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

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  How often do persons with new febrile illness access coronavirus testing and receive a test result within 7 days of illness onset?

Findings  In this cohort study, generally low rates of coronavirus testing were observed in 2679 participants reporting new onset of febrile illness. Although testing rates improved somewhat during the study period, timely coronavirus test results were sought and received by only 25.9% of newly febrile persons at the end of the study analysis period in late October 2020.

Meaning  Our results suggest systematic underuse of coronavirus testing in patients with febrile illness that may contribute to community transmission.


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.

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Article Information

Accepted for Publication: March 11, 2021.

Published: May 3, 2021. doi:10.1001/jamanetworkopen.2021.8500

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Pletcher MJ et al. JAMA Network Open.

Corresponding Author: Mark J. Pletcher, MD, MPH, Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th St, Mission Hall, 2nd Flr, San Francisco, CA 94143-0560 (

Author Contributions: Dr Pletcher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Pletcher, Olgin, Peyser, Martin, Carton, Marcus.

Acquisition, analysis, or interpretation of data: Pletcher, Olgin, Peyser, Modrow, Lin, Beatty, Vittinghoff, Marcus.

Drafting of the manuscript: Pletcher.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Pletcher, Lin, Vittinghoff.

Obtained funding: Pletcher, Olgin, Modrow, Martin, Carton, Marcus.

Administrative, technical, or material support: Olgin, Peyser, Modrow, Martin, Carton, Marcus.

Supervision: Olgin.

Conflict of Interest Disclosures: Dr Beatty reported Apple Inc stock ownership and employment from 2018 to 2019 outside the submitted work. No other disclosures were reported.

Funding/Support: This study has received support from the Patient-Centered Outcomes Research Institute (PCORI, contract COVID-2020C2-10761), the Bill and Melinda Gates Foundation (INV-017206), and the National Institutes of Health (3U2CEB021881-05S1).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors would like to thank the Citizen Scientists participating in the COVID-19 Citizen Science Study. They were not compensated.

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