Answering Your Questions About How To Get A COVID-19 Test

Stan Bunger
May 26, 2020 - 3:23 pm

    As we continue to navigate these unprecedented times, KCBS Radio is getting the answers to your questions about the coronavirus pandemic. Every morning at 9:20 a.m. Monday-Friday we're doing an "Ask An Expert" segment with a focus on a different aspect of this situation each day.

    Today we're talking about testing with Dr. Jocelyn Freeman Garrick, Alameda County's director of coronavirus testing.

    For everybody in the medical world, I'm just fascinated to ask you: six months ago, a year ago you were doing something totally different, I'm sure and never saw this on the horizon.

    Not at all. I was just a regular emergency medicine physician working in emergency medical services for Alameda County and now I have a whole new role, as you state. So it's impacting everyone; my family, you, our friends and definitely my job.

    As far as testing, do you think we're at a situation right now where people are aware of the options, are able to get to it and so on? Or do we have a ways to go?

    I think what your question addresses is communication and sharing of information as well as testing availability. I think that people are starting to become more aware through their providers as well as the community testing opportunities of the testing options that are out there, but I do think we could do a better job. Which is why I appreciate being on this radio show to spread the word that in the Bay Area, all of our counties are offering testing whether it's through your provider or through a community testing site that offers it for free, with a focus on our essential workers, our first responders, our frontline workers and those who are symptomatic. 

    But when we say testing, what do you mean? We could be talking about the PCR RNA antigen test, or are we talking about antibody testing? And that's where it also causes some confusion and it changes from week to week. Some centers are considering antibody testing but we are not. We are waiting for antibody tests in Alameda County that have enough sensitivity and specificity - with a disease like COVID that has low prevalence - to give us a true presence of immunity or antibodies that we want to test. And right now, we're waiting for that antibody test that has more than 99% specificity and more than 97% sensitivity.

    And let me ask you because again, these terms confuse people who don't have "M.D." after their names, what do we mean when we say sensitivity and specificity?

    It means that if you really have it, it tests positive and if you really do not have it, it tests negative. So we have false negatives and false positives with a lot of the tests and we're trying to not say, "you have COVID" when you really don't, or "you have antibodies" when you really don't.

    And is the state of the science right now such that the antibody tests are more likely to have this issue in terms of false positives and negatives than the tests for the virus itself? Is that fair to say?

    Yes, it is.

    Let's get to these questions, which have been sent in to askus@kcbsradio.com. How often should someone get tested? What is the best test to take?

    If you want to get tested for COVID, you should get the PCR antigen test which most of our sites are offering. If you have symptoms, if you are at risk for symptoms because you're over the age of 65 or you may be immunocompromised, if you have a chronic medical disease like diabetes or hypertension, if you have cancer and you're on chemotherapy, your providers are likely recommending that you get tested. And then we are encouraging all of our frontline workers, our essential workers and healthcare workers to get tested.

    How often, the second part of that question is a challenge. Should you get tested every few weeks? Should you wait to see if you have symptoms? Right now, for example, in our long term care facilities the state has requested that all staff who are working with individuals who are high risk like in our skilled nursing facilities get tested every week. If you are an essential worker who drives for Uber and you are practicing safe practices for infection control like wearing your mask and limiting your contact with the public, then getting tested once is likely sufficient. If anyone develops symptoms they need to get tested.

    How long does it take, once you've been exposed to the virus, for an accurately positive test to be possible? Whether you're asymptomatic or symptomatic (I think this is called the incubation period)?

    That's a good question. Thankfully that incubation period is from the time you're exposed to the virus to when you develop symptoms. You usually don't have symptoms the day you were exposed to the virus. So if you think you've been around someone or they confirm, "I'm COVID positive" and they live with you and you enter that home for the first time, on Day One it is likely that the test will not be positive. If you wait until you develop symptoms or if you have a high risk exposure and wait for 48-72 hours, that is a better time to get tested - waiting for two to three days after exposure. 

    I was around a lot of people recently and I'm wondering how long I should wait to try to get tested.

    I have a question for the person who wrote that: who were they around? Though we are relaxing some of the sheltering in place restrictions, we're still encouraging that there's no mixing of households. If you had to be around people because you are an essential worker, then I understand that you may be concerned and want to get tested. So you can wait as we said two to three days after that exposure. But if you're an essential worker, frontline worker, healthcare worker you should get tested. But I'm encouraging that there's no mixing of households. It was beautiful this weekend, a lot of people were out at the beach. Hopefully they were wearing their masks and still practicing social distancing. That should still be occurring. 

    Which type of COVID-19 testing is more useful; nasal or antibody testing? The nasal testing, to me, only shows present state of the person and may require periodic re-tests whereas the antibody test indicates whether the person has been infected and may now have some sort of immunity. It may also show how widespread the disease is.

