Desperate to save its pandemic-delayed football season last fall, the Pac-12 made a wager.
Rapid antigen tests — a new technology for detecting the coronavirus — had hit the market in recent months, offering results in 15 minutes. The Pac-12, and other athletic conferences, wanted to try an unproven use: to screen healthy athletes daily for the coronavirus.
Conference Commissioner Larry Scott brokered a deal with Quidel, a prominent test manufacturer, and hailed the tests as a “game-changer.”
But behind the scenes, a debate raged over whether the tests could live up to their promise.
A UW Medicine testing expert warned colleagues the tests wouldn’t catch asymptomatic carriers. UW President Ana Mari Cauce worried the universities were being “duped” by Quidel. And the UW head of sports medicine, who helped lead the conference’s testing efforts, feared giving the public impression that students were serving as “guinea pigs.”
In the end, the University of Washington spent more than half a million dollars on these tests, saw three of its football games canceled and lost millions in revenue, contributing to the athletic department’s financial troubles.
Throughout the Pac-12, nearly one out of every five athletes in high-contact sports tested positive for COVID-19, and the conference grappled with two outbreaks.
New research on antigen testing, including a study of Pac-12 athletes, reveals how even daily testing can fall short. False negative test results, while rare, left Pac-12 schools unlikely to catch every case where someone is newly infected and could soon be shedding virus.
And the tests are likely to produce some false positive results, also rare, in a population of healthy young adults. A separate study on Midwest college campuses found that antigen tests returned two false positive results for every true positive in asymptomatic people.
Even with those limitations, rapid antigen tests — relatively cheap and easy to operate — are likely to become a larger part of daily lives, appearing on pharmacy shelves, at K-12 schools and in workplaces.
The UW and Pac-12 experience offers an important lesson: Testing alone can’t stop the spread of the coronavirus in environments like a locker room. And while antigen tests found infections and likely helped contain or prevent outbreaks, universities also decided to regularly use expensive PCR tests, considered the “gold standard” for diagnosing COVID-19 — a luxury likely not available to many organizations.
The UW doctor who led the conference’s testing efforts said antigen tests were among the best tools available at the time, and paired with PCR tests, the screening allowed play to resume. Most of the athletes were infected away from the locker room and off the field, she said.
“We did a very good job of preventing spread playing sports,” said Dr. Kim Harmon, the head of sports medicine for UW. “I do think it was a game-changer then, but it’s not a perfect solution.”
“We will have been duped”
Facing a loss of hundreds of millions of dollars in revenue from television rights fees, and with many students eager to play, the Pac-12 and universities were up against enormous pressure last summer to safely return football and other sports to the field.
“It was very obvious early on that without sports on TV you were going to go bankrupt,” said David Harris, a professor of immunobiology who helped launch antigen testing at the University of Arizona. “To pay a couple million for tests instead … The alternative is there are furloughs, layoffs.”
As part of its “groundbreaking” deal with Quidel, the Pac-12 promised a study of the rapid testing regime, with researchers examining how the virus behaves in asymptomatic and pre-symptomatic carriers.
But antigen tests had skeptics.
Before the deal was signed, Dr. Geoffrey Baird, the acting chair of the UW’s Department of Laboratory Medicine, warned Pac-12 team doctors that the tests would not catch asymptomatic carriers of the coronavirus, and that most of the positive results would be false positives, according to an email by Baird obtained by The Seattle Times in a public disclosure request.
“They will probably be not much more effective in detecting cases than symptom checking,” he wrote.
When Cauce, the UW president, learned about Baird’s concerns — after the Quidel deal had already been announced — she was surprised.
“I am hoping that we turn out to be wrong and the test works beautifully for asymptomatics,” she emailed Scott, the Pac-12 commissioner. “But, if this is NOT the case we will have been duped and the academic reputation of our universities will have been not only misused but tarnished.”
In another email chain, officials commented on draft versions of the Pac-12 news release announcing the testing and study plans. “I understand we need to walk the line between putting together a research proposal and using our athletes as guinea pigs,” Harmon commented.
The debate over testing may have remained out of the public eye if The Seattle Times had not sued the University of Washington for access to internal emails — which are public records — after the UW denied the records existed.
UW spokesman Victor Balta said in a prepared statement that the university initially did a “reasonable search” for messages and found none, but that “another look, prompted by The Seattle Times’ challenge, turned up about a dozen email threads.”
“The records in question were not withheld and there was no effort to deny access to them,” Balta said.
A critical part of the Pac-12’s back-to-the-field plan was to buttress the rapid antigen tests with widespread PCR testing.
Considered slower and more expensive but more accurate, the PCR tests detect genetic material specific to the coronavirus. They are able to spot trace amounts of viral RNA very early in an infection.
Antigen tests, on the other hand, look for protein fragments associated with the coronavirus, but those proteins may not yet be detectable while the virus is initially replicating inside cells.
While less accurate, antigen tests had the advantages of cost and speed. In the fall some universities could obtain PCR tests for about $60 a piece, while Quidel’s tests cost about $20. PCR tests could take days to turn around, while antigen results could be ready in 15 minutes.
Relying on both systems, the Pac-12 testing program required a monumental effort. Eleven universities ultimately participated in the Pac-12 study analyzing that work, which was funded by Quidel and conducted independently by university researchers.
These universities conducted 81,175 antigen tests and 42,187 PCR tests from late September to late February for football, basketball, water polo and wrestling athletes who had agreed to share medical data.
