Survey data yields improved estimates of test-confirmed COVID-19 cases when rapid at-home tests were massively distributed in the United States

ImportanceIdentifying and tracking new infections during an emerging pandemic is crucial to design and deploy interventions to protect populations and mitigate its effects, yet it remains a challenging task. ObjectiveTo characterize the ability of non-probability online surveys to longitudinally estimate the number of COVID-19 infections in the population both in the presence and absence of institutionalized testing. DesignInternet-based non-probability surveys were conducted, using the PureSpectrum survey vendor, approximately every 6 weeks between April 2020 and January 2023. They collected information on COVID-19 infections with representative state-level quotas applied to balance age, gender, race and ethnicity, and geographic distribution. Data from this survey were compared to institutional case counts collected by Johns Hopkins University and wastewater surveillance data for SARS-CoV-2 from Biobot Analytics. SettingPopulation-based online non-probability survey conducted for a multi-university consortium --the Covid States Project. ParticipantsResidents of age 18+ across 50 US states and the District of Columbia in the US. Main Outcomes and MeasuresThe main outcomes are: (a) survey-weighted estimates of new monthly confirmed COVID-19 cases in the US from January 2020 to January 2023, and (b) estimates of uncounted test-confirmed cases, from February 1, 2022, to January 1, 2023. These are compared to institutionally reported COVID-19 infections and wastewater viral concentrations. ResultsThe survey spanned 17 waves deployed from June 2020 to January 2023, with a total of 408,515 responses from 306,799 respondents with mean age 42.8 (STD 13) years; 202,416 (66%) identified as women, and 104,383 (34%) as men. A total of 16,715 (5.4%) identified as Asian, 33,234 (10.8%) as Black, 24,938 (8.1%) as Hispanic, 219,448 (71.5%) as White, and 12,464 (4.1%) as another race. Overall, 64,946 respondents (15.9%) self-reported a test-confirmed COVID-19 infection. National survey-weighted test-confirmed COVID-