On Wednesday, Dr. Sandhya Venugopal spoke on the phone with the family of a 70-year-old patient who was coughing and had had a fever for three weeks.
Take him to the emergency room, Venugopal, an internist with a private practice in Phoenix, told the family. Don’t bring him to my office.
Without testing, she had no way of knowing what illness the man had. Maybe it was a form of the flu, or an infection of some sort. Or, maybe it was the new coronavirus, COVID-19, which is more deadly than the flu, especially for the elderly, and which to date has killed 4,613 people around the world and infected at least 125,000.
If it happened to be the new coronavirus, Venugopal couldn’t risk seeing him in person or having him in her clinic.
And even if she had brought him in, she had no way of testing him, despite the fact that commercial labs have, with considerable fanfare, announced expanded COVID-19 testing in the last week.
Those laboratories are supposed to increase the limited testing capacity of state and federal laboratories, which must follow strict guidelines issued by the federal Centers for Disease Control and Prevention, which allows government labs to conduct COVID-19 testing for a select few.
The parameters are so strict, doctors and public health experts say, because the government has so few tests that it must ration them, saving them for the people with the worst symptoms.
Under the CDC's specifications, those who qualify for COVID-19 testing by government laboratories must have symptoms, like a fever and respiratory symptoms, and must also either have had contact with a person confirmed to have COVID-19, or must have traveled to an affected area. Or, they must have symptoms so severe that the person has to be hospitalized, with other illnesses ruled out and no obvious source of exposure to the virus.
In health official parlance, these people are known as Persons Under Investigation, or PUIs. As long as the number of PUIs remains low, state labs can handle them. Arizona's own state laboratory can process a maximum of 450 samples a day.“There may be cases in the community that are undetected.” - Chris Minnick, spokesperson for the Arizona Department of Health Services
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But not everyone with COVID-19 has symptoms. People who actually have the virus might not qualify as a test-worthy PUI — and thus could be unintentionally spreading the virus. The Maricopa County Department of Public Health acknowledged this gap in its latest guidance on testing, which directed doctors and nurses to commercial laboratories “for patients who do not meet PUI criteria.”
On March 5, a company called LabCorp began offering commercial COVID-19 testing. On Tuesday, Sonora Quest, the state’s largest clinical laboratory network and a subsidiary of Quest Diagnostics, did too.
LabCorp’s criteria for testing patients are more expansive than the CDC’s. The company directs doctors, nurses, and other health care providers to CDC guidance, allowing them to “consider COVID-19 testing for a wider group of symptomatic patients.”
But Sonora Quest’s criteria are no broader than the CDC’s, which means it won't actually expand testing to more people. Its guidance for health care providers says that the test “is to be performed only using respiratory specimens collected from individuals who meet CDC clinical and/or epidemiological criteria for COVID-19 testing.”
“These are the same guidelines that are being recommended for state and federal labs,” Dr. Brian Koeneman, Sonora Quest's clinical director of molecular diagnostics, confirmed.
Not Practical to Test
In practice, commercial testing has not made made COVID-19 more accessible in Arizona, experiences of doctors and patients show. Hospitals do not appear to be offering testing to a broader swath of patients than the CDC allows. Doctors are ill-equipped to take nose or throat swabs from potentially infected patients to send to commercial labs for testing.
Commercial laboratories themselves, like LabCorp and Sonora Quest, won’t collect those specimens directly from patients, saying that doctors or health care professionals have to take them instead — which Venugopal said most doctors cannot do.
“It’s not practical for doctors to do it in their offices at this point,” Venugopal told Phoenix New Times by phone. “The practicality, or impracticality, of testing … is not allowing us to test.”
To take specimens from people who might have COVID-19, doctors or other health care providers should don masks, gowns, head gear, goggles, gloves, and other personal protective equipment, the CDC recommends. In enclosed spaces like doctor’s offices, they have to bring the patient to an isolation room, which is kept at negative pressure so that air is continually pulled out of the room and filtered before it is recirculated, to limit the spread of pathogens.
Venugopal’s practice doesn’t have an isolation room, so she screens patients via telemedicine, and if they’re sick enough to warrant testing, she sends them to urgent care centers or the emergency room.
If people have only mild symptoms, she tells them to go home and self-quarantine for 14 days, because they won’t meet the CDC’s stringent criteria for testing anyway, unless they happened to have traveled to an affected area or were exposed to a person who tested positive.
These people may or may not have COVID-19 — people can have COVID-19-like symptoms, like a fever or a cough, for any number of reasons — but because they can’t get tested, the only practical option is to send them home to recuperate and hope they don’t infect others.“It’s not practical for doctors to [collect COVID-19 samples for testing] in their offices at this point,” Dr. Sandhya Venugopal
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And if those mildly sick patients aren’t better in five to seven days, they should go to the hospital, Venugopal tells them. She tells them to go Abrazo, which, she said, told doctors last week that it could do COVID-19 testing.
Keith Jones, a spokesperson for Abrazo, which operates a half-dozen hospitals in the Valley, told New Times that the hospital was testing patients who met the CDC’s criteria for COVID-19 testing and sending samples to CDC-appointed laboratories. He was unable to answer questions about whether tests had been or would be sent to commercial labs.
“We just follow CDC guidelines for identification and treatment of patients with suspected or confirmed cases of coronavirus,” Jones said.
Asked whether the hospital had sent any tests to commercial labs, he said, “You know, we follow what the latest guidelines are.”
A spokesperson for NextCare, which operates more than 40 urgent care centers around the Valley, did not respond to a question from New Times about COVID-19 testing at its clinics.
