COVID-19 testing is more widely available in Wisconsin, but some doctors and patients haven't gotten the message

In Hortonia on April 7, Lyn Neuenfeldt was one of just four people working the polls. 

Like others who ventured out that day in person for Wisconsin's spring elections, she was nervous — particularly because COVID-19 had just taken the life of a town official she'd had contact with in recent weeks. Doctors told her enough time had passed since she'd seen him without developing symptoms, so Neuenfeldt believed she avoided exposure. 

About four days later, she and her partner fell ill. 

Despite aches, nausea and bad coughs, their symptoms were never severe enough to require hospitalization. Still, two weeks later, she called the state health department to ask if they qualified for a COVID-19 test. 

The nurse she spoke with told her she likely had the coronavirus that causes the disease and recommended she continue to isolate herself. But she didn't meet the criteria to receive a test. It puzzled her, especially because she'd heard reports that tests were becoming more widely available.

"It's very frustrating to hear, 'Yeah, there's tests, and yes, you can get one,'" Neuenfeldt said. "Because I don't know who's getting these tests."

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As coronavirus testing in Wisconsin has gone from a small-scale operation in just two public labs to a massive effort involving 50 labs that say they can run over 11,000 tests a day, the narrative of who qualifies for a test has changed rapidly as well.

When supplies were limited, tests were given only to those who needed it most: critically ill patients and health care workers. Now, because of scaled-up production of lab supplies needed to process the tests and an influx of collection kits from the State Emergency Operations Center, the scope of those who can be tested is much wider. 

People such as Neuenfeldt and the providers who cared for her might not have gotten the message. 

Doctors heeded the warnings about earlier supply chain problems, and sick people heeded them, too, said Dr. Alana Sterkel, assistant director of the state hygiene lab's communicable disease division. 

"The message has gotten through," Sterkel said. "I'm not sure if they (were) satisfied with that answer." 

The question now is whether the updated message is getting through so that Wisconsin tests as many people as state officials say are necessary to begin reopening more businesses and public facilities.

The list of who can be tested is spreading faster than word of mouth

Everything about the new coronavirus seems to change at the speed of light, including testing updates. That hasn't made it easy for doctors and nurses to know what to tell their patients, said Julie Willems Van Dijk, Wisconsin's deputy health secretary. 

At the outset, "we had to be really, really strict with health care providers about which patients under which conditions could get a test," she said. "Now, a few weeks later, we're saying, 'Hey, now we have lots of tests. Test everybody!'" 

By "everybody," the state means to open testing to patients with mild symptoms like Neuenfeldt and her partner.

Experts say if the health care system tests only specific subsets of people, such as hospitalized patients, that artificially limits the number of people known to have the virus that causes COVID-19. And they say that as state officials claim reopening Wisconsin hinges on understanding how many are infected, it's best to walk as close to "anyone who wants a test can get one" as possible.

Though the public labs still have specific criteria for who can be tested, some major Wisconsin health systems have opened their doors wider.

Bellin Health, Gundersen on the state's west side, Prevea, Aspirus, Agnesian and UW Health in Madison now say they will test anyone with symptoms of the virus, which expanded recently to include chills, muscle pain, headache, sore throat and loss of taste or smell. That's in addition to a host of other categories, such as newly admitted hospital patients and women set to give birth. 

ThedaCare says it can test patients with moderately severe symptoms, Aurora will test those who come in for urgent procedures, Froedtert will test anyone with a provider's approval and who is under investigation for COVID-19, and ProHealth Care focuses largely on older adults or those with compromised immune systems. Ascension, Marshfield Clinic and SSM Health did not respond to a USA TODAY NETWORK-Wisconsin request for their testing criteria. 

Still, the number of tests completed each day lags behind what the state advertises as full capacity. The state has run an average of 2,820 tests per day over the last week, roughly a fourth of the more than 11,000 tests a day labs say they could run. 

"We haven't had a tremendous influx of patients coming in," said Dr. Nasia Safdar, medical director of infection control at UW Health. "I think it will take a little bit more messaging to get this new message out there." 

Only about 1% of Wisconsin residents have been tested so far, or 76,248 people as of Thursday, returning an average of about 9% positive tests in the last week.

State Department of Health Services chief medical officer Ryan Westergaard said approaching about 5% positive would provide a good indication that labs are testing enough people, and the right people. 

The state uses a system called the Health Alert Network to pass guidance, like the expanded testing capacity, on to physicians. 

But Westergaard acknowledged getting more patients tested has been a "slower and more difficult" process. 

