Laurie Saloman, MS

Technically, anyone who wants a COVID-19 test can walk into a pharmacy or health care office and get one. In actuality, though, access to the tests has been uneven and questions remain about the accuracy of the various tests. “We know that molecular testing has the highest sensitivity for ruling out—for excluding—COVID,” says Nira Pollock, MD, PhD, a member of the Infectious Diseases Society of America (IDSA), which is keeping tabs on the state of COVID-19 testing. Pollock, who is the associate medical director of the Infectious Diseases Diagnostic Laboratory at Boston Children's Hospital, points out that questions also persist about “turnaround time, with cost, and with supplies facing both patients and laboratories.”

Even as testing has evolved, long lines at health care facilities may persist, Pollock says. It may be hard to get an appointment at a pharmacy, and fewer state testing sites remain open. Supply chain problems mean testing supplies are not always abundant. Samples may be sent to labs that have long turnaround times. And while the tests themselves are free to consumers, office visits may entail copays.

 offers many more conveniences with a potential pitfall: the possibility of a less accurate result. “Most of the available home tests are...antigen rapid diagnostic tests, or RDTs, 

and those have significant potential advantages,” says Pollock. These include fast turnaround time and lower costs, at least to third-party providers. Because home tests are relatively cheap and fast, they can be used for 

, although there is no consensus on the optimal interval between tests. However, the 

 the virus is somewhat reduced compared with that of PCR tests. “There’s still disagreement about whether a negative RDT can effectively rule out infection in a symptomatic individual,” Pollock notes, adding that a person can have a negative antigen test and positive PCR test and be infectious.

One problem with home tests is that people might administer them incorrectly, which could affect results. Another issue is that positive results may not be reported. “I think we will probably lose track,” says Dial Hewlett Jr., MD, FIDSA, an IDSA Fellow and medical director of the Division of Disease Control at the Westchester County Department of Health in New York. “We won’t have as accurate an idea in terms of what the prevalence of the disease is at any given time. On the other hand, I think that having access to these results in a very rapid way will be helpful in terms of the practical issues of 

Rapid testing may indeed be the key to keeping kids in school, although there are obstacles.

No agreed-upon definition exists that spells out exactly which symptoms trigger the need for a test. There also is no consensus about the need for school testing if transmission rates in an area are low. Pollock mentions the 

 program being piloted in certain districts by the Centers for Disease and Control and Prevention (CDC), which involves regular rapid onsite testing and contract tracing of potentially exposed children and staff so they don’t have to quarantine at home.

While PCR tests catch more positive results than do rapid tests, the lag time between testing and results can be as long as several days. This can be problematic if people don’t quarantine while waiting for results. Hewlett explains that under the vaccine mandate for health care workers, those in his county who receive exemptions must take molecular tests once a week. “The shortcoming of this is that an individual may test negative on Monday and then they may actually start to develop symptoms on Tuesday,” he says. Meanwhile, coworkers are potentially exposed during that time.

For vaccinated but asymptomatic individuals, when and whether to test is more of a nuanced discussion. If a group is planning to gather for the holidays and all are vaccinated, should they all take COVID-19 tests beforehand? The answer depends on whether anyone is vulnerable due to age or comorbidities, the experts agree. “[T]esting in vaccinated people really is a balance of risk--risk for those around you, risk for yourself and your health history, and also access and resources,” Pollock says. Hewlett says that if the gathering includes, for example, someone with Stage 4 cancer, it would be appropriate for all attendees to test before coming together.

The panel’s experts lamented that finances might factor into someone’s decision to get a COVID-19 test. While tests administered at an urgent care center or lab are free to the consumer, reports of third-party bills sent to insurance companies or the government are not unheard of. And rapid tests for home use can start at $25 for a 2-pack and run to $35 or more, which may be out of reach for many families, especially those with multiple children. “The fact that someone with means can more quickly get a test to exclude COVID in their child and get that child back to school than potentially someone without those resources--it just shouldn't be that way,” says Pollock.

Pollock adds that it has been difficult to find rapid tests of late, although the Biden administration has invested heavily in their development and availability, which should make them easier to obtain heading into the winter season.

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No agreed-upon definition exists that spells out exactly which symptoms trigger the need for a test. One expert says that if a get-together includes, for example, someone with Stage 4 cancer, it would be appropriate for all attendees to test beforehand.

Consider COVID-19 Testing Before Holiday Gatherings

We’ve gotten used to a “shrinking world” in the last several decades: shrinking because of advances in transportation, communication, and interconnected economies, among other things. Keep that in mind, because even as the United States 

 and its COVID-19 transmission rate declines, the situation in many other nations remains precarious. The Infectious Diseases Society of America (IDSA) held a press briefing to discuss the state of affairs in India and Africa, as well as the reasons behind the surge and what the global community can do to help.

The loudest alarm bells are ringing in India, with news outlets describing residents desperate for oxygen and hospital beds and cremating bodies on funeral pyres that burn at all hours.

“The India situation is really an unprecedented public health emergency,” asserted Krutika Kuppalli, MD, FIDSA, an IDSA Fellow and vice chair of its Global Health Committee as well as assistant professor in the Division of Infectious Diseases at the Medical University of South Carolina in Charleston. “As of today, it’s estimated that there are 23.3 million cases related to COVID, and over 250,000 deaths, and it’s likely that these are underestimated given problems with testing, given problems with keeping accurate counts of fatalities in the country.” Kuppalli said current projections predict more than 1.5 million deaths in India by September 1 unless drastic measures are taken.

One reason for the fast spread of the virus in India is the 

, which displays increased transmissibility, Kuppalli said, outcompeting the B.1.1.7 variant that has been prevalent in Britain. The B.1.617 variant has appeared in 49 other countries as well.

Another cause of the virus’ wildfire spread is the demographics of India itself. “India struggles with complex population density issues, given that it is a country of over a billion people, complex socioeconomic issues, and—now that they overcame the first wave of infections—there was this false narrative that maybe India had overcome COVID” Kuppalli said. “And with that narrative there was a relaxing of public health measures. So when you have the relaxing of public health measures with the population density and socioeconomic issues, it really was ripe for the development of the spread of these infections.”

The COVID-19 horror stories unfolding in India and other nations should give pause as the U.S. celebrates the relaxing of 

 and as vaccinations here keep surging (even starting to include children as young as 

), while infections, hospitalizations, and deaths decline. Over 700 epidemiologists surveyed by the 

 say that “the true end of the pandemic—when it becomes safer to return to most activities without precautions—will arrive once at least 70% of Americans of all ages are vaccinated…. Adolescents just began receiving vaccines … and those for children younger than 12 are not yet approved.”

David Celentano, the chair of epidemiology at Johns Hopkins University and one of the 723 epidemiologists who participated in the survey, tells the newspaper that “children are key to ending the pandemic.”

The epidemiologists surveyed are confident that the pandemic will end in the U.S. (but perhaps not as quickly as some assume) and in about 5 years COVID-19 “will be more like the flu, circulating at a lower rate and with some deaths every year—but no longer a public health crisis necessitating lockdowns,” according to the 

Meanwhile, the situation in India remains frought. The virus is beginning to migrate from India’s urban centers to rural locales, which Kuppalli said will be especially challenging given the lower level of COVID-19 understanding in more outlying villages.

Working with other medical and scientific professionals, Kuppalli has been instrumental in raising awareness of the disease in India. She and her team created an infographic on how people can care for themselves when they have COVID-19 and when to call for medical help. The infographic went viral on social media and was translated into 20 Indian languages, plus Nepal and Sri Lankan tongues. She also helped found the nonprofit 

, which aims to share relevant info about COVID-19 and provide help to the suffering population.

Because Indian hospitals are at capacity, the international community can help by providing resources such as oxygen, along with tackling the logistics of transporting oxygen in India. Also needed is help with setting up field hospitals, providing telemedicine support, and expanding the use of rapid testing. “If we can leverage capacities that are already there and develop public or private partnerships to increase genomic sequencing, that would be helpful,” Kuppalli added.

Kuppalli noted that the Serum Institute of India is responsible for delivering close to 200 million doses of vaccine to the COVID-19 Vaccines Global Access (COVAX), which helps distribute vaccines in resource-limited countries. Due to the public health emergency in India, those doses will be delayed at least until July. High-income countries that have a surplus of vaccines can make a real difference by donating those doses to India and other 

countries having difficulty battling the virus

The rest of Southeast Asia is also a potential tinderbox, Kuppalli said. Nepal is already beginning to see a surge, and experts are concerned about highly populated, high-density nations such as Pakistan, Afghanistan, and Bangladesh “If COVID starts wreaking havoc in these areas, it could make Southeast Asia destabilized and cause huge repercussions throughout the globe,” Kuppalli said, stressing that it’s in everyone’s interest to support India now and stave off long-term global health and economic repercussions.

Another locale where COVID-19 may be poised to run wild is Africa. Although the current caseload there is somewhat lower than what was reported over the winter, that is a function of limited testing and incomplete data, said Dawd Siraj, MD, FIDSA, an IDSA Fellow and vice chair of its Global Health Committee as well as professor of medicine, Division of Infectious Diseases at the University of Wisconsin-Madison.

Nigeria, for instance, has reported only 165,000 COVID-19 cases--yet it is the most populous country in Africa. “We really have to translate and interpret those numbers very cautiously,” Siraj said. Roughly 45 million tests have been administered in Africa compared with 300 million in India. The U.S. has tested almost 40 times more than Africa. With a test positivity rate of 10.4%, well above the 5% threshold at which the pandemic can be considered under control, Africa likely has many more positive cases than it is catching. The case fatality rate of 2.7% also is higher in Africa than elsewhere, Siraj pointed out: Globally, the virus has a death rate of about 2%, with the U.S. death rate at 1.76%.

With the high transmission rate among a young population that has not yet experienced a devastating surge, new 

 making the rounds, the absence of real-time data, and a relative sliver of the population vaccinated, Siraj is apprehensive about the situation: “The pandemic has yet to unfold on the continent of Africa. My fear is that the worst is yet to come.” The continent must double down on basic public health measures, he insisted, as well as scale up treatments such as oxygen and ventilators.

The original version of this article first appeared in 

Despite good news in the U.S., victory over a worldwide pandemic can’t exclude half of the world.

Laurie Saloman, MS

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Consider COVID-19 Testing Before Holiday Gatherings

COVID-19 Endgame? Maybe for the U.S., but Not the Planet