Factors Associated With Access to and Timing of Coronavirus Testing Among US Adults After Onset of Febrile Illness

JAMA Netw Open. 2021 May 3;4(5):e218500. doi: 10.1001/jamanetworkopen.2021.8500.


Importance: Active SARS-CoV-2 (coronavirus) transmission continues in the US. It is unclear whether better access to coronavirus testing and more consistent use of testing could substantially reduce transmission.

Objective: To describe coronavirus testing in persons with new onset of febrile illness and analyze whether there are changes over time and differences by race and ethnicity.

Design, setting, and participants: This cohort study used data from the COVID-19 Citizen Science Study, launched in March 2020, which recruited participants via press release, word-of-mouth, and partner organizations. Participants completed daily surveys about COVID-19 symptoms and weekly surveys about coronavirus testing. All adults (aged at least 18 years) with a smartphone were eligible to join. For this analysis, US participants with new onset of febrile illness from April 2020 to October 2020 were included. Data analysis was performed from November 2020 to March 2021.

Main outcomes and measures: Receipt of a coronavirus test result within 7 days of febrile illness onset.

Results: Of the 2679 participants included in this analysis, the mean (SD) age was 46.3 (13.4) years, 1983 were female (74%), 2017 were college educated (75%), and a total of 3865 distinct new febrile illness episodes were reported (300 episodes [7.8%] from Hispanic participants, 71 episodes [1.8%] from Black participants, and 3494 episodes [90.4%] from not Black, not Hispanic participants) between April 2 and October 23, 2020. In weekly surveys delivered during the 14 days after fever onset, 12% overall (753 participants) indicated receipt of a test result. Using serial survey responses and parametric time-to-event modeling, it was estimated that by 7 days after onset of febrile illness, a total of 20.5% (95% CI, 19.1%-22.0%) had received a test result. This proportion increased from 9.8% (95% CI, 7.5%-12.0%) early in the epidemic to 24.1% (95% CI, 21.5%-26.7%) at the end of July, but testing rates did not substantially improve since then, increasing to 25.9% (95% CI; 21.6%-30.3%) in late October at the start of the winter surge. Black participants reported receiving a test result about half as often as others (7% [7 of 103] of survey responses vs 12% [53 of 461] for Hispanic vs 13% [693 of 5516] for not Black, not Hispanic; P = .03). This association was not statistically significant in adjusted time-to-event models (hazard ratio = 0.59 vs not Black, not Hispanic participants; 95% CI, 0.26-1.34).

Conclusions and relevance: Systematic underuse of coronavirus testing was observed in this cohort study through late October 2020, at the beginning of the winter COVID-19 surge, which may have contributed to preventable coronavirus transmission.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • COVID-19 Testing* / methods
  • COVID-19 Testing* / statistics & numerical data
  • COVID-19* / diagnosis
  • COVID-19* / epidemiology
  • COVID-19* / prevention & control
  • COVID-19* / transmission
  • Disease Transmission, Infectious / prevention & control*
  • Ethnicity
  • Female
  • Fever* / diagnosis
  • Fever* / epidemiology
  • Fever* / etiology
  • Health Services Accessibility* / standards
  • Health Services Accessibility* / statistics & numerical data
  • Health Services Misuse* / prevention & control
  • Health Services Misuse* / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care* / ethnology
  • Patient Acceptance of Health Care* / statistics & numerical data
  • SARS-CoV-2 / isolation & purification*
  • Symptom Assessment / methods
  • Symptom Assessment / statistics & numerical data
  • United States / epidemiology