very often slow. Samples have to be collected by a professional, then sent out for processing; people can be left waiting for several days, during which their infection status might have changed.

Using a rapid test can be much more convenient, especially if people feel unwell at home—and these tests do work great for that. But things get hairier when these products are used for screening purposes. Asymptomatic infections are a lot harder to detect in general, because there’s no obvious bodily signal to prompt a test. “You’re essentially randomly sampling,” which means more errors will inevitably crop up, Linoj Samuel, a clinical microbiologist at the Henry Ford Health System in Michigan, told me. To patch this problem, the FDA has green-lit several rapid tests that tell users to administer them serially—at least once every couple of days. A test that misses the virus one day will hopefully catch it the next, especially if levels are rising.

But for those hoping to narrow in on the people who are carrying the most virus in their airway—and probably pose the biggest contagious risk to others—rapid antigen tests might be enough to do the trick precisely because they are less sensitive. They won’t catch all infections, but not all infections are infectious; a positive antigen result, at least, could be a decent indication that someone should stay home, even if they’re feeling perfectly fine. That logic isn’t airtight, though. Antigen-positive is not precisely synonymous with infectious; antigen negatives cannot guarantee that someone is not. “For SARS-CoV-2, we don’t know the threshold—how much virus you need to be carrying” to be contagious, Melissa B. Miller, a clinical microbiologist at the University of North Carolina at Chapel Hill, told me. People on the border of positivity, for instance, might still transmit.

Many tests weren’t designed for one of the most basic ways we are using them.

People are turning to testing for asymptomatic check-ins that can give them peace of mind before a big event, or even give them the go-ahead to travel overseas. But a lot of these screening tests were initially designed to diagnose people who were already sick—and the tests’ performance won’t necessarily hold when they’re being repeatedly used on symptom-free people at home.

Part of the problem can be traced back to how the United States’ thinking on testing has evolved. Early on in the pandemic, regulatory agencies like the FDA prioritized tests for symptomatic patients; the agency has since noticeably shifted its stance, authorizing dozens of tests that can now be taken at home. But there are still some relics that have influenced how the tests have, and have not, been evaluated for use.

Tests such as the Abbott BinaxNOW, for example, were first studied as a rapid diagnostic that people could take shortly after their symptoms first appeared. It can now be used as a screener, when it is serially administered at home to asymptomatic people (which is why the tests are sold in packs of two). But to nab that expanded authorization from the FDA, the company didn’t have to submit any data on the test’s performance when it was serially administered at home, or how well it worked in asymptomatic people. Instead, the FDA has been green-lighting serial tests based on how well their outcomes match up to PCR results in symptomatic people. They just have to detect 80 percent of the infections that the super-sensitive molecular tests do, in a clinical setting.

I asked the FDA why that was. “The FDA does not feel that requiring specific serial-testing data from each manufacturer is necessary due to the current state of knowledge on serial testing,” James McKinney, a spokesperson, told me. (Some companies that already have products for sale, including Abbott and Becton, Dickinson, are collecting additional data now under FDA advisement.)

The repurposing of tests feels a little weird, experts told me. “I don’t see how you can reuse the same data, for very different goals,” Jorge Caballero, a co-founder of Coders Against COVID, who’s been tracking coronavirus-evaluate availability and performance, told me. That doesn’t mean these tests are useless if you don’t have symptoms. But without more evidence, we’re still determining exactly what they’re able to tell us when we self-administer them once, twice, or more, even as we’re feeling fine.

Test results can tell us just so much.

The results produced by a coronavirus test aren’t actually the end of the testing pipeline. Next comes interpretation, and that’s a nest of confusions in its own right. Sure, tests can be wrong, but the likelihood that they are wrong changes depending on who’s utilizing them, how, and when. People don’t always talk about what to do when they’re shocked by a result—but that sense of surprise can sometimes be the first sign that the test’s intel is wrong. “People should have some confidence on how likely it is they have the disease when they test,” Coffey told me. “Ideally, the test should confirm what you already think.”

Consider, for example, an unvaccinated person who starts feeling sniffly and feverish five days after mingling unmasked with a bunch of people at a party, several of whom tested positive the next day. That person’s likelihood of having the virus is pretty high; if they test positive, they can be pretty sure that’s right. Random screenings of healthy, vaccinated people with no signs and no known direct exposures, meanwhile, are way more likely to be negative, and positives here should raise at least a few more eyebrows. Some will be correct, but truly weird results may warrant a re-check with a more sensitive test.

Yet another wrinkle has become particularly relevant as more and more people get vaccinated. Tests, which look only for pieces of pathogens, can’t distinguish between actively replicating virus that poses an actual transmission threat, and harmless hunks of virus left behind by immune cells that have obliterated the threat. A positive test for a vaccinated person may not mean exactly the same thing it does in someone who hasn’t yet had a shot—maybe, positive for positive, they’re less contagious. That’s not to say that noninfectious infections aren’t still important to track. But positives and negatives always have to be framed in context: when and why they’re being taken, and also by whom.

Tests will have to be part of our future, for as long as this virus is with us. But understanding their drawbacks is just as essential as celebrating their perks. Unlike masks and vaccines, which can proactively stop sickness, tests are by default reactive, catching only infections that have already begun. In and of themselves, they “don’t stop transmission,” Coffey informed me. “It’s about what you do with the test. If you don’t do anything with the result, the test did nothing.”


This article previously misstated the type of coronavirus test manufactured by the business Ellume.

Jobber Wiki author Frank Long contributed to this report.