Arkansas has tested a lower percentage of its residents for coronavirus than all of its neighbors but Texas, according to a comparison by the Arkansas Democrat-Gazette.

The state's guidelines for testing have broadened in the past three months, but still, obtaining a test depends on where in Arkansas a person is.

As of Monday afternoon, Arkansas had tested more than 26,000 people. With a population of about 3 million, that means fewer than 1% of state residents have been tested for the virus.

A comparison of Arkansas with 13 other states -- its neighbors, plus other states to the east -- showed that most of them also tested fewer than 1% of their residents.

The lowest in the comparison was Texas, which tested 0.63% of its 8.5 million population.

In contrast, Louisiana -- which has more than 24,500 cases and more than 1,300 deaths -- has tested 3.04% of its 4.6 million residents. Louisiana has the highest number of cases among southeast states, but is also testing more of its residents -- more than 141,000 as of Monday.

Tennessee has tested 1.42% of its 6.8 million population. That state has 7,070 confirmed cases and 148 deaths.

Arkansas' first case was reported on March 11. By Monday afternoon, the state had more than 2,000 positive cases and 42 deaths.

CHANGES IN TESTING

In Arkansas, testing has been limited first by capacity, then by shortages of materials to run tests, both of which led to restrictive criteria for who was eligible for testing.

As covid-19 began its U.S. spread, the Arkansas Department of Health's guidelines for who should be considered a "person under investigation" -- i.e., who's a likely candidate to receive a test -- were once quite limited, records show.

In February, almost a month before the first case was discovered in the state, only people with symptoms and a history of exposure or who recently had traveled to China were considered likely cases.

Those guidelines expanded by March 5 to include hospitalized people with fever and respiratory issues who tested negative for flu and other infections.

On March 19, state Health Secretary Nate Smith wrote that providers should use "their best clinical judgment" in deciding who needs a test, but "some facilities are running low on testing supplies, so please consider the following criteria for priority testing in order to preserve supplies."

He proposed prioritizing hospitalized patients who might spread infection in health care settings; people at risk of poor outcomes because of age or health status; and people with known exposure to covid-19, including health care workers.

Recent criteria on the Health Department's website separated potential patients into three priority groups for testing. They are, in descending order:

• Hospitalized patients and health care workers with symptoms.

• People with symptoms who are residents of long-term care facilities, over age 65, who have other health conditions or are first responders.

• Symptomatic critical infrastructure workers or people who don't fit in other categories; people with mild symptoms in heavily impacted communities; and health workers and first responders

People without symptoms are a "non-priority" group, the guidance said.

"This has been a fast-moving, fast-changing pandemic and we are learning so much so fast that our [recommendations] and guidelines and priorities have had to change," Dr. Joel Tumlison, physician specialist with the Health Department, wrote in an email.

On Wednesday, Smith announced that the agency's criteria for who should receive a test would broaden to include any patient with symptoms, as long as the health care provider has adequate testing supplies.

The Health Department also is ramping up its staffing in order to do more of identifying who has had contact with a known positive case. About 150 extra staffers will be added, Smith said.

TESTING CAPABILITY

Arkansas has dozens of testing sites around the state. The higher the population, the greater number of sites.

In the southern half of the state, though, the sites are widely scattered and few, according to a Health Department map.

In Union County, the Health Department only lists one testing site -- a medical clinic in Strong. No testing sites are listed for the county's seat, El Dorado. Likewise, only one site is listed for Clark County -- a clinic in Arkadelphia.

The screening criteria vary from site to site and from doctor to doctor. For some, an asymptomatic person can be tested if they've been exposed to the virus, while other sites test those with symptoms.

At Conway Regional Health System, the drive-thru testing can only be used by those with a referral from their doctor. Still, even with a doctor's order, those without covid-19-type symptoms may be denied testing.

"If the volume picks up, we may have to prioritize our testing even further," said Matt Troup, president and chief executive officer of Conway Regional.

