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November 6, 2020

First It Was Masks; Now Some Refuse Testing for SARS-CoV-2

JAMA. 2020;324(20):2015-2016. doi:10.1001/jama.2020.22003

At a September webinar entitled, “Until We Have a COVID-19 Vaccine,” epidemiologist Michael Osterholm, PhD, MPH, expressed concerns about insufficient testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the US.

The problem has morphed from inadequate testing capacity to inadequate numbers of people agreeing to be tested, said Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

In the pandemic’s early weeks, when a shortage of tests meant that mainly hospitalized patients were being tested, the demand was greater than the supply. Months later, laboratories have greater testing capacity, but in some states, testing rates have dropped as cases have increased.

Test avoidance appears to be a growing problem, at least anecdotally. Many of the same people who dismiss the need to test feel the same way about wearing a mask, in part because they think no one has the right to tell them to do either.

“There are challenges with the messaging, from the top to the bottom,” said Charity Menefee, MA, director of communicable and environmental disease and emergency preparedness at the Knox County Health Department in Tennessee. “The [pandemic] fatigue has set in; the politics have gotten more intense.”

How Much Testing Is Enough?

Testing is a key component of contact tracing, and only testing can reveal whether flulike symptoms are due to influenza or to the much more contagious and deadly SARS-CoV-2.

But most states aren’t performing enough tests, as evidenced by their 7-day average positivity rates, according to the Johns Hopkins Testing Tracker. As of October 23, only 16 states and the District of Columbia had a positivity rate of 5% or lower, which the World Health Organization has said jurisdictions should achieve for at least 14 days before reopening.

Not only does a positivity rate of more than 5% suggest greater community transmission, it also “indicates a state may only be testing the sickest patients who seek out medical care and is not casting a wide enough net to identify milder cases and track outbreaks,” the tracker’s website notes.

Apparently, that’s a difficult concept to grasp for some people, including the governor of Missouri. Missouri’s 7-day average positivity rate reached an all-time high of 18.3% on October 16, a record that Republican Governor Mike Parson mistakenly attributed to increased testing, echoing similar assertions by President Donald Trump and Vice President Mike Pence.

“We went from like 2,000 tests a week to 125,000,” Parson explained to a St Louis television station.

Test Anxiety

Some states might have a higher positivity rate in part because they still lack the capacity to test residents with mild or no symptoms, but some jurisdictions are waiting with open arms for more such individuals to show up for testing.

Take Knox County, population approximately 470 000, in which Knoxville, Tennessee, and the flagship campus of the University of Tennessee (UT) system are located. At its peak, the Knox County Health Department was testing 500 to 600 people a day, Director Martha Buchanan, MD, said in an interview. By mid-October, though, that number had dropped to 200 or so a day, she said. Meanwhile, Knox County’s hospitalizations for COVID-19 had risen to an all-time high, and the average daily positivity rate for the week ending October 19 was 12.75%.

The decline in testing extends beyond the health department, which, Buchanan said, conducts only about 15% of SARS-CoV-2 tests performed in Knox County. In early August, total weekly tests surpassed 10 000 but fell below that for the next 2 months, said Deborah Crouse, a spokeswoman for the Knox County COVID-19 Joint Information Center. By the last week in October, though, it appeared that the county was heading back up to around 10 000 weekly tests, thanks to public health messaging about the importance of testing, Crouse said in an email.

In her weekly livestream briefing October 16, UT Chancellor Donde Plowman, PhD, noted that students who live on campus are required to provide saliva samples if the school notifies them that they need to be tested. And yet, she said, participation for the week had dropped to around 48%, down from nearly 65% the previous week. At a Knox County Board of Health meeting September 30, Plowman talked about a “huge” reduction in the number of students’ requests for testing through the Student Health Center.

“It really gets down to the fear of isolation and quarantine,” Menefee said. Athletes don’t want to risk testing positive and keeping their whole team off the playing field, she said. “We’ve been hearing more and more of that.”

Likewise, parents of students at New York City Jewish schools in September circulated social media posts that advised keeping sick children home but not testing them for SARS-CoV-2 because the city health department had announced it would close schools if 2 or more students tested positive.

“We encourage all New Yorkers to get tested and have worked to ensure that message is received through social media, community-based partners, local providers and other channels,” a spokesman for the New York City Department of Health and Mental Hygiene said in a statement provided to JAMA. The spokesman noted that many of the Jewish schools still had to close for at least 2 weeks in October because they’re located in COVID-19 hotspots.

In Utah, a Republican state lawmaker who is among a growing number in the state declaring they won’t get tested for coronavirus disease 2019 (COVID-19), recently told The Salt Lake Tribune that he worried a positive test would put him “on the radar.” “The health department doesn’t need to know if I’m sick or not,” Mark Strong said.

But, of course, the health department does need to know whether Strong or anyone else is infected with SARS-CoV-2. “It’s critical for people to get tested, and for those who are positive to isolate,” Pennsylvania Health Secretary Rachel Levine, MD, president of the Association of State and Territorial Health Officials (ASTHO), said in an interview.

That need to isolate if positive might be why some working adults avoid getting tested, said Marcus Plescia, MD, MPH, ASTHO chief medical officer. They can’t afford to stay home from work, as recommended by the US Centers for Disease Control and Prevention (CDC).

“We have to deal with some of these disincentives, and also just make it fair,” Plescia said in an interview. “We have to make the health choice the easy choice. I don’t think we have.”

In addition, while COVID-19 doesn’t carry a stigma like several other infectious diseases, some individuals still feel embarrassed if they test positive, Plescia said. They think, “I might have infected all kinds of people I might have come in contact with,” he explained. On the other hand, “if you don’t get tested, you don’t know.”

A Question of Autonomy

One of the arguments against testing is the same as one made against wearing masks. As a 65-year-old Utah woman, a member of the far-right Constitution Party, proclaimed to The Salt Lake Tribune, “I will not get tested [for SARS-CoV-2]. That’s my right.”

Bioethicist Arthur Caplan, PhD, would beg to disagree. “What we don’t need is people playing politics with testing,” Caplan, founding head of the Division of Medical Ethics at the NYU School of Medicine, said in an interview. “Ethically, it’s hollow. It doesn’t make sense.”

But in early October, several Republican senators, including Iowa’s 87-year-old Chuck Grassley, declined to be tested, even though 3 of their colleagues had positive test results for SARS-CoV-2 and might have infected them. At least one observer speculated that Grassley and the other senators who might have been exposed to SARS-CoV-2 avoided testing because they didn’t want to set back Amy Coney Barrett’s nomination to the US Supreme Court.

Caplan cited a quote often attributed to the philosopher John Stuart Mill, although its origins are murky. It goes something like “your liberty to swing your fist ends just where my nose begins.”

The Equal Employment Opportunity Commission (EEOC) agrees. Employers can mandate that employees be tested for SARS-CoV-2 before allowing them in the workplace, as long as it’s consistent with CDC guidelines. Such testing meets the Americans with Disabilities Act’s “business necessity” standard, according to the EEOC.

A recent article by UK clinical geneticists described refusal to be tested for SARS-CoV-2 as “an emergent ethicolegal issue.” Although patient autonomy is “a key pillar of medical ethics,” in exceptional circumstances, such as a serious infectious disease pandemic, autonomy is overridden by competing interests, the authors wrote.

Patients who refuse preoperative SARS-CoV-2 testing put themselves and health care workers at risk, notes a statement from the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation. If patients refuse to be tested, the ASA recommends delaying procedures until they agree to be tested and have negative results or, if they’ve had symptoms suggestive of COVID-19, are asymptomatic for at least 10 days.

Claiming that people need to mind their own business when it comes to refusing SARS-CoV-2 testing is “morally repugnant,” Caplan said. “Of course it’s other people’s business. You’re testing not just for yourself, but for your grandmother, and your elderly neighbor, and your immune-compromised kids.”

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    6 Comments for this article
    People in Prison Who Refuse Testing
    Kelsey Kauffman, Ed.D (Harvard); B.A. Yale | Constructing Our Future
    One crucial population that is reluctant to be tested but is not mentioned in the article are the 2.3 million people in our nation's 5,000 jails, state and federal prisons, and ICE detention centers. People in prison who are asymptomatic often have far greater incentive not to be tested than college students or athletes. They risk being put in solitary confinement or warehoused with others who are very ill. One prison in Indiana recently had a large outbreak with 100 sick men placed in a converted warehouse reportedly with one toilet, one water fountain, and one portable shower for everyone, and a Tylenol per person twice a day. The stakes are greatest in prisons where testing is very limited or non-existent until a large number of people are already sick.

    The Indiana Dept. of Correction (with which I am most familiar) has tolerated very high positivity rates since the beginning of the pandemic. If we don’t count the men's and women's intake units (where everyone is tested on arrival), the weekly test positivity rate for adult prisons was above 50% until August (1). It did not fall below 30% until the end of October when it was 28%.

    Some prisons are much worse than others (1,2). For example, by the end of October in Indiana:

    o Plainfield prison, where 8 men have died, has a cumulative test positivity rate of 82%.

    o New Castle, a privately-operated prison holding state prisoners, has seen 8 men die in the past month alone, with 121 positive cases; yet its test positivity rate during that time has never dropped below 35%.

    o Over the past 3 months, Putnamville has had 197 positive cases, with a weekly test positivity rate of 22%. For the four months before that large outbreak, the test positivity rate at Putnamville was greater than 50%.

    o At Pendleton Reformatory, which saw a large outbreak and four deaths in May, the test positivity rate did not fall below 58% until mid-October. (In contrast, the prison next door, CIF, which has had no cases, had tested more men by mid-October than Pendleton had.)

    o At the Indiana Women’s Prison, which currently has a large outbreak, the test positivity rate during the outbreak has averaged 37%.

    Indiana is not atypical.

    The very high positivity rates in prisons are probably more the result of resistance on the part of prison officials to testing people whose lives matter little than to reluctance on the part of asymptomatic people to be tested, but both reasons need to be addressed. (The reluctance on the part of officials to test no doubt predominated at the beginning of the pandemic and may diminish further post-election; the reluctance to be tested, on the other hand, seems to be rising.) In any case, state and federal governments need to (1) drastically and immediately reduce the number of people in prison, including everyone who has served more than half their time and has less than 12 months to serve (about 20% of the prison population in Indiana); (2) bring prison test positivity rates below 3% and then begin testing sewage and taking other measures to keep the rate low; (3) start treating people humanely who do test positive so that those who are asymptomatic don't refuse to be tested.

    Kelsey Kauffman, Ed.D
    Founder, Director Emeritus
    Higher Education Program
    Indiana Women's Prison

    Alex Roehrkasse, PhD (no conflicts of interest)

    Andrew Kornfeld (Yale, undergraduate, no conflicts of interest)



    Address questions to:
    Michael Mundorff, MBA, MHSA | Integrated healthcare system
    “The health department doesn’t need to know if I’m sick or not,” Republican state lawmaker Mark Strong said.

    The testing issue is related but not identical to the regulatory force of reportable diseases in Utah — and I suspect most other jurisdictions. If Rep. Strong is in fact sick with COVID-19, the Utah State Department of Health needs, and has the legal right, to know. What does “on the radar” even mean? He is already a state legislator whose associated acts are part of the public record.

    This is just one more example of the GOP’s
    dangerous emphasis on illusory individual “freedom” at the expense of public health and community well-being. It would be interesting to know whether Rep. Strong feels he doesn’t have to comply with government mask mandates, either. His legislative district is in Salt Lake County, which is currently, and has for quite awhile been, subject to a mask mandate.
    The "Rights" Argument
    Dennis M, BSME | none
    Testing needs to be put in the same category as car seat belts. People have the "right" to not wear the belt and the attendant "right" to pay the fine for not doing so. Exercise of bogus rights costs the rest of us money and potentially our health. The US should institute a nation-wide significant fine for not wearing a mask in public. Scofflaws would want to stop being fined and in a short time mandated mask wearing would become a socially normal thing to do just as seat belts have become.

    Your right to
    throw a punch ends at the tip of my nose. It's mandated most places that doctors report cases of STDs to the public health services. Why should this more easily and unavoidably transmitted lethal disease be any different?

    After a recent uptick in cases, New Zealand re-instituted their 1000 NZD (roughly 360 USD) instant fine for not wearing a mask in public. One need only look at infection and death rates for New Zealand versus other countries to see the result.
    Don’t support laws you are not willing to kill to enforce
    Thomas Morgan, MD | Vanderbilt Health
    Reflect on this quote of Yale Law Professor Stephen Carter:

    ‘’On the opening day of law school, I always counsel my first-year students never to support a law they are not willing to kill to enforce. Usually they greet this advice with something between skepticism and puzzlement, until I remind them that the police go armed to enforce the will of the state, and if you resist, they might kill you” (1). The context in which this injunction was publicized was the death of Eric Garner during an arrest for selling cigarettes on the curb. But
    it applies to all laws and regulations backed up by state monopoly on the use of force.

    I have no doubt that many would be willing to deploy whatever is deemed necessary to compel compliance with mandatory masking, social distancing, and testing even for asymptomatic individuals. They might even be willing to apply force to those who are not like them. The “Other” is always the enemy and scapegoat. Such “Others” may be of a different social class or political affiliation.

    I am far more fearful of the ambitions of a few than of a theoretical incremental uptick in viral spread rates  because the public has not yet fully embraced the guidance of public health authorities. I would argue for better communication and education instead of a coercive, punitive approach. Threatening and punishing non-adherent “patients” is absolute anathema in medical ethics, absent some proof of preventable imminent serious harm to an identifiable person or persons.  

    We don’t force people to be tested for HIV. Those who want to be sure that they aren’t exposed must abstain from high risk behavior, possibly using consensual couple testing to mitigate risk. Similarly, those who go out and about in public spaces bear the risk of SARS-CoV2 infection. People should take voluntary precautions. Those who need or want to shelter in a secluded place with strict infection control protections should be helped and accommodated to the extent possible.

    Masking and Testing Should be Mandatory for COVID-19
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    The informative perspective on the wearing of masks and testing for the SARS-CoV-2 virus that causes the COVID-19 disease leads to questions of how this is even worth discussing.

    Any cities, regions, states, and countries where the wearing of masks is standard, whether through society's acceptance with or without a government's mandatory legal enforcement, has a significantly higher chance of mitigating the spread of the virus.

    In addition to the wearing of masks, high testing rates for any symptoms associated with possible infection, whether through COVID-9 or any other virus, should be strongly encouraged, for purposes of contact
    tracing, together with self isolation at home, if at all possible.

    In a number of countries, local governments have made accommodation available for compulsory communal quarantining.

    Refusal to self isolate or quarantine is not be a matter for discussion, and will lead to fines if official orders are flagrantly disregarded.

    The same condition should be mandated for the wearing of masks, which is essential to protect any individuals in society who might come into contact with asymptomatic carriers.

    The degree of positivity rates should be calculated for at least 14 days, as in many countries, and retested in the period before the end of the 14-day period, rather than for 7 days, which does not allow accurate identification of infection or retesting.

    It is difficult to understand the irresponsible and ignorant position of senior administrators in states and countries who argue that increased testing leads to more cases being reported, with the ridiculous false causality that decreased testing will lead to fewer realized cases of COVID-19 rather than fewer reported cases.

    Health departments and governments need to know how many individuals have been tested for COVID-19, and how many positive outcomes can be reported, for effective public policy considerations.

    Failure to wear masks and refusal to be tested for a disease that kills susceptible and immune compromised and aged members of society, as well as infecting healthcare workers, should not be an optional or purported unconditional right, but a requirement to behave as a responsible member of a caring society.
    What's behind the resistance
    Shawn OBrien, Psy.D. | Retired
    As an older person with pre-existing conditions, my personal reaction to others' resistance to testing and mask wearing is anger. I vacillate between wanting to yell at such people at how selfish they are and wanting to educate them about how they are increasing the risk that they and/or loved ones will die. However, as a psychologist, I know that neither shaming nor facts and logic will have any effect on most people. As the article pointed out, there is a variety of factors contributing to such resistance, and certainly the disincentives to get tested must be addressed. But those are a relatively small portion of the resistance, and does not explain resistance to mask wearing at all. Some folks ARE getting tested, and when they test positive, they continue to circulate in the community. The unfortunate reality is that compliance with all the needed mitigation measures is unenforceable. Will better education and communication, as the law professor comment suggests, actually work? That depends on whether the major underlying psychological forces at work are addressed. I sincerely hope that those who work on such messaging consult psychologists, and that those psychologists are experts in Self Determination Theory (SDT) (1), and in Terror Management Theory (TMT) (2). There are ways to craft messaging that respect autonomy (SDT), and increase self-esteem (TMT), and those messages are much more likely to be heard and implemented. The articles below are just a brief and incomplete introduction; further reading is highly recommended.