The Impact of Changes in Diagnostic Testing Practices on Estimates of COVID-19 Transmission in the United States

Am J Epidemiol. 2021 Sep 1;190(9):1908-1917. doi: 10.1093/aje/kwab089.


Estimates of the reproductive number for novel pathogens, such as severe acute respiratory syndrome coronavirus 2, are essential for understanding the potential trajectory of epidemics and the levels of intervention that are needed to bring the epidemics under control. However, most methods for estimating the basic reproductive number (R0) and time-varying effective reproductive number (Rt) assume that the fraction of cases detected and reported is constant through time. We explored the impact of secular changes in diagnostic testing and reporting on estimates of R0 and Rt using simulated data. We then compared these patterns to data on reported cases of coronavirus disease 2019 and testing practices from different states in the United States from March 4, 2020, to August 30, 2020. We found that changes in testing practices and delays in reporting can result in biased estimates of R0 and Rt. Examination of changes in the daily numbers of tests conducted and the percentages of patients who tested positive might be helpful for identifying the potential direction of bias. Changes in diagnostic testing and reporting processes should be monitored and taken into consideration when interpreting estimates of the reproductive number of coronavirus disease.

Keywords: basic reproduction number; coronavirus; mathematical model; reproductive number; transmission dynamics.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Basic Reproduction Number
  • COVID-19 / diagnosis*
  • COVID-19 / epidemiology*
  • COVID-19 / transmission
  • Computer Simulation
  • Diagnostic Techniques and Procedures
  • Documentation
  • Epidemics
  • Humans
  • Models, Theoretical
  • Reproducibility of Results
  • SARS-CoV-2
  • United States / epidemiology