With free testing programs ending, collection sites closing and an abundance of at-home test kits available free or for purchase, Hawaii residents are asking themselves – is it worth it to schedule an in-person Covid-19 test anymore?

For many, the answer seems to be no.

The decline of lab-processed PCR tests in favor of at-home antigen tests not included in official case counts is coinciding with an increase in coronavirus infections in the islands, and has raised fears that a new surge may be looming even as it is becoming more difficult to track Covid’s spread.

The number of lab tests reported by the state has dropped to some of the lowest levels since the early stages of the pandemic, hovering around an average of 2,800 per week, according to the state’s most recent figures released Wednesday.

Medical technicians prepare COVID-19 tests, for sending to labs, at the Blaisdell drive-through testing site in Honolulu, Monday, December 27, 2021. (Ronen Zilberman photo Civil Beat)
With Covid testing sites closing and the increasing use of at-home tests, fewer residents are opting to schedule a lab test. Ronen Zilberman/Civil Beat/2021

Fewer Testing Options

By comparison, Hawaii logged more than 15,000 tests daily at the height of the omicron surge in January.

The combination of fewer free testing options, the convenience of doing tests at home and a general feeling of weary complacency is fueling the lack of interest in lab testing, policymakers and experts say, leading some to warn that Hawaii is now navigating the pandemic with one eye closed.

“The case trend is very misleading right now because the number of tests is dropping,” said Tim Brown, who leads the East-West Center’s disease modeling team. “I think it’s anybody’s guess as to which direction it’s going to go, except that right now we’re headed upward, for sure.”

With fewer people booking a Covid test at their local pharmacy, hospital or pop-up clinic, experts warn Hawaii’s case tallies are an undercount. In early March, the state Department of Health also switched to reporting Covid-19 data weekly instead of daily.

Hawaii’s pandemic curves have remained largely flat, with the DOH on Wednesday reporting a weekly average of 210 cases per day.

The positivity rate, however, tripled to 7.1% over the past month, driven by omicron hybrids.

“We are moving from an emergency response to Covid to disease management.” — DOH spokesman Brooks Baehr

The last time the positivity rate rose above 7% was mid-December, when the highly contagious omicron variant began its surge and Hawaii counted an average of 720 new infections from nearly 8,000 daily tests.

As the pandemic enters its third year, experts and officials have been reevaluating the role of Covid testing and placing increased emphasis on hospitalizations in policy decisions such as the lifting of restrictions and mask mandates.

They’re also looking for new ways to detect the virus, including testing sewage.

Screenshot Hawaii Covid Testing Data 4-20
While testing numbers, in gray, remained flat, positivity rates, indicated by the purple line, have risen to 7.1%. Screenshot/DOH/2022

Federal Funds Drying Up

State and county governments and medical providers have gradually curtailed their testing programs, citing a shortage in staff and a lack of interest as omicron cases initially plummeted.

Hawaii Pacific Health, for example, closed its four drive-up testing sites on Oahu and Kauai at the end of March. Melinda Ashton, executive vice president and chief quality officer for HPH, said the decision was made “because the volume of requests for specimen collection appointments was so far down, it really had dropped dramatically.”

The hospital system still conducts testing in clinics by appointment, but only if patients are referred by a health care provider or have a legitimate medical need.

“We’re in the business of providing appropriate testing for health care reasons, so it’s not a surveillance program as we have done,” Ashton said.

Around the same time, the City and County of Honolulu, which offers free antigen testing based on the same technology as at-home tests, stopped offering testing on Sundays and Wednesdays at its Daniel K. Inouye International Airport mobile lab and shortened hours at other sites.

In response to rising cases, the city announced this week that it would reopen its airport site on Wednesdays.

Meanwhile, the health department’s testing program, which offered free PCR testing at select locations across Hawaii to all residents regardless of medical need, swabbed its last nostril on Wednesday.

The federally funded program ran for around 10 months at a cost of more than $80 million.

“Funding is drying up, but this is really all part of the plan,” DOH spokesman Brooks Baehr said. “We are moving from an emergency response to Covid to disease management.”

Even when laboratory testing is available, experts warn systemic barriers continue to prevent low-income residents and other vulnerable communities from taking advantage of it.

Drive-thru collection sites make testing inaccessible to people who don’t have a car, while limited testing hours disproportionately affect lower income residents unable to take time off work, said Jennifer Nuzzo, director of Brown University’s Pandemic Preparedness Center.

The federal program that reimbursed Covid testing, vaccination and treatment for uninsured patients also stopped accepting claims around the end of March “due to a lack of sufficient funds,” its website reads.

While at-home tests may seem widely available, Nuzzo cautioned the Biden administration’s decision to send eight free at-home tests to American households disadvantages larger, multi-generational homes, which Hawaii has in abundance.

While President Joe Biden has required insurance plans to pay for eight at-home tests per person every month, “it’s not easy,” Nuzzo said. “And again, if you don’t have insurance, that’s yet another avenue that’s not available to you.”

Abbott Covid-19 test negative. December 16, 2021
It’s more difficult for multigenerational households and people without insurance to find at-home rapid tests. Cory Lum/Civil Beat/2021

And while vaccine-or-test mandates for workers and travelers have largely ended, a lab test is still needed to access lifesaving Covid treatments such as Pfizer’s Paxlovid anti-viral pill, Brown said.

“Congress’ inability to free up this funding is almost criminal because it basically is putting poor people in this country in a very disadvantaged position in terms of accessing testing, treatment and even vaccines,” he said.

‘It’s Hard To Know What’s Going On’

Hawaii is not alone in its testing woes. The national average for laboratory Covid tests has hovered around a yearlong low of 600,000 tests daily since mid-March, despite positivity rates rising from 0.7% to 4.4% in the same period, according to the Johns Hopkins University Coronavirus Resource Center.

Nationwide, authorities are only detecting around 7% of actual infections, according to estimates from the University of Washington’s Institute for Health Metrics and Evaluation.

And while positivity rates are generally viewed as a more accurate indicator of community transmission, their reliability decreases as test numbers plummet, said Nuzzo, who previously analyzed Covid testing trends for Johns Hopkins.

Eyeing these trends, policymakers have increasingly departed from regular testing to inform pandemic response. In its latest guidelines, the Centers for Disease Control and Prevention uses hospitalizations and available beds to determine Covid risk and the need to wear masks.

Brown cautioned against basing decisions solely on hospitalizations as the data can lag infections by weeks, allowing the pandemic to spread while “doing nothing to try to arrest it during that rising phase.”

But as the virus has evolved to become highly transmissible while causing milder symptoms, Ashton said it makes sense to pay less attention to daily infections and positivity rates.

“When we didn’t have vaccines, when we did have more severe disease, we had a higher risk of death and a higher risk of the hospital system being overrun,” the HPH executive said. “We’ve now moved to a place where that is not the case.”

The state had hoped wastewater testing would provide valuable insight into the spread of Covid at the community level, but the DOH has struggled to bring its own sewage testing lab online, with the state currently sending samples to the mainland for analysis, Baehr said.

While its role as the singular metric for Covid detection has diminished, the general consensus among experts and policymakers is that PCR testing will play a smaller but still critical role in the suite of pandemic surveillance tools.

And in this mandate-free era of personal choice, it’s more important than ever for residents to have access to reliable data, whatever form it takes, Brown said.

“It’s not only more important, it’s absolutely critical,” he said. “You cannot make an informed choice if you do not know what Covid is doing in the community.”

Civil Beat’s health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and Papa Ola Lokahi.

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