A woman is tested for COVID-19 in a parking lot in Richmond where the health department set up a temporary walk-up testing center. (Ned Oliver/Virginia Mercury)

In late May, 536 people registered for one of the Richmond-Henrico Health District’s COVID-19 community testing events. Throughout the summer, including much of August, attendance rarely dipped below 150.

But for the past few weeks, registration numbers have taken a dive. One of the district’s latest events, organized in the parking lot of the Eastern Henrico Health Department earlier this month, only attracted 48 people. Other health departments and their community partners across Virginia have noticed a similar trend. 

New River Health District, which stretches across four counties in Southwest Virginia, pared down community testing events to three days a week in late September, attributing the new schedule to “low-level community spread and a decrease in demand.” Thomas Jefferson Health District — centered in Charlottesville with local departments in Fluvanna, Greene, Louisa and Nelson counties — has seen testing decrease in “more rural localities,” with anywhere from a 10 to 50 percent drop in attendance, according to emergency manager Jessica Coughlin.

While explaining the decline isn’t always clear-cut, some health officials are citing “COVID fatigue” as the ongoing pandemic stretches into its eighth month. “I think a lot of it has to do with people kind of learning to live life and navigate life with COVID,” said Dr. Noelle Bissell, director of the New River Health District, in a media call last week. “A couple of months ago, people who practiced very low-risk lifestyles and were abiding by the precautions still wanted to get tested to know. And we’re just not seeing that right now.” 

But other experts worry part of the drop has to do with people fearing the loss of a job or a paycheck because of a positive test result. When the state’s General Assembly convened in August for a special session largely focused on the pandemic, legislators listed protections such as paid sick time and expanded worker’s compensation as some of their biggest priorities. Those pieces of legislation have been largely unsuccessful as the session draws to a close. 

A particular blow to workers and their advocates was the death of a bill — less than a month after lawmakers first met in Richmond — that would have guaranteed two weeks of paid quarantine leave to most employees working 20 hours or more a week.

“Particularly for lower-income communities, the calculation that you make, about fear of the disease versus the consequences of having a positive test, is different than it might be for other folks,” said Dr. Danny Avula, director of the Richmond-Henrico Health District. “They know that if they have a positive test, they’re going to be out of work for 10 days.”

“I actually think it’s a very widespread concern,” he added. “It’s not just a small percentage of folks. For low-income African Americans, and particularly undocumented Spanish-speaking residents, it is a major, major liability for them to get tested.”

As COVID cases in some parts of the state begin to increase after a significant drop through much of September — a month that saw Virginia’s percentage of positive tests fall below 5 percent — public health experts worry the lack of protections could hinder testing efforts. Dr. Mike Murchie, the medical director for CrossOver Healthcare Ministry, a free clinic in Richmond, said his office saw testing numbers fall significantly in late July after the Centers for Disease Control and Prevention changed its guidelines for when employees should be allowed to return to work after testing positive.

Previously, one option recommended by the agency was a test-based strategy, which called for at least one negative follow-up result before employees could return to the workplace. But that guidance changed as more research began to show that some patients continued to test positive for the virus for more than 10 days — past the window when doctors believed they were still at risk for spreading it to others.

“Now they’re actually discouraging that strategy,” Murchie said. “And that’s been a significant factor because we used to get tons of calls for people who had COVID and were trying to get back to work.” 

He is worried about the possibility that more patients are choosing not to get tested because they don’t have to be, or that less emphasis on testing might mean that some workers are choosing to forgo it rather than risk missing work with no pay.

But Murchie also described himself as “a little bit ambivalent” about the recent decline in attendance. While local health centers always worry about a lack of access to health care, he said the drop could also mean that communities were taking precautions like social distancing and quarantining more seriously. In May, the clinic had a staggering 46 percent positivity rate among the tests it was conducting. By September, that had fallen to 13 percent, according to Megan Mann, CrossOver’s director of resource development and communications.

A medical worker with Neighborhood Health, a chain of community clinics in Northern Virginia, swabs a resident for COVID-19 at a testing event in Alexandria. (Photo courtesy of Neighborhood Health)

“So, at the same time, there’s likely some good news in the decreased demand,” Murchie added. The clinic has been getting fewer calls from the Hispanic community — one of the groups hit most disproportionately by the virus — with concerns over possible symptoms. Another potential theory is that the virus has run its course through some vulnerable communities and left them with some degree of immunity, though it’s still not totally clear how long that immunity lasts (some studies have found antibody responses that remained for at least three months) or how many people need to contract COVID-19 for a community to truly be protected.

“This is where it gets to be speculation,” Murchie said. “It’s possible, but nothing right now is certain.” For Avula, policy is the most direct way of making sure no one opts against testing for financial reasons.

“Particularly during a pandemic, we should just be really generous and not force people to make a decision about whether they’re going to potentially expose others or not have food on the table,” he said. Catherine Long, the collective impact and communications coordinator for the Richmond Health District, added that some of the department’s community health workers have heard from residents who are worried their supervisors might find out if they get tested — especially in more transient industries such as construction.

“It’s been surprising to me, but maybe not to others, that a lot of people don’t necessarily know the company they work for,” she said. “They might know their direct supervisor, but they’re not quite sure who they work for officially. And I would speculate that if you don’t know the name of the company you work for, you might not know your rights and your HR policies when it comes to testing.”

Many health officials are taking a wait-and-see approach into the fall and winter, when cases are expected to rise as people spend more time inside. After September’s significant decline, COVID-19 metrics are trending upward again in some areas of Virginia. That includes Richmond, where a new nursing home outbreak — and recent wedding — caused a spike in cases.

The flu and other seasonal respiratory diseases could also complicate things. Long said the department is still waiting to see if people assume potential COVID symptoms are the result of another illness (driving demand down) or if they decide to get tested more often as a precaution. Health officials are universally urging Virginians to get their flu shots, hoping it will reduce potential confusion around two diseases with very similar symptoms.

“People should err on the side of testing,” Murchie added, “because it’s a lack of awareness that leads to people getting exposed.” But he also expects recent testing trends will reverse as seasonal illnesses begin to circulate again. 

“We can’t rest on our laurels,” he said. “I think the demand is going to spike.”