The Conway hospital has performed about 1,300 call-center screenings and about 900 covid-19 tests in its drive-thru testing site, the emergency room and inpatient testing.

"We prefer a doctor's referral, but we also have a nurse practitioner on site to perform assessments," Troup said.

At Washington Regional Medical Center in Fayetteville, all symptomatic individuals, age 10 and older, are being tested, regardless if they have a doctor's referral or not.

"We are not testing individuals without symptoms," said Natalie Ladd Hardin, the hospital's marketing director.

The University of Arkansas for Medical Sciences in Little Rock has performed about 3,364 tests and has screened nearly 14,000 people, said spokeswoman Leslie Taylor. A doctor's order is not required.

The health system has numerous testing sites and also conducts mobile testing at locations around the state, such as Helena-West Helena, Forrest City and Texarkana. Mobile screenings are planned in Marianna, McGehee and East Camden.

"Patients undergo a screening first. They are asked a variety of questions including if they have been out-of-state in the last 14 days, if they have had contact with someone known or suspected to be positive for COVID-19," Taylor said. "They are also checked for symptoms like fever, cough, shortness of breath. From that screening the health care professionals determine if the patient should be tested."

Those without symptoms will not be tested at UAMS, Taylor added.

[CORONAVIRUS: Click here for our complete coverage » arkansasonline.com/coronavirus]

At St. Bernards Healthcare in Jonesboro, a doctor's order is not required for testing because the hospital conducts its own screening using the app St. Bernards Go or through the facility's hotline, said spokesman Mitchell Nail. If further testing is indicated, the patient is directed to the hospital's urgent care clinic, where he or she receives additional screening in their vehicle.

A person who does not exhibit covid-19 symptoms will not be tested, Nail added.

"We have not reached the point where we test every person who logs onto our app or visits our clinic," Nail said.

The Jonesboro hospital has an adequate supply of test kits and is receiving more, but Nail said one of the challenges it has experienced is not receiving the test kits quickly enough.

"We hope to eventually open testing to a greater number of individuals," Nail said.

According to the U.S. Centers for Disease Control and Prevention, the main way the virus is thought to spread is through respiratory droplets when someone sneezes or coughs. People who are infected but don't have symptoms can likely still infect others.

SUPPLY NEEDS

States across the nation have grappled with a shortage of covid-19 testing supplies, and Arkansas is no exception.

UAMS develops some of its tests in its own labs, but also purchases test kits from a commercial supplier, Taylor said.

At Conway Regional, Troup said the hospital partners with Mayo Clinic in Rochester, N.Y.

"They have to have a special swab that preserves the sample until it can get up to Rochester for testing," Troup said. The testing supply is adequate now, Troup said, but that could change when the hospital resumes elective surgeries.

"Today we're in a pretty good spot with Mayo," Troup said. "When we start doing elective surgeries, I can see us testing patients before we operate and we don't know what to anticipate at that time. It's an unknown."

Nationally, the Trump administration announced plans for states to reopen businesses and schools, but public health experts and politicians say widespread testing is needed first.

Tennessee Gov. Bill Lee has announced that free covid-19 testing will be available for any resident, regardless of symptoms.

"As we look to reboot our state's economy, we must have a greater understanding of how this virus is operating in Tennessee," Lee said in a news release. "Expanding our COVID-19 testing capacity allows more Tennesseans to have improved access to testing which will empower citizens to make informed health decisions."

The Tennessee National Guard and the Tennessee Department of Health Nurses will perform tests at various pop-up sites around the state.

"Our clinical understanding of COVID-19 is changing rapidly and we need every Tennessean who isn't feeling well, even outside of the traditional COVID-19 symptoms of cough, fever or difficulty breathing, to come out and get tested," said the Tennessee Department of Health commissioner, Dr. Lisa Piercey.

The national shortage of reagents -- chemicals and materials necessary to run tests -- continues to weigh on UAMS' efforts to expand testing in its lab.

In mid-April, Taylor said the site has been able process about 80-100 tests per day. UAMS also has processed samples through commercial labs.