    That listener is correct, but it does allow me to elaborate that the nasal or antigen testing, when they put the swab in your nose is to check if you have it right now. Those questions prior saying, "should I keep getting tested?" because you don't know if you tested negative the first time, you may be exposed thereafter. This is the ongoing question: how often should you get tested if you are constantly interfacing with the public. So yes, it's just a one time test, today you're negative. Once you're positive though, unless you are hospitalized and going into another congregant setting, you don't need to get tested again. The antibody test will hopefully equate with immunity or show that you've been exposed.

    Summit Hospital in Oakland postponed my cancer surgery because I can’t do their coronavirus test due to a deviated septum on one side and they need to use that side in the test, or both sides, I was told. Santa Clara County announced last week that they have a short Q-tip swab that people can insert just inside their own nose (not down the back of their nasal passage), which is a valid test. Why can’t we have this type of test in Alameda County for people like me, at-risk?

    So this question is getting to that nasopharyngeal test. There's a longer Q-tip or a shorter Q-tip. The longer Q-tip is the one that had the better sensitivity and specificity when we first were able to test more broadly. The mid-terminate, or short Q-tip, just goes in the tip of your nose, it doesn't have to go all the way. Those were recently found to be just as good so they're releasing more of the mid-terminate swabs. I do believe those are starting to get introduced in our county, I would have to confirm. I do know for our community testing sites we are going to be switching to the mid-terminates in the next couple of weeks. So, I'm sorry that listener wasn't able to get their procedure but I do think shortly they will be able to get that mid-terminate or short Q-tip swab soon.

    And let me just toss in here: what about the ones we've been hearing about that could use saliva?

    So the saliva tests are also another option. Same principle, sensitivity and specificity initially weren't that good. They are better now with lower false positives and false negatives. So I anticipate this summer we'll also be seeing more of the saliva tests.

    I have been sheltering in place since March 16th. I am 62, diabetic type two with high blood pressure. My work is asking if I will be returning to my job as a receptionist at a veterinary hospital on June 1st. I don't know if I should return. Should I get tested? I would like to get an antibody test. I came back from a trip to Thailand in January where I got sick on the 4th; respiratory, deep coughing lasting for several weeks and continued to work after returning from the trip.

    That listener should contact their physician and see if they have access to a high sensitivity antibody test. There is a clinical trial that's occurring; one in Southern California, one in Northern California. I think UC San Francisco is trying to validate the antibody test that we hope to use. If not, if that listener has been sheltering, they haven't been interfacing with the public I don't recommend getting a COVID test now if they don't have symptoms. If they return to work, I would absolutely use a face covering and hand sanitizer and frequent hand washing. But I think that person's provider can advise them better.

    Do you have any data on where people are getting tested? In other words, big cities versus suburbs, neighborhood by neighborhood, etc?

    We do for Alameda County, and I believe all of our neighboring counties offer similar information. If you go to acphd.org, "Alameda County Public Health Department" or just google that, on the front page under "COVID" if you click the "COVID" link, "where can I get tested?" should be a link and it'll show you all of the private insurers that are offering testing as well as our free community testing sites.

    Is there any way to get both tests at the same time? The one that tells me if I have the virus and the one that show if I have the antibodies?

    I haven't heard of that Stan. I do know it's one or the other. We may move to that, but I haven't heard of getting both tests at the same time.

    Will you please tease out the benefits of individual testing to develop a community understanding of virus activity/presence?

    I think that question is asking, "why are we doing the PCR testing?" And that's to establish prevalence of the disease in our community, as well as identify those at risk who need to isolate and quarantine to control the virus. And then those who are at higher risk for complications, the ones who end up hospitalized and unfortunately require ventilatory support, to prevent death. So the more we test early and identify those who may, two to three weeks later, develop complications - if we can identify them early we can provide treatment sooner to help prevent some of those complications.

    And then Governor Newsom did outline with his six indicators for reopening the state that testing is one of those indicators. So the more we test, the more we can determine how many of our citizens have been exposed to and have the virus, which helps them with planning and modeling.

    That kind of leads into this next question: maybe your expert can help me understand because I'm confused. We keep hearing that we have to have more testing before we can move ahead with reopening, but if the only people getting tested are the ones who are sick or think they might have been exposed, how are we going to have more testing?

    So we have expanded the testing guidelines. And I know it's confusing, it's confusing for me as well. All of the clinicians and everyone who's involved in this is learning something new with this SARS-CoV-2 that we've never seen. But our public health professionals and the modeling shows that we can predict based on data, so we need more data. We have tested a paucity of people in our community, so we at least need to test about 150 people per 100,000. And if your listeners google, "the German Model", Germany has led with testing in the world and they've been able to safely reopen their economy effectively. But their researchers show that they tested about 152 people per 100,000. 