Venugopal said she was seriously concerned that COVID-19 cases are being undercounted, because “we’re rationing the tests for the really sick people.”
'We Cannot Give You the Test'
Johnny Carey, a resident of Peoria, said Friday that he had been sick for five days with some kind of virus — his eyes were bloodshot, and this morning he had a fever over 101 degrees Fahrenheit — and that his 5-year-old son, who is autistic, has been sick for the past five weeks with a slew of illnesses: flu, a sinus infection, strep throat, conjunctivitis, and an ear infection.Earlier this week, about 40 minutes after he put his son on the transport van to school, Carey got a phone call from the driver, saying he had to bring his son back, because a staff member at the school had had “some level of exposure to the coronavirus,” Carey recalled the driver saying.
With his son’s immune system clearly compromised, and Carey feeling ill himself, he called a nearby hospital, Banner Estrella, in west Phoenix. On Thursday morning, he brought his son to the emergency room, where staff met them at the door and escorted them to a secure room. There, both Carey and his son were tested for influenza A and B, Carey said.
“They said if the test came back negative that they would be very happy to test us for COVID,” he said. The flu tests came back negative, and so the doctors swabbed them for the new coronavirus. But shortly after, a hospital staffer told them that because the CDC had no confirmed reports of a staff member at the school being exposed to or confirmed to have the coronavirus, Carey and his son could not be tested.
“‘The CDC is refusing permission for us to test you,’” Carey recalled her saying. “‘We cannot give you the test without their permission.’”
No one at the hospital mentioned anything to him about commercial testing, he said, even though Carey was at the hospital a week after LabCorp announced that would offer offering testing.
Carey reserved his disgust for the CDC, not the hospital, he emphasized.
“I just was angry that the CDC has the right to say, ‘We’re not going to test you,’” he said, even when Carey’s son, who has been sick for more than a month, might have been exposed to the new coronavirus.
Hospital staff promised to stay in touch, saying that if they did learn that someone at the school had tested positive for COVID-19, they would immediately bring Carey and his son back for testing.
Until then, “we were to go home, stay home, and wait,” Carey said. “Because there was nothing else that they could do.”
He wasn’t immediately billed for the hospital visit, but he worried that it might end up costing hundreds of dollars. Carey also wants to return soon to his job in retail. All of the anxiety and fears that he or his son might have coronavirus could be easily alleviated, if only they could be tested.
“I’m not trying to create panic or hysteria,” Carey said. “I just want to be tested.”
A spoksperson for Banner Health, Becky Armendariz, said that she was "unable to provide specific details" in response to New Times' questions about who could get tested for COVID-19 at Banner hospitals, how many tests it had completed, and how many COVID-19 tests patients had requested.
She said that the network's primary care clinics were equipped to test for the virus "if patients meet CDC criteria for testing," but she could not say whether Banner facilities were sending samples to commercial laboratories, like LabCorp and Sonora Quest.
"I will have more information to share about our testing process on Monday," Armendariz said.
Fewer Tests, Fewer Known Cases
South Korea has created a vaunted drive-thru testing system for COVID-19 that can test up to 15,000 people per day and so far has tested 250,000. The country has tested people at a rate of 3,600 tests per million people. In the U.S., the ratio is five tests per million people. Some cities in California, Colorado, New York, Pennsylvania, and Washington are just starting to offer drive-up testing.
It is a much different story here in Arizona. Nine people are known to have been infected with the novel coronavirus to date. Only 143 people have been tested.
Venugopal said she was seriously concerned that because of the lack of testing, COVID-19 cases are being undercounted and that people who have the virus but aren't symptomatic could be infecting those around them.
Former and current state officials agree.
“Right now, there’s not enough tests to go around,” said Will Humble, a former director of the Arizona Department of Health and now the head of the Arizona Public Health Association. Without testing, he added, “you don’t know who’s positive.”
Because not all people who have COVID-19 show symptoms, or have only mild ones, “there may be cases in the community that are undetected,” said Chris Minnick, spokesperson for the Arizona Department of Health Services.
Contrary to what doctors, patients, and labs have told New Times, commercial testing has rolled out smoothly in Arizona, according to the health department.
“There has been quick implementation and availability of commercial laboratory tests for COVID-19 in Arizona,” Minnick said. “Testing at the Arizona State Public Health Laboratory is conducted based on specific testing criteria. We are not aware of similar restrictions for testing at commercial laboratories.”
Sonora Quest can’t yet say how many people it can test, how many tests it has received so far, or how many people it expects to qualify for or need testing Arizona — or whether it can meet the need.
“We are just beginning to understand the demand for testing,” said Koeneman, the lab's clinical director of molecular diagnostics. “Given the short timeframe that this testing has been available, we are closely monitoring the volume of tests and we are working all angles to ensure we are prepared to meet an increased demand.”
The Mayo Clinic, in Scottsdale, has in-house tests available only for its own patients, spokesperson Jim McVeigh told New Times by phone. He said he did not know how many tests were available. He asked New Times to send specific questions via email, then did not respond to those.
The dearth and slow pace of testing by state and federal health agencies, combined with stringent qualifications to be tested in the first place, has contributed to mounting criticism of the federal government’s slow response to the crisis.
It wasn’t until February 29, five weeks after the first coronavirus case was confirmed in the U.S., that the Food and Drug Administration created a policy to open up testing to certain commercial and academic labs in the United States. And it wasn’t until early March that Arizona became able to process its own coronavirus tests in state, rather than sending them to the CDC.
