Expert Insight from Dr. Nicole Lurie: The State of COVID-19 Testing

Regulation | April 28, 2020 | by Gene Mitchell

Former HHS Official Offers LeadingAge Members Sobering Thoughts on Testing

On April 23, Dr. Nicole Lurie was a guest on the LeadingAge Daily Coronavirus Member Update, offering sobering thoughts about the state of testing for COVID-19.

Lurie, who served as assistant secretary for preparedness and response at the U.S. Department of Health and Human Services from 2009-15, is now leading the COVID incident management team for the Coalition for Epidemic Preparedness Initiatives (CEPI).

She began her discussion with LeadingAge members by calling the testing situation “an incredible morass right now.” She went on to detail two different categories of tests, and how our country reached the current state of infection.

Tests to Detect Current Infections

There are more than 100 “antigen detection tests” now on the market. Lurie believes these tests, which detect whether a person has those “building blocks of infection,” are generally reliable, showing false negative and false positive rates of 2-7%. Reliability can be affected by the population they are used with, and the method of gathering specimens.

The best specimen test is from the nasal pharynx, as Lurie describes it, “way up somebody's nose and into the back of their throat.” Close behind that for accuracy, she says, are swabbing of the nose and getting saliva.

The FDA just approved self-swabbing, which means health care workers could swab themselves at home. She cautioned that different labs work on different turnaround times, and some labs can electronically transmit results to a local health department or the CDC.

Tests will perform differently with different populations—one of the reasons Lurie says doctors are careful about avoiding unnecessary tests. A consequence of these variations, she warns, is that it is possible for a symptomatic person to show a negative COVID-19 test. She advises treating such cases as though they are infected, despite the test results.

On the question of day-to-day screening of health care workers or residents, she pointed out the limitations of fever screening, noting that older people often do not develop fevers. She cited a new study, showing that in New York City, 70% of people sick enough to be admitted to the hospital with COVID-19 did not have fevers. She thinks pulse oximetry might offer valuable information but admits there is not yet good data to support that screening option.

Tests to Detect Antibodies

“In general, when you come through an infection and you develop antibodies, you're immune for some period of time,” she says. “However, we don't know enough yet about this disease to know if you're immune, and for how long. We are making some assumptions that like most other diseases, you have immunity for at least some time.”

For this reason, Lurie recommended great caution about the second type of testing—those designed to detect antibodies. Of the 90 antibody tests on the market today, only a few have been authorized under emergency use by the FDA. She believes many of these unvetted tests can produce false negatives and positives to an unknown degree.

“The idea that we have lots and lots of people with immunity who are just ready to go back to work is an idea I want to disabuse you of,” said Lurie. She is hopeful the situation will improve in the coming months, but pointed out that many labs are facing shortages of materials for performing tests, which can become a serious limitation to their capacities.

Why Are We So Unprepared?

Lurie believes national and state leadership was slow to recognize the crisis, and slow to do anything about it.

“Had we started on January 7, testing, screening, surging the production of personal protective equipment, activating our contracts to make more ventilators and buy them […] we would be in such a different place than we are now,” she says.

There was, she says, “a very comprehensive playbook and checklists about what you do at every step. And I think it's fair to say it was disregarded. It's also fair to say that where the federal government has really fallen down, a number of states have stepped up, and […] there are some terrific governors on both sides of the aisle that have used all the principles of crisis leadership, they've put somebody in charge, they've communicated clearly, and have acted decisively on behalf of their public. Many of them took early action. And they're doing really well.”

“It doesn't really track with political party, but it does tell you that leadership and decision-making are really important. You can have the best plan in the world and without that you will fail.”

We recommend listening to Lurie’s presentation in this recording of the LeadingAge Daily Member Update, beginning at the 3:14 mark.