    So that's what we are using in the state of California and locally here in our county. So for us to do that, we need to test 3,100 people a day. To reach that goal, we have to test where they're hardest hit. We have over 3,800 residents of long term care facilities, so we have to test in that population. We're hoping to test, as I've said multiple times, anyone with symptoms, anyone who's an essential worker, anyone who's a frontline worker, a healthcare worker. And we have a lot of those individuals, whether they are symptomatic or asymptomatic, who have not been tested. If those people get tested at their community testing sites or with their providers in addition to testing the people in our long term care facilities who we know are at high risk, in addition to testing people who are high risk in hospitals and clinics with symptoms, we can reach our goal. So that's the three-pronged strategy based on population approach that we're trying to employ now.

    Why does Berkeley lag so far behind other places in testing? The few places we have are far from where I live and are so restricted that I would not qualify even though I am over 65 with pre-existing conditions, though no symptoms. I want to know if I ever had it, was exposed or am a "silent carrier".

    I do know that Berkeley is doing a great job with outreach, and their numbers for mortality and morbidity remain low. I can't comment on what their testing criteria is, but if that citizen lives in Berkeley and they are over the age of 65 with co-morbid conditions, they can get tested at any of the Alameda County community testing sites. 

    Roche test for antibodies has 97% sensitivity and 100% specificity - I'm not sure about those numbers but that's the question here - how come you're not using this test?

    I believe that is the test, the Roche antibody that UC San Francisco is trying to validate. So we are hoping that that is accurate and then we will eventually have antibody tests like that one that we can use.

    I'm having surgery next week, should I get tested either before or after?

    Their surgeon will recommend whether they should get testing. Most of the outpatient procedures are getting patients COVID testing prior to the procedure.

    How can someone get antibody testing in Alameda County? My mom had symptoms of coronavirus in early March, has since recovered. She also has cancer and has been quarantining at home for months. We'd love to know if she's already had the virus and recovered and could more safely leave the house.

    Yeah I understand the angst around all of that, with a father who also had malignancy and hasn't been tested. We currently are not doing antibody testing through the county's public health department. They would have to research on their own. I would just caution, you want to ensure that it's a test that really gives you a true positive or true negative.

    And do we know at this point what the real story is around immunity and antibodies?

    No, unfortunately. We've never seen this before, so this is what everybody is discussing and debating. If you get an antibody test that's positive, they're not sure until the fall or winter when we get exposed again to the virus or if you get exposed later if that equates with immunity and that you will not either have COVID as severe or develop symptoms that lead to complications. So we're not at a place where we can say, "oh you had it so you can re-enter in the community, we have 60-70% herd immunity." We still have to gather data and see what that means. So that's why in Southern California and many other major academic institutions, those who have had documented COVID, they're asking them to participate and give their blood to evaluate for antibodies and see in the lab if those antibodies are showing some type of immunity.

    Can a 12-year-old be tested? My grandson will be returning home from a two month stay in Denver.

    Yes, and in Alameda County, UCSF Benioff Children's Hospital Oakland is a pediatric testing site and a lot of the other community testing sites do test children. Your child's pediatrician can arrange for testing with you if you need it as well.

    I'm confused: if I don't have any symptoms, should I get a test? And if so, who pays for it?

    If you don't have any symptoms and you are not any of those populations I talked about - a healthcare worker, an essential worker, a frontline worker - if you've been isolating appropriately at home, you're 42 years old with no medical problems, it's not recommended that you get tested. If you meet any of those testing criteria though where they want you to get tested, you can go to the Alameda County Public Health Department website if you don't have a provider who can offer it to you and go to one of the free community testing sites that are available throughout the county.

    I know this is an area of concern for a lot of people: the question of cost. Do we know what's happening on the insurance side? How's that working?

    Yes, so they do ask for insurance. For example, I'll just comment on the free community testing sites they do ask you for your insurance and bill your insurer. But if you do not have insurance then they are trying to retrieve FEMA disaster funds to get reimbursement for the testing.

    So before I let you go Doctor, what's the best resource you can give our audience no matter where they're listening in the Bay Area for where they should look online, or a phone number or something that will give them a place to start? Because this is confusing stuff.

    Stan, if I knew that then I would have $100 million. (laughs)

    See, I knew I'd get one in there you couldn't answer.

    Come on, now. It's all over the place. Most clinicians go to Johns Hopkins' website for statistics if you want to see the impact across the world. The New York Times, for laypeople, I think has great information everyday. They do a COVID update and you can sign on right now, they're offering it for free so you don't have to have a subscription. But they have COVID updates for laypeople that I think are well-researched and well-informed.

    And then in terms of testing here in the Bay Area, if you want to know where you can go or if you even can go?

    ACPHD.org. Please go to the testing link under "COVID" that I referenced and they'll show you map of the testing sites as well as additional resources for food and shelter, which we haven't talked about. So all of that is available on the Alameda County Public Health Department website.