By Dora Anne Mills, MD, MPH, Chief Health Improvement Officer at MaineHealth
Originally published Saturday, August 7, 2021

With the significant increases in COVID-19 cases, I’m receiving a number of questions about testing and treatment. So, I thought I’d provide an update on these two topics. Because information changes frequently, rather than trying to provide direct answers, I’ve provided a number of links to websites that are regularly updated.

First, the first lines of defense are the most effective: vaccination, vaccination, vaccination, masking, distancing, and ventilation. With the Delta variant surging, we all should be layering all of these strategies as is possible.

But sometimes, even when using all of these layers, we’re exposed or become ill, or someone we know does. The information below is not meant to be medical advice; that’s something you need to seek from your own provider. But the links provided below give general approaches.

Testing

Situations below are when you may want to get tested:

  • Get tested if you have symptoms. Illness with the Delta variant reportedly often starts out with symptoms the same as a common cold, including a runny nose. Here is the US CDC official list of common symptoms from COVID-19.
  • Get tested if you have had a close contact, i.e., you have been within 6 feet for a total of 15 minutes or more over a 24-hour period with someone with suspected or confirmed COVID-19:
    • People who are fully vaccinated should get tested 3-5 days after exposure, and wear a mask in public indoor settings for 14 days or until they receive a negative test result.
    • People who are not fully vaccinated should quarantine and be tested immediately after being identified, and, if negative, tested again in 5–7 days after last exposure or immediately if symptoms develop during quarantine.
  • If you’re not sure if you need to be tested, you can use the US CDC self-checker.
  • Other examples of when testing may be needed (e.g., for travel) may be found here.

What types of tests are there?

Here is a great user-friendly FDA site on testing basics.

For the most part, tests should be offered for free and/or are covered by insurance.

Where to get tested

A number of chain pharmacies offer testing, some offer antigen, some PCR (molecular or others in the category of nucleic acid amplification testing or NAAT), and some both types of tests. In general, PCR tests are considered more accurate, but often take one to several days for the results.

Home testing kits

You may want to consider having at-home testing kits on hand that you can test and see the results right away (there are also some at-home collection kits that you mail the sample and get the result a few days later). Because of the rise of the Delta variant that has a higher viral load and a higher vaccine breakthrough rate, I’ve recently purchased such a kit. There are four such kits currently authorized for use in the U.S. – three antigen test kits (Abbott, Quidel, and Ellume) and one rapid PCR kit (Lucira) as well as another rapid PCR kit that has been FDA authorized but is not yet for sale to the general public (Cue).

Information on test kits currently authorized for use in the U.S.

  • Abbott Lab’s BinaxNOW rapid antigen test is widely available, costs about $20 – 25 for a two-test kit. Abbott’s site shows how these tests can be used, e.g., for return trips from international travel.
  • Quidel’s QuickVue rapid antigen test is also readily available for at-home use for about $20 – 25 and contains two tests per kit.
    • Ellume: a rapid antigen test kit has one test per kit and retails for about $30 – 40.
    • Lucira: a rapid at-home PCR test. It retails for about $55. They seem to be sold out for now.
  • Cue also has a rapid at-home PCR test that’s been FDA authorized, but does not yet seem to be available yet for the general public:

For a concise article on what situations these at-home kits may be helpful for, check out this NY Times article (from June but recently updated).

In general, when used sequentially, e.g., two tests at least 24 hours apart, antigen tests are more accurate, i.e., there is higher sensitivity, meaning there are fewer false-negative results, and therefore fewer cases of disease are missed. An example would be if you want to visit someone who is immune-compromised (and the assumption is you’re already vaccinated, otherwise you should not be visiting someone who is immune-compromised). Test two to three days ahead of visiting the person, and then test again on the day of the visit. This type of testing is an additional layer of protection, on top of vaccination, distancing, masking, and ventilation – all being used during the visit.

Another situation is if a household member has symptoms, and you’re quite sure it’s likely their allergies, but you want to make sure. Conducting an antigen test one to three days apart provides more accuracy of the negative test than only one test. This is one reason why the Abbott and Quidel test kits contain two tests.

