Who should get tested for COVID-19? Depends who you ask.
The controversy sparked by the Centers for Disease Control and Prevention's recent shift in guidance, saying asymptomatic people exposed to COVID-19 shouldn't necessarily be tested, highlights a growing frustration for doctors and health officials: Differing guidelines, rules and practices determine how the country's limited testing supply is allocated.
Shortly after the CDC issued its recommendations, the governors of New York, New Jersey and Connecticut called them "reckless" and said they won't follow them. They're "a recipe for community spread and more spikes in coronavirus," according to the American Medical Association.
That leaves health-care providers, individuals, employers and schools to navigate the chaotic mix of federal, state and local recommendations and mandates in deciding what to do.
"You're trying to do the best for your patients, trying to make sure you hit all the regulatory requirements," said Kara Mascitti, an infectious disease physician at St. Luke's University Health Network in Bethlehem, Pennsylvania, and medical director for its infection prevention program. "Frankly, you feel like your head is spinning sometimes."
Public-health experts say that deferring to state and local authorities, which has long been the White House strategy, is problematic for just that reason.
"Lack of guidance on a federal level creates mass confusion," said Leana Wen, a physician who formerly served as Baltimore's health commissioner and is a visiting professor of health policy and management at George Washington University. The CDC guidance change will result in "even more of a piecemeal approach" to public health, she said.
As the CDC dialed back testing recommendations, the Centers for Medicare and Medicaid Services issued new rules for nursing homes, for the first time requiring facilities test workers.
COVID-19 has killed almost 50,000 people in U.S. nursing homes, whose residents are particularly vulnerable to the virus. But testing practices have been inconsistent as CMS had merely recommended it and state policies varied widely.
For example, Michigan requires weekly tests for staff, as well as for residents in facilities where there were recent cases.
But repeated testing of asymptomatic residents strained labs and exacerbated waits for results, said Bart Buxton, an executive at McLaren Health Care, a Michigan health system. Processing delays mean some residents were tested again before earlier results were in, he said. But providers have to keep up with guidelines regardless.
"You've got all of that on top of a pressured supply line, and you've got chaos," Buxton said. "We're leading through chaos."
The U.S. has performed more than 70 million COVID-19 tests, and is testing around 4.7 million per week, according to data from the COVID Tracking Project. That's down from a peak of more than 5.7 million in late July.
But to contain the virus, the U.S. should be testing many more. Ashish Jha, head of the Harvard Global Health Institute, told NPR in June that it would take 1 million tests a day to contain it, 4.3 million to suppress it. But supply shortages and challenges getting results quickly have hamstrung efforts to test more Americans.
There's a tension in deciding who should be tested when supplies are limited. Screening people, including those who have no known exposures or risks, can spot carriers of the virus and prevent them from spreading it. But doing large-scale surveillance testing can exacerbate bottlenecks at labs, delaying diagnoses.
With about 1.2 million Americans living in nursing homes, testing weekly would take up a quarter of the current number of weekly tests being performed.
Premier Inc., a large purchasing group that works with hospitals, nursing homes, and other medical providers, recommends combining testing with other prevention strategies and is advocating for federal funding to help facilities install electronic systems to better keep track who may be at risk.
"Blind testing of all nursing home residents regardless of risk factors is likely a waste of resources," said Soumi Saha, senior director of advocacy at Premier.
Pressure will likely increase as schools, colleges, and workplaces count on screening tests to bring people back safely, she said. "Scarce resources are only going to become worse as society returns to normal."
Early on, the lack of widespread testing allowed the virus to spread invisibly, blindsiding health officials. Since then, the country has sharply increased production of tests as well as the supplies required to perform them. But doctors warn there still isn't enough to do blanket surveillance.
So groups including the AMA urged the Trump administration this month to update guidelines "to ensure that the limited testing resources available are directed at those with a medically-indicated need for tests and those identified by well-defined public health surveillance efforts."
The CDC guidance shifted away from testing those who were in close contact with to a diagnosed case. But the AMA letter recommended that tests go first to people with symptoms, known exposures to COVID-19, or those who needed tests before medical procedures, citing the surge in demand from students, employees, and people seeking a clear test to travel.
"We simply do not have the resources to meet the huge demand for testing by asymptomatic individuals without exposure to COVID-19," the AMA wrote.
Weekly testing of the nation's 3.7 million teachers or 20 million college students would quickly outstrip capacity.
Yet some places are attempting to test at that pace. Undergraduates and grad students in Columbia University dorms, for example, will begin the semester with weekly surveillance testing, according to the university's plan. The University of Illinois at Urbana-Champaign aims to screen twice a week with a new saliva-based test it developed.
Testing plans are as rooted in what a group can afford as they are in anything else. Tests are being used "not necessarily according to the value of the information, but more often according to the ability to pay for these tests," said Blythe Adamson, an infectious disease epidemiologist and economist who serves as an adviser to the nonprofit Testing for America. The group is working with historically Black colleges and universities to help them use testing to safely reopen.
Lynn University hired CVS Health to test students and staff on campus in Boca Raton, Florida. The school of about 3,200 students will prioritize people who are showing symptoms or may have been exposed, said Chief Strategy and Technology Officer Christian Boniforti. Under the agreement, Lynn can do between 30 and 90 rapid tests a day, with the option for more as needed.
That colleges and other groups are using frequent testing for students who lack symptoms isn't "necessarily a negative thing," because it's something the rest of the country can learn from, said Wen, the former Baltimore health commissioner.
"Is this something that's effective? Can we actually rein in coronavirus this way?" she said. The aggressive testing of National Basketball Association players or by the University of Illinois may show whether it's a viable strategy to fight transmission, "especially if they're in places of widespread surge," Wen said.