More People Are Using At-Home Tests to Diagnose COVID—How Will We Know if There's Another Surge?

COVID-19 cases have declined sharply in the United States in recent weeks, with an average of about 30,000 new cases being reported per day. Compared to the nearly 900,000 cases reported daily during the Omicron surge of mid-January, the new numbers have been an encouraging sign for Americans eager to return to pre-pandemic life.

The latest case counts, however, are not necessarily an accurate representation of the reality across the country right now, according to infectious disease experts.

"People are testing less and they're living with minor symptoms or tolerating exposure without testing," Mark Loafman, MD, MPH, chair of family and community medicine at Cook County Health and a family physician in Chicago, Illinois who specializes in infectious disease outbreaks and public health, told Health, "The number of tests, themselves, are going down significantly as people aren't pursuing it."

Here's a closer look at what's driving the declining case numbers and how current realities may impact our ability to assess the current state of the pandemic.

Behind the Dropping Case Numbers

Ever since the federal government made free COVID-19 tests available—along with testing reimbursement programs—more people have been home testing. Despite this fact, most health agencies and departments do not allow people to self-report positive tests, which has led to "a significant increase in underreporting," Dr. Loafman said. The current reporting and accuracy challenges are compounded by the fact that less demand for tests has resulted in the closure of numerous COVID-19 testing sites across the country.

And even while COVID-19 cases aren't being fully reported amid widespread use of at-home tests and lack of testing in general, transmission and infection is still occurring, Loafman said. In fact, the BA.2 Omicron subvariant makes up nearly 86% of cases in the U.S. and is considered more contagious than other variants.

Dr. Loafman's assessment of the current situation is echoed by other experts, as well.

"We are absolutely seeing infection and there's an increasing incidence of COVID-19 occurring, especially right now in the Northeast," Pia MacDonald, MPH, an infectious disease epidemiologist and senior director of applied public health research at RTI International, told Health. "Data coming out of New York City, for example, shows that the majority of the cases are BA.2 and there's even a soft variant of BA.2 that is growing in prominence in terms of transmission."

State-level data from Florida, for instance, also suggests COVID positivity is spiking again. The same situation is being seen in states like Arizona, New Jersey, and Massachusetts. But, if people are getting infected and it's not being accounted for, should at-home tests be reported in the interest of public health? And if at-home tests are not allowed to be reported, how will experts know if there's another surge?

Should People Report At-Home Test Results?

As it stands now, local health departments and agencies are not accepting self-reported at-home COVID test information. While there are some benefits to collecting self-reported results, such as having more data and the ability to gauge what's happening in a community, there are concerns over people administering tests to themselves inaccurately, and tests providing invalid results based on external factors (such as temperature and storage conditions), Dr. Loafman said. There may also be people who falsely report their results.

"If you were to ask people to self-report home testing, you would get people who are willing to do it and other people who won't be," Dr. Loafman said. "We're just not at a place where people are comfortable with "big brother" like that, sharing data, which is a shame because so much of our data is available to the corporate world for all kinds of nefarious purposes."

MacDonald, meanwhile, said she doesn't think it's possible at this time to get people to uniformly self-report their home testing results.

How Will We Know If There's Another COVID-19 Surge?

With daily COVID cases in the U.S. being undercounted, it's important for health officials, political leaders, and citizens to keep a close eye on hospitalization and death rates in order to identify a potential surge, Dr. Loafman said.

"If we start to see a surge in hospitalization and death again, then that's one of the mainstays of stopping an epidemic," Dr. Loafman said. "If we start to see those trends coming back, then we should be willing to proactively put some steps in place so it doesn't get disastrous."

Currently, daily hospitalization and death rates have decreased in the U.S., with an average of around 450 new deaths and 1,500 new admissions to the hospital per day, as reported by the CDC.

"As long as we don't see the surge manifest itself in admissions, we are at low risk for increased death and health care resource constraints,, Rob Rohatsch, MD, emergency medicine physician and chief medical officer at Solv Health, told Health.

Experts can also use other methods to recognize a potential surge, including local wastewater surveillance—a technique used to track and detect the presence of a virus in communities using wastewater samples. Data report changes in nursing homes, prisons, and schools are additional indicators, MacDonald said.

The Ramifications of Uncounted Cases

Although there are methods health experts can use to identify a surge, the existence of unreported positive COVID-19 cases can be problematic, causing local health departments and agencies to lack a full understanding of transmission in their community, said MacDonald.

This could also affect policies and precautions that may need to be implemented or reinforced in areas of high transmission, but Dr. Loafman said at this point in the pandemic, he doesn't see government leaders or officials putting mitigation restrictions back into place.

"Based on data that people can't feel or without consequence, it's not going to motivate people to do anything," Dr. Loafman said. "As much as we would like that data, I don't think it's going to change policy, it's going to be hospitalizations and death. That's what it's going to take and, right now, we're not seeing those. We are seeing them but not at a level that could change any behavior."

Uncounted COVID cases could also impact work policies and benefits that were initially offered to employees during certain spikes in the pandemic, including working from home options, extra sick time when exposed to the infection, and extra pay, Dr. Loafman said.

Protecting Yourself Amid the Unknowns

In the absence of definitive case counts for your community, health experts advise taking safety precautions to protect yourself from potential infection.

• Check in with local health departments and agencies to get updated information on COVID transmission, hospitalizations, death, and new variants.
  
• Continue to wear a mask in crowded and enclosed areas.
  
• Opt for outdoor activities whenever possible.
  
• Get tested if you're exposed to someone with COVID-19 or if you're showing symptoms.
  
• Isolate and quarantine based on recommended days from the CDC if exposed.
  
• Get vaccinated if you're eligible.

"The more we…do all of those things, the more we can continue on this move toward normalcy," Dr. Loafman said.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.