But antigen tests can also be used for one-time tests to add a layer of safety. For instance, if you’re hosting a wedding or other event, and don’t want it to hit the news as the next big super spreader event, you can test the guests as they arrive. At about $10 per guest, it’s expensive, but if you’re already spending a lot of money on the event, it may be worth it.

Also, sometimes a test using these kits can be used for international travel or other situations that require a negative test result. Some of these companies include an app that is used to show the airlines your test results.

If you use an antigen test, then you should look at this US CDC algorithm on what to do with the results, since in general, there are higher rates of false negatives (and to a lesser degree false positives) with antigen tests than with PCR tests.

If you have results that you have confidence in, what should you do next, e.g., with a negative or a positive test.

Treatments

Some at-home advice if you are sick with COVID-19 (besides medical advice from your own provider)/

• From US CDC

• From Mayo Clinic

In general, at this point in time, many people with COVID-19 can recover at home with symptomatic treatment, e.g., getting rest, staying well hydrated, and taking medications such as acetaminophen to relieve fever and aches and pains.

Outpatient Monoclonal Antibody Treatments

However, for someone at risk for hospitalization, there are medications that are FDA authorized. Several monoclonal antibody treatments are authorized for non-hospitalized people over age 12 with mild to moderate COVID-19 symptoms and who are at risk for developing severe COVID-19 (e.g., at risk for being hospitalized with it).

Timing is important. To be most effective, these medications need to be given as soon as possible after symptoms develop and must be given intravenously (IV). Because of a limited number of locations they can be administered and because the infusion process takes several hours, it is important that if you meet the criteria for them, you seek these medications as soon as possible.

These mediations include:

  • Combination of casirivimab and imdevimab, made by Regeneron called REGN-COV.
  • Sotrovimab made by GSK
  • (Combination of bamlanivimab and etesevimab, made by Eli Lilly, though distribution has been on hold since June due to resistance to the Gamma and Beta variants).

As of July 2021, the Regeneron product (REGN-COV) is also authorized for post-exposure prophylaxis for those with immunocompromising conditions who have been exposed to COVID-19 (see EUA Fact Sheet).

Those at-risk for hospitalization and who may qualify for monoclonal antibody treatment include people over 65, people with obesity, and those with certain medical conditions. CDC list of such conditions. As of early August 2021, these conditions include:

  • older age (for example age ≥65 years of age)
  • obesity or being overweight (for example, adults with BMI >25 kg/m2, or if age 12-17, have BMI ≥85th percentile for their age and gender based on CDC growth charts
  • pregnancy
  • chronic kidney disease
  • diabetes
  • immunosuppressive disease or immunosuppressive treatment
  • cardiovascular disease (including congenital heart disease) or hypertension
  • chronic lung diseases (for example, chronic obstructive pulmonary disease, asthma [moderate-to-severe], interstitial lung disease, cystic fibrosis and pulmonary hypertension)
  • sickle cell disease
  • neurodevelopmental disorders (for example, cerebral palsy) or other conditions that confer medical complexity (for example, genetic or metabolic syndromes and severe congenital anomalies)
  • having a medical-related technological dependence (for example, tracheostomy, gastrostomy, or positive pressure ventilation (not related to COVID-19)).

Other medical conditions or factors (for example, race or ethnicity) may also place individual patients at high risk for progression to severe COVID-19. Authorization of monoclonal antibodies under the EUA is not limited to the medical conditions or factors listed above.

For those with severe enough COVID-19 to be hospitalized, there are additional medications that are authorized, including antiviral drugs like remdesivir; corticosteroids like dexamethasone; different types of monoclonal antibodies such as tocilizumab, which is an anti–interleukin-6 receptor monoclonal antibody; anticoagulants (“blood thinners”) such as heparin. Critically ill patients often require such interventions as being placed on high supplemental oxygen and/or on a ventilator; on kidney dialysis or renal replacement therapy, or on ECMO (extracorporeal membrane oxygenation).

Unfortunately, despite an increasingly longer list of authorized medications and treatments, as well as a number of studies underway, the effectiveness of many of these interventions is very limited. The most effective strategy is to prevent severe disease and death by vaccination. But with much of the world without access to vaccinations, variants continue to emerge and circulate. Therefore, it makes sense for us to be familiar with general testing and treatment approaches. Below are additional resources on treatment.

Medical treatment websites that are frequently updated: