The reason U.S. COVID-19 numbers aren’t higher? Not enough tests

“We do not need to go get tested, do we?”

As Alexa Malloy, a high school English teacher in Livermore, California, heard more about something called novel coronavirus in late February, she emailed her doctor to ask whether that specific illness could have given her a fever of 103 degrees and a cough so loud and powerful she couldn’t catch her breath.

“People look at you like you’re a criminal when you cough like that,” said Malloy, 56.

In the U.S., officials have identified 1,215 confirmed cases of novel coronavirus, or COVID-19, in 42 states, especially in Washington state and California, as well as the District of Columbia to a lesser degree. According to the latest available CDC estimates, 36 people have died from the virus in the U.S. But, public health experts say the only reason why those numbers have not exploded is that the nation has far too few diagnostic test kits. Lagging inventory has slowed testing. That means people simply don’t have them where and when they need them.

For Malloy, a dry, racking cough had made her body ache for three weeks. She could not eat solid food, only drank broth, coughed up blood and could not sleep without taking doses of codeine at bedtime. She was unable to teach because her uncontrollable coughing fits drowned out any other sound in the room. Each member of her family — her husband and three adult children — eventually fell ill with the same symptoms.

Months earlier, she had gotten her flu shot (“I always get it right away because I work with kids”). She suspected she might have pneumonia, which she had in 2010. But her family could not figure out what was going on. Her symptoms were unlike anything she’d had before. So she wrote to her physician to ask if she should be tested for COVID-19, which she thought could be spreading through her community. Instead, her doctor assured her that she needed to be tested for influenza.

While she doesn’t fault her doctor, Malloy still doesn’t know whether she and her family had that virus or not. She has recovered, but her voice remains raspy.

In the U.S., Malloy’s story is not an isolated case. Compared to the number of people who have been tested for COVID-19 in China, Japan, and South Korea, the U.S. has so far tested “only a tiny fraction,” said Dr. Lawrence Gostin, who directs the World Health Organization Collaborating Center on National and Global Health and the O’Neill Institute for National and Global Health Law. “We are likely to have much more testing capacity in the coming weeks, but it may be too little, too late.”

The World Health Organization declared COVID-19 a global pandemic on Wednesday. So far, the virus has sickened nearly 127,000 people worldwide and almost 5,000 have died. Research suggests roughly 80 percent of people who become sick endure mild to moderate symptoms that include fever, cough and shortness of breath. And people who are older, or are medically frail, are more likely to experience more severe outcomes or die from the virus.

WHO’s decision to call COVID-19 a global pandemic “is long overdue,” Gostin said, since the virus has already spread uncontrolled for weeks across borders. In announcing the pandemic status, WHO director-general Dr. Tedros Adhanom Ghebreyesus again urged nations to take “aggressive action,” noting that they can “change the course” if they “detect, test, treat, isolate, trace and mobilize their people in the response.”

“We are deeply concerned by the alarming levels of spread and severity, and by the alarming levels of inaction,” he added.

In recent weeks, President Donald Trump has often downplayed the risk of the virus, but he has also said every American who wants to get tested should be able to. A week ago, the Trump administration said that 1 million kits would be available. But as of Monday, the Centers for Disease Control and Prevention reported that just 75,000 test kits were available at 73 state and local health departments across 50 states.

In China, where the virus originated, the trajectory of cases has notably slowed after health authorities switched from collecting samples of people’s spit and mucus, to making the initial diagnosis of whether or not someone was sick with COVID-19 by taking chest x-rays . China rethought how it was diagnosing the illness because health workers there also faced a shortage of tests, and a CT scan was much faster and more available.

Other countries set up testing efforts much faster than the U.S., said Dr. Amesh Adalja, an infectious disease expert and senior scholar at Johns Hopkins University Center for Health Security. While the U.S. is slowly improving its testing capacity, Adalja said, “we are not testing at a rate that’s necessary to really understand the community spread of this virus.”

If testing were improved, the public health community could better estimate how deadly the disease really is. To figure out the mortality rate, you divide the number of people who die from an illness by the total number of people who got sick.

Right now, not “everyone who needs a test is able to receive one,” said Dr. Leana Wen, emergency physician and public health professor at George Washington University who previously served as Baltimore’s Health Commissioner. That means health care workers must ration tests — “something that shouldn’t happen in the middle of an epidemic.”

“The U.S. is weeks behind where we should be,” Wen said. “That means we don’t have a handle on how widespread COVID-19 is here. We could be missing hundreds, if not thousands, of cases.”

To speed up testing in Washington state, where the nation’s first confirmed case of COVID-19 was identified and where the CDC says community spread is happening with 366 cases confirmed in the state so far, Dr. Seth Cohen of the University of Washington helped launch drive-thru testing after seeing similar stations created by South Korean health care workers. Setting up in a parking garage was ideal, Cohen said, because it was ventilated and offered some shelter from wind, rain and snow.

The drive-thru clinic, where Cohen said his team is testing between 40 to 50 people per day, is designed to test staff affiliated with the University of Washington medical system, with the goal of reducing the risk of the virus spreading among health care workers and their patients.

Cohen’s team is also working to build a website that will allow them to share their protocols with other health care institutions that want to create their own drive-thru testing centers.

Now that researchers at the University of Washington have developed their own tests for COVID-19, Cohen and his colleagues are also able to test more members of the public who come in seeking care. When testing was initially only available through the CDC, testing turnaround took between three and five days. Now, their in-house test results take around 10 to 12 hours, allowing physicians to test a “much larger portion” of the patients they see.

“We’ve gone from essentially testing only people who were the sickest patients or somebody who had contact or travel to China” per CDC’s original guidelines, Cohen said. “And now, we’re essentially testing most people who are coming in with respiratory symptoms.”

Another issue that has emerged when it comes to accessing COVID-19 tests is cost. There has been growing pressure on the Trump administration to ensure tests remain affordable, if not free. Rep. Katie Porter, D-Calif., has estimated the price of “the full battery” of testing amounts to at least $1,331 per person, and in a hearing on Thursday, she seemed to persuade CDC Director Dr. Robert Redfield that testing should be made “free to every American regardless of insurance.”

This week, Dr. Emily Skoda-Mount, an outpatient pediatrician based outside Washington, D.C., said her practice received notice that they could send COVID-19 tests to commercial labs, waiting two to three days to receive results. In theory, Skoda-Mount said, nursing staff would collect a nasal swab of one’s mucus, freeze it, and have it picked up for testing. Presumably, a person who got tested would self-quarantine until they got those results, she said.

“Everyone’s nervous about it,” she said.

But how does she figure out who gets a test? Patients are asked a version of this question:

Do you have a fever, cough, shortness of breath and been in contact with a known case or recently traveled to a highly affected country, such as China, Italy, Iran or South Korea?

So far, none of her patients have met the screening criteria, Skoda-Mount said.

Those specific conditions are problematic. Not everyone has severe symptoms. And public health officials suspect community transmission — where you cannot trace everyone who has been in contact with a sick person before they caught a virus — is already happening in the U.S., including the Bay Area in California, where Malloy and her family live.

Since a viable vaccine and medication designed to combat this virus are still several months away from being available to the public, the best advice so far is that people stay home if they feel sick, wash their hands with soap and warm water for at least 20 seconds often throughout the day and cover their mouth and nose if they cough or sneeze.

Even if the bug that Malloy had last month wasn’t COVID-19, she isn’t taking any chances now, she said. She and her husband had planned to attend a wine release party. That’s cancelled, along with dinners with friends, she said. How long will she live this way? She’ll play it by ear.

“I would like there to be better treatment available,” she said. “The longer we wait, the more doctors will know how to address this.”

Bella Isaacs-Thomas contributed to this report.