The in-house tests can be processed in about six hours, while the commercial labs results come back in two days, she said.

Lab results through the Health Department are taking about 48 hours to come back, but the department does not have a good estimate for results from commercial labs, a spokeswoman said.

PERSONAL STORIES

When Tau Carter, 44, developed symptoms, including a headache, backache and a fever of 99.8 earlier this month, he went to a testing facility to get screened, but was denied a test.

"They said, 'Well, you don't meet the criteria, so you need to go home and self-quarantine for seven to 10 days,'" the Little Rock resident said.

He wondered if he was denied a test because of his race, and said that he "felt marginalized" when he learned that the coronavirus has disproportionately caused the deaths of black Americans.

A Conway mother who did not want to be identified said she and her family returned from a Florida funeral when her teenage son developed a dry cough and chest tightness. The family tried to get tested at Conway Regional, but were denied.

"My concern was at that time, why didn't they test us?" she said. "We drove through Tennessee, Mississippi and Florida up there and back. We stopped at numerous gas stations for gas and bathroom breaks."

The family was never tested, but are now symptom-free, she said. Her two teenagers work at big-box retail stores and she said her biggest fear is that they transmitted the virus to others.

A Sherwood woman said that in early March, she started having difficulty breathing and chest discomfort. A scan to determine if she was experiencing heart problems and a flu test were both negative.

Her condition worsened and her doctor prescribed an inhaler and prescribed Tessalon Perles, a medication used to treat coughs and other respiratory ailments. Her doctor ordered a coronavirus test, but the woman said Conway Regional declined to test when she said she had not traveled out of the country.

"I really think I had bronchitis, but with a negative flu test and clean X-ray, we were really concerned about coronavirus," she said.

Alicia Austin said that when her 6-year-old daughter's sore throat expanded to a cough and a 103-degree fever, she took her to the pediatrician for a flu and strep test. Both were negative.

When her daughter began coughing so bad her inhaler wasn't helping, she took her to the emergency room at Arkansas Children's in Little Rock. An X-ray showed that her lungs were cleared, so she was sent home with steroid.

"I asked both Children's Hospital and her doctor about a covid-19 test, but they said kids weren't getting it and we were refused a test," Austin said.

Her daughter still requires regular albuterol inhaler treatments and her son also later contracted the same symptoms.

"His lasted about four days," Austin said. "So we still don't know if that's what she had. The doctors just said it was a virus."

LOOKING AHEAD

Serological tests -- which examine the blood for antibodies or proteins that developed in response to specific infections -- are on the horizon.

Because those tests are unlikely to identify those cells early in an infection, they should not be used as the sole basis for diagnosing covid-19, the U.S. Food and Drug Administration said earlier this month.

However, they may help doctors better understand who has already been infected and recovered.

On April 1, the agency approved the first serological test for covid-19 -- made by North Carolina-based diagnostics company Cellex, and intended for use by clinical labs -- under an emergency-use authorization. Two others were recently approved.

Gov. Asa Hutchinson said at a news conference Friday that a downward trajectory of either documented covid-19 cases over two weeks or positive tests as a percent of total tests must be met before the state can begin the first phase of the "Opening Up America Again" plan proposed by the White House last week.

Public health officials and advocates, including former FDA Commissioner Scott Gottlieb, have emphasized the importance of easily available testing for any plan to return to normal life.

But the lack of accessible, widespread testing may also skewer the reported number of deaths in the state, some officials say.

Crittenden County Coroner William Wolfe, echoing his colleagues nationwide, said he believes the announced count of covid-19 deaths will be less than the actual deaths. People who die in their homes could have contracted the virus without knowing it, he said.

Wolfe said he's made two house calls in which he believed the death could have been related to covid-19, but he did not have tests to verify whether the disease was present.

"In my mind, that's what it was," he said April 9, adding: "It's not just here. It's nationwide."

Information for this article was contributed by Eric Besson of the Arkansas Democrat-Gazette.

A Section on 04/21/2020