From the very beginning of the coronavirus outbreak in the US, there have been issues with testing for who does and doesn’t have the virus. The testing challenges make is impossible to know the extent of the outbreak because the country cannot determine exactly how many people have the virus.

Here is a look at what went wrong, the current state of coronavirus testing in Massachusetts, and what future tests may look like.

Early Challenges

At the very end of December 2019, Chinese officials confirmed that they were treating dozens of cases of a new virus that was soon identified as coronavirus disease 2019 or COVID-19.

In late January, the Centers for Disease Control and Prevention, or the CDC, put out a protocolfor testing, said Elizabeth Talbot, a professor and infectious disease doctor at Dartmouth-Hitchcock Medical Center and the deputy state epidemiologist for New Hampshire. The protocol specified exactly what symptoms and criteria a patient needs to get approval to be tested.

Then, in early February, the CDC approved a test. Six days later it was sent out, said Talbot.

“But we found very quickly that there was a flaw in some technical aspect of the test that put a halt on our using this locally,” said Talbot. “So, in the first weeks of this unfolding epidemic, really, clinicians were hamstrung. We were not able to test the people that we thought should be tested.”

The immediate answer was for doctors who see patients that fit the criteria for testing to ask the CDC to approve a test. Then the doctors would send their patients’ specimens to Atlanta, where the CDC is headquartered, for their lab to test.

“But you can imagine, each of these steps introduces important hours and days before we have the answer,” said Talbot. She said that wasted valuable time that could have been used trying to contain the spread of the virus.

In other countriesresponding to the outbreak of COVID-19, testing has been widely available. In South Korea, for example, there are drive-through testing sites, and the total number of people tested is now more than 100,000. Similarly, in Australia, testing is both free and available widely.

Current Testing in Massachusetts

Fast forward to today, Massachusetts can perform tests in the state, but there are still some significant limitations.

If a healthcare provider sees a patient that fits the CDC guidelines for testing, then they call a phone line set up by the state’s Department of Public Health to discuss the situation and get authorization for testing.

If testing is approved, the patient’s samples are then sent – usually by courier – to the Massachusetts State Public Health Lab, which is the only lab in the state approved to do testing. It takes about 24 to 48 hours to get results back from the lab.

“The State Public Health Lab is working on a 24/7 process to run these labs,” said Monica Bharel, the State’s Public Health Commissioner, on Tuesday when speaking at a press conference where Governor Charlie Baker declared a State of Emergency.

Bharel said the state received approval from the CDC this week to automate part of the testing.

“You’ve heard us talk about this before, ‘[We are] running roughly 50 tests a day.’ This will increase our capacity to over 200 tests a day because of this automation piece,” said Bharel.

Two days later, at a press conference in Pittsfield on Thursday, Baker said, “we need much more testing capability.”

All labs must be approved by the federal government before doing testing and Baker has called on the federal government to expedite that process.

Baker could not say exactly how many people in the state have been tested. He did say the state now has an additional 5000 coronavirus tests, in addition to its previous supply.

However, on social media, doctors in Massachusetts have expressed outrage at the lack of testing availability.

“Saw several people w probable coronavirus this week, some had been on buses and planes even this week, testing pending for some but the State wouldn’t let us test them all. Not enough tests!!” wrote Monique Aurora Tello, a physician at Massachusetts General Hospital, on Facebook on Wednesday.

Eyal Kimchi, also a doctor at Mass. General, tweeted on Thursday: “Testing has been limited in the city that perhaps does more biomedical research than any other in the world.”

Baker has said he’d like to see labs at academic medical centers get approved to do the testing.

“I certainly think this is right up there on the list of things we want to see the feds [federal government] help us with as quickly as possible,” Baker said. All labs must be approved by the federal government before doing testing.

Bharel said Massachusetts had just received 2,000 more test kits from the federal government and that the state is requesting more testing kits.

What Will Future Testing Look Like?

Despite the scramble to get more labs approved to do testing, Talbot said the ultimate goal is that testing does not happen in labs.

“What we really want is a test that tests for infectiousness and could even be done at what we call ‘point of care.’ So how about a rapid test that can be done in the time that you’re sitting with your doctor? This is the model of our strep test, our pregnancy tests, our flu tests,” said Talbot.

Even better, she said, would be a test you can do at home and send into the hospital so that nobody else is exposed at the doctor’s office. Talbot said lots of places are working on developing this capability, but it is likely many months away.

But, she said, another option might come sooner: an antibody test that can tell us a bit more about the infected person.

Whereas the current test the CDC is performing can only detect whether the person has any fragment of the virus in them, Dr. Talbot said an antibody test can determine whether someone is currently contagious or was previously infected but is no longer contagious.

At the epicenter of the outbreak in Wuhan, China, they are already using an antibody test throughout the population, said Talbot. This kind of test is critical because “sometimes people are so minimally symptomatic they wouldn’t necessarily consider coming to a doctor or going to an emergency room,” she said.

But even if they don’t have symptoms, they would give the illness to someone else and that person could be at higher risk because of an underlying health problem or being elderly.

Talbot said getting better tests and more tests is key. But, she also warned, we should start thinking about this coronavirus outbreak lasting months and not just a few more weeks.