“I did not want to depend on antigen testing alone to make important decisions about our students’ health and safety, which is why we did weekly PCR tests,” Cauce said in response to emailed questions from The Seattle Times.
Football players took antigen tests before practices and games, lining up in small groups before swabbing their own nostrils and dropping the swabs in a tube. Social distancing and masks were enforced.
When cases rose among teams, PCR testing also increased, with up to seven tests a week for some athletes. UW spent $380,000 for the fiscal year on PCR testing.
To date, UW has spent $517,588 on Quidel test kits and analyzers — including about 1,450 tests each week, according to Balta.
San Diego-based Quidel doubled its revenue in 2020 from $534.9 million to $1.7 billion, with most of the increase attributed to COVID-19 tests in the fourth quarter of 2020 — after the Pac-12 deal was struck.
“All of us at Quidel are deeply proud of our COVID-19 testing partnership with the Pac-12 Conference and the tremendous success achieved in protecting student athletes and facilitating their return to the sports competition,” Quidel CEO Douglas Bryant said in a statement.
Other conferences, including the Big Ten, also relied on antigen testing, but COVID proved to be a problem across college football and basketball, including an outbreak on UW the football team.
The UW Athletics Department projects a $65 million drop in revenue for fiscal year 2021, which ends in June. That reflects a decrease in Pac-12 football distributions due to game cancellations and a loss of ticket sales. Increased fundraising offset $15 million of the losses.
While the science is still early and unsettled, with much of it yet to receive peer review, a handful of separate studies on antigen testing at college campuses — including the Pac-12 research — underscores the trade-offs of the rapid results.
In a U.S. Centers for Disease Control and Prevention report on Midwest campuses, tests of 871 asymptomatic college students and staffers found that with antigen testing “for every true positive, we got two false positives,” said Ian Pray, the study’s lead author.
While false positives are disruptive — forcing students to unnecessarily quarantine — a single false negative test could carry significant consequences.
After an outbreak among 32 University of Wisconsin football players and staffers, researchers used genomic sequencing to map the virus’ spread. They found that the player whose infection likely started the outbreak had tested negative by Quidel’s antigen test, then attended team meetings and interacted with roommates.
The next day, when the athlete’s daily antigen test was positive and he developed symptoms, it was too late, said Gage Moreno, a lead author of a study examining the outbreak.
“A few days later, seven additional individuals had tested positive,” Moreno said. “They eventually decided to shut down the team, they canceled all practices, they stopped their competition and they quarantined everyone.”
Moreno’s research of a separate outbreak among hockey players at two schools suggests that the coronavirus was likely transmitted during competition.
Although both antigen and PCR performed well when people were likely contagious, the more sensitive PCR tests were more often able to identify people earlier in their infection — even one or two days before they began to shed virus, according to a study led by University of Illinois researchers.
Antigen testing “may miss people during those first few days of infection,” said Christopher Brooke, an assistant professor in microbiology with the University of Illinois.
That could explain why — very rarely — Pac-12 athletes who received negative antigen results were actually positive the same day when tested with PCR. On days when schools used both tests, this happened 64 times out of 23,463 results. (Inaccurate PCR results are another possible explanation.)
All of these studies tell portions of the same story: that daily antigen testing couldn’t prevent the virus from penetrating locker rooms or keep it off the playing field entirely. However, it could help identify cases and limit spread.
“The ideal testing regime would be frequent [PCR] testing with rapid results reporting. That’s not possible everywhere,” Brooke said. “In the absence of that, antigen testing can be really effective at identifying infected individuals, but it’s going to have to be part of a serial, frequent testing program where you’re testing every few days.”
From Harmon’s perspective, the Pac-12 testing program — with the combination of PCR and antigen testing — performed admirably.
The Pac-12’s study found that most cases of COVID-19 among athletes originated outside of sports, but it documented two outbreaks attributed to sports activities that involved two teams and a total of 48 football players.
False positives were rare and manageable, Harmon said, and players would simply miss a day or two of practice.
UW continued to rely on antigen testing this spring. UW running back Richard Newton missed two of his team’s first three practices because of false-positive COVID-19 tests, head coach Jimmy Lake said on April 14.
Elsewhere in the Pac-12, false-positive tests kept Stanford quarterback Davis Mills, senior wide receiver Connor Wedington and junior defensive end Trey LaBounty out of their season opener at Oregon on Nov. 7. Without their starting quarterback, the Cardinal lost, 35-14.
For game days, UW relied on antigen testing to catch infections. Two-hour PCR tests were available to assess positive results.
Perfect or not, antigen testing and screening might become a fixture of daily life, as long as the coronavirus endures.
Tests are now available on local pharmacies’ shelves. The Food and Drug Administration granted Quidel emergency authorization allowing it to market its own at-home test.
The federal government in March announced it would provide free at-home tests to 160,000 residents in Tennessee and North Carolina in hopes that regular testing will drive down transmission.
K-12 schools in Washington have used the tests to screen students. Last fall, the Pierce County Council approved spending $7.8 million in federal funding on antigen screening in the Eatonville, Peninsula and White River school districts.
Critics like Baird remain skeptical of the tests’ utility.
“It allows outbreaks because it misses infectious people,” he wrote in an email. If Big Ten football programs — with “robust” protocols — couldn’t prevent outbreaks, he asked, how could we expect that in K-12 schools?
But Cauce, the UW president, called it a “useful tool” that, when used frequently, identifies infectious people.
She added: “What we learned was that you can’t test your way out of a pandemic.”
Seattle Times staff reporter Mike Vorel contributed to this story.