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Covid-19 testing practices impacted public perception as much as they did clinical protocols — which now poses significant challenges as new variants emerge. For millions of Americans, the jarring memory of a swab probing deeply into their nasal cavity led to fear of testing, avoidance, a general sense of test fatigue and the strongly held sentiment of “Never again!”
With the reputation of upper respiratory infection (URI) sampling still shaped by pain and loathing, healthcare systems are facing a widening diagnostic gap undermining outbreak preparedness and response. To close it, we must reassess not only the efficacy of our samples, but also how we collect them.
Fortunately, recent advancements in nasal lavage have positioned this long-established method to play a larger role in modern specimen collection — just as practical as the swab, but offering a host of additional benefits to patients, healthcare personnel and labs.
How and why swabs became the Covid-19 sampling standard
When the pandemic descended upon healthcare systems around the world, speed was paramount. Nasopharyngeal swabs thus became the default for URI specimen collection; not because they were the ideal method, but because they were the only one that could meet the unprecedented demand.
Existing supply chains, manufacturing capacity and provider familiarity allowed swabs to be distributed and deployed more rapidly than other methods. For example, although evidence-backed nasal lavage had been used in clinical and research settings for decades prior to Covid-19, it lacked the standardization and logistical feasibility needed for worldwide rollout.
But as the limitations of swab-based testing became more evident, we learned widespread adoption didn’t equate to clinical excellence. These devices were subject to healthcare personnel technique and patient cooperation and behaviors, often leading to safety risks, inadequate samples and delayed diagnoses. Add in significant discomfort for the patient, and it’s no surprise testing avoidance surged.
Despite the important role of nasal swabs during the pandemic, experts acknowledged that supply chain decisions sometimes came at the expense of long-term diagnostic quality.
Nasal swab discomfort and injury risks drive avoidance and fuel the spread
During the peak of Covid-19 testing, patient nasal swab complaints were very common. Swab-based specimen collection requires deep insertion into the nasal cavity (4 to 6 inches), which provoked involuntary reactions such as flinching, sneezing, gagging, coughing eye-watering or nosebleeds, resulting in testing avoidance and fatigue:
Beyond discomfort, these tests can cause rare but dangerous adverse effects. A 2022 American Journal of Rhinology & Allergy study revealed complications such as retained foreign bodies and nosebleeds occurred in one in every 600 cases. This may seem trivial at first, but considering the 363 million pandemic sample collections, potentially half a million people faced nasal swab harmful outcomes.
Testing avoidance, for the reasons cited, results in the loss of our most valuable tools in slowing viral spread: early identification and isolation. This reluctance then translates to missed or delayed diagnoses and treatment falling outside the ideal clinical windows for oral antiviral medications.
To improve participation and compliance, specimen collection methods must evolve to be both clinically effective and patient-friendly.
The ripple effect: Fewer people tested means more public health setbacks
Reduced testing volume makes it harder to accurately track disease spread, delaying interventions as outbreaks escalate unchecked. But even if patients get tested:
Nasal swab techniques vary greatly depending on the user, especially with self-administered tests. Lower sensitivity specimens result in fewer PCR testing diagnoses.
Nasal swabs paired with antigen tests have low sensitivity; just 35.8% in asymptomatic individuals and 64.2% in symptomatic individuals, according to the Centers for Disease Control (CDC).
False negatives are common among nasal swab antigen tests, with the CDC reporting false negative rates averaging 30% to 50% within three to five days of symptom onset.
When samples are inconsistent, sensitivity is low and infections go undetected, patients miss critical treatment windows, infectious persons may not self-isolate and the spread of disease is unchecked. Ultimately, testing avoidance and its downstream effects weaken healthcare systems’ ability to manage both seasonal and emerging URIs.
Evolved nasal lavage as a better specimen collection standard
In the wake of widespread testing fatigue, but without the urgency that once propelled pandemic-era protocols, healthcare professionals are reevaluating longstanding practices in URI specimen collection. The focus has shifted toward methods that reduce patient discomfort while improving diagnostic standards.
Amid this shift, evolved nasal lavage has gained traction as a patient-centered alternative that also produces swab-superior outcomes for providers and labs.
Rather than relying on deep insertion, nasal lavage gently flushes sterile saline through the entire nasal cavity to collect epithelial cells and subcellular pathogens. This results in a liquid specimen less susceptible to inconsistent administration and better patient tolerance across all demographics.
The many benefits are significant:
Essentially eliminates patient trauma, injury and adverse reactions; largely eliminates pain, fear and anxiety resulting in greater testing volumes.
Simpler administration for healthcare personnel, especially in pediatrics and geriatrics.
Higher-sensitivity samples for labs with multi-pathogen detection, which seamlessly integrate into existing workflows.
As healthcare systems actively recalibrate their diagnostic strategies, evolved nasal lavage presents a safer, smarter specimen collection standard that results in more accurate and timely diagnosis plus more effective virus containment.
Rethinking our approach to testing alongside our tools
Swapping out devices is a main catalyst in combating testing avoidance, but we also need a broader shift in how we approach specimen collection. Patient education is key. When individuals understand that gentler, more tolerable testing methods exist, they’re more likely to engage.
Clear and transparent communication from healthcare providers about what to expect during testing — including the risks, benefits and available options — can also increase compliance.
On a systems level, public health policy decisions should prioritize sampling methods that strike the right balance between comfort, sensitivity and scalability. The right method won’t force us to compromise between patient satisfaction and an overall more resilient diagnostic infrastructure.
The takeaway: Long-term preparedness starts now, with reimagined methods
The pandemic made clear that specimen collection methods carry lasting implications on patients’ willingness to engage. As healthcare systems transition from reactive to proactive strategies, approaches prioritizing safety, consistency and user experience will set the foundation.
While nasal swabs certainly met the needs during the pandemic crisis, reemerging tools like evolved nasal lavage sampling are helping shape more tolerable and high sensitivity testing for today and for future healthcare crises.
Photo: Jmsilva,Getty Images
Michael C. Wadman, MD, FACEP, is Chief Medical Officer of University Medical Devices, developer of the MicroWash nasal lavage system. A board-certified emergency physician with more than 30 years of clinical experience in a high-volume academic health center emergency department, Dr. Wadman also holds tenured professor and endowed chair positions at University of Nebraska Medical Center (UNMC). Most notably, he also serves as the Medical Director of the National Quarantine Unit at UNMC, the only federally supported quarantine facility in the U.S.
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