A couple weeks ago at my local CVS, I spied them in the wild for the very first time—Abbott BinaxNOWs, currently America’s most sought-after rapid, at-home coronavirus test, piled neatly behind the counter.
With the fall and winter holidays on the way, I figured it was a good opportunity to stock up. But after I asked for a few tests to cover my multi-person household, the pharmacist plucked just a single box off the stack. “One box per customer,” she told me, shaking her head as if she’d already had this conversation four or five times that day. “Sorry, but we can’t keep these tests on the shelves.” She paused. “I mean,” she added, “there’s two tests in this box.” I left the store clutching my lone, overpriced purchase ($23.99! For one box!) to my chest like contraband, feeling frustrated.
As the weather cools and people flock indoors, tests, when combined with other measures such as vaccines, ventilation, and masks, could help make our upcoming festivities safer—we’ve known that for a very long time. But nearly two years into the pandemic, America still hasn’t bothered to prepare for the tough months ahead. Cheap, at-home coronavirus tests have been in short supply, and although their availability is slowly ticking up, a crush of demand around Thanksgiving will almost certainly make the search difficult again. This year, tests, not turkeys, might turn out to be the most expensive, prep-heavy fixtures of many a Thanksgiving table. The power of tests depends on people being able to access and afford them, and use them correctly and frequently enough. But scarcity could prompt people to use the tests in nonideal ways, as my pharmacist was verging on advising me to do.
“A box of two tests is really meant to be used on one person,” Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, told me. The goal here is serial testing, particularly if the first result is negative. Tests offer snapshots, not forecasts, and a virus that’s at first sparse in the airway can rocket up to high levels in a matter of hours or days, especially if it’s a speedster like the Delta variant. The BinaxNOW actually spells this out in the instruction manual: “A positive result is highly accurate, but a negative result does not rule out infection.”
Other types of coronavirus tests, including PCR tests, typically need just one try to detect the virus. (Of course, no test is perfect.) Those tests repeatedly xerox SARS-CoV-2’s genetic material, so they can pick up the pathogen even when it’s not abundant. Antigen tests such as the BinaxNOW, however, simply scan for the bits of coronavirus proteins that are already there. They’ll probably catch most dense infections—ones that saturate the airway with virus, as tends to happen when people are quite contagious—but an early, low-level infection could be easily missed. The tests are also best at spotting the virus in the few days after symptoms first appear; when they’re used to screen people who feel healthy, including people who were very recently exposed, the results can be a bit more mixed. Those imperfect results wouldn’t be such a big deal if we could say that people carrying less virus didn’t pose a huge transmission risk. But “we still don’t know how much virus you need to transmit,” Esther Babady, a clinical microbiologist at Memorial Sloan Kettering Cancer Center, told me. A negative result can’t guarantee that someone won’t spread the virus.
To buoy accuracy, Abbott tells users to take a second test 36 to 72 hours after the first—that’s how the product can provide “the best coverage,” Mary Rodgers, a principal scientist in Abbott’s diagnostics business, wrote in an email. Say I split a box of two tests between my spouse and me; the confirmation goes away, and the products lose punch.
After my disappointing CVS encounter, I wanted the security of having more tests around. But when I checked, CVS was sold out of the tests online too, as well as a very similar product, the Quidel QuickVue. So was Walgreens. And Walmart. Amazon had the QuickVue in stock—if I was willing to buy 45 two-packs for $1,079.55 (and swaddle myself in swabs while my bank froze my credit to investigate aberrant spending). It’s no wonder that several experts told me they’d started stockpiling tests for the holidays weeks, if not months ago, long before most Americans were even thinking about preordering their birds.
Even when not purchased in bulk, the tests quickly add up in cost: For Thanksgiving, for example, I’d ideally want a two-pack for myself, so I could take one in advance, a day or two before the dinner, and then a second one right before the event. Then I’d want another two-pack that I’d start about three days after, to make sure that I hadn’t caught the virus while celebrating. Multiply that by eight people—a totally reasonable size for a Turkey Day soiree—and I’d be looking at 32 tests, packaged into 16 boxes, and close to a $400 bill, if we’re talking standard-price BinaxNOWs. (Consider: A budget turkey, buxom enough to feed eight people, can go for about $15; even truly bougie birds don’t often cost more than $150.) Even absent a shortage, that’s way out of reach for most American families, including many of the ones who most need access to fast and easy tests.
The Biden administration has, in recent months, taken big steps to juice up the manufacture and distribution of rapid tests in the United States, including invoking the Defense Production Act, and pledging some $3 billion in federal funds to the cause. Dozens of these products already have an emergency green light from the FDA; more will follow. Mara Aspinall, an expert in biomedical diagnostics at Arizona State University, told me that she expects tests to be significantly more available through November and December. (Aspinall is on the board of OraSure Technologies, one of several companies that manufactures rapid coronavirus tests.)
Not all of those tests will be headed straight to drugstore shelves, though. Many will end up in doctor’s offices and other health-care settings, to be used as point-of-care alternatives to slower laboratory tests; others will be bought by businesses hoping to screen people at conferences or workplaces, perhaps to comply with a mandate. The Biden administration’s pledge to produce more “rapid” tests is also a catchall—every test that falls into this category is fast, but not all are intended for easy, at-home, over-the-counter use. A few require a prescription; a few need a telehealth proctor to supervise the process. Their design and price tags vary too; some, like the BinaxNOW, look for antigens, while others, such as the Lucira, are sped-up PCR-like tests. Those latter ones also tend to cost a lot more, many upwards of $50 a pop. The administration has said that about 200 million at-home rapid tests could be available to Americans each month by the end of the year, but in a country with 330 million residents, that will go only so far.
I’ve been intermittently checking online retail sites since the CVS incident, and the tests do seem to have become more available. My CVS is still limiting purchases, but in the past couple of days, I was told once that I could now buy two boxes and another time that I could buy four. Even so, several experts told me they’re worried about the surge in demand that could come in the few days before Thanksgiving. “Trying to get those tests the week of will be an unmitigated disaster,” Susan Butler-Wu, a clinical microbiologist at the University of Southern California’s Keck School of Medicine, told me. The best move will probably involve nabbing some tests well before the turkey starts defrosting or brining.
Aspinall also recommends taking a “test agnostic” approach. Serially administering antigen tests is great; so is scoring a no- or low-cost PCR swab at a community site, if there’s time to wait for results. If needed, families with no recent exposures, who are headed into low-risk gatherings—at which everyone’s vaccinated and meeting outdoors, for instance—might be able to get away with antigen-testing just once. Shortcutting tests, though, gets riskier when entering crowds of strangers or places where the virus is surging, or mingling with uninoculated people, sans masks or indoors. “Then you should be doing two [at-home rapid] tests,” Aspinall said. (She and her husband always test twice before visiting their young grandson.) And no matter how or how often negative results are produced, they aren’t insta-armor against SARS-CoV-2, Babady told me. Tests offer none of the protection that vaccines do, and work best when accompanied by other measures that actively prevent infection from taking hold.
But tests can be such a powerful partner to shots and masks that they’re worth seeking out. After spending some quality time with my laptop this weekend, I was able to find several retailers selling at-home antigen tests at $14 per two-pack (about as cheap as they come in the United States); I finally bought enough to keep my household supplied through our expected December gatherings. Even testing at home drains time and resources. More supply will hopefully solve the first problem and help with the second—but for now, adequate testing remains a privilege reserved for those who can afford it.