"It is going to be a shared responsibility to scale up testing in all health care settings if we are going to complete enough tests to support our public health response," he said in an email Friday. 

Public health requires doctors to think about testing differently

Even if providers hear that they can order tests for almost anyone, it might at first sound foreign. 

Clinical procedures dictate that if a patient's care won't change because of a diagnosis — essentially if they have mild symptoms and are sure to recover at home regardless — there's no diagnosis necessary.

Not many of us, for example, take a test to determine if we have influenza. The doctor determines the diagnosis based on symptoms, recommends rest and moves on.

"I hate ordering something unless there's action to it," said Dr. Ashok Rai, president and CEO of Green Bay-based Prevea. "Just ordering it so we know really doesn't have usefulness." 

It's not just usefulness standing in the way of clinicians testing those with mild symptoms.

A statewide shortage of personal protective equipment, though now somewhat offset by donations and shipments from the federal stockpile, initially made doctors wary of bringing a possible coronavirus patient into their clinic. If a diagnosis wasn't needed to dictate their care, using limited PPE to administer the test might be more of a risk than a reward. 

If a person is already isolated at home, bringing them in to a clinic and potentially exposing them to others is the last thing a doctor typically wants, Willems Van Dijk said. 

"That's a very logical, clinical approach to this," she said. "However, we're asking (them) to think not like traditional medical providers, but to think like public health professionals."

Testing for the coronavirus isn't just about what to do with the patient, Rai said in reference to changes to clinical procedure in the face of COVID-19. It's about understanding who else could be infected.

Testers get creative to cut exposure, PPE use 

Shifting doctors' mindsets toward public health doesn't eliminate their other challenges. It's still a tall task to mask up for every potential patient who wants a test, and keep them away from others in waiting rooms or elsewhere inside the clinic. 

Drive-thru testing sites help solve the PPE problem, said Todd Kowalski, an infectious disease physician at Gundersen Health in La Crosse. Gundersen has operated such a testing site since March 16. 

Rai agreed — staff at Prevea's drive-up sites wear PAPR masks, a more permanent form of protective gear that allows for more than just one use per patient. That, along with an influx of collection kits sent by the state, means each of Prevea's Brown County sites can run about 200 tests a day if needed. 

Gov. Tony Evers announced Friday that the state's National Guard would be administering drive-thru testing in areas of the state that need it most, beginning with Pepin and Buffalo counties on Wisconsin's west side. 

The U.S. Food and Drug Administration also authorized last week the first diagnostic coronavirus test that allows a patient to collect their specimen at home.

Run through LabCorp, the tests aren't yet available to everyone, just front-line health care workers and first responders. Once they complete an eligibility survey reviewed by a doctor, they collect their sample with a small nasal swab, ship it back to the lab and view their results online.

It's a safer way for patients to get their samples checked without needing to come in to a clinic, but experts say there are still risks to contend with, including the possibility of returning false negatives or spreading the infection by mail if a person doesn't follow packaging instructions correctly. 

Some Wisconsinites may never know if they were infected

Neuenfeldt and her partner were both feeling better during the last week in April. They've followed the guidelines the nurse gave her on how many days to stay isolated, but it still unsettles her that she'll never know for sure. 

The same is true for Katie Doyle, a 30-year-old Milwaukee resident who developed respiratory symptoms five days after voting in person on April 7. 

Her sister, a nurse practitioner, advised her to keep an eye on it, but said that she likely wouldn't qualify for a test anyway. When she began to feel worse, she scheduled a virtual visit with her provider, where she was told her symptoms were consistent with the coronavirus but that she indeed could not get a test. 

"i definitely feel really lucky that I didn't have bad symptoms, I didn't need medical attention," Doyle said. "But I did worry. I live with my boyfriend; what if he had gotten a really serious case, or what if I had somehow passed it to my neighbor who is elderly?" 

Neuenfeldt, 47, also wonders whether it's safe for her to deliver groceries to her parents, or whether she's safe to walk around town.

She said the confusion around who's eligible for a test makes her think back to the HIV/AIDS crisis, which unfolded when she was in college. 

"There was just this immediate push (to get tested). That was ingrained in me," Neuenfeldt said. "Going through this situation ... that's exactly what you'd think everyone would be wanting to do, is know." 

Willems Van Dijk said the state eventually will reach the point where anyone who needs the test can get one. 

It just may take more communication to get there. 

Contact Madeline Heim at 920-996-7266 or mheim@gannett.com. Follow her on Twitter at @madeline_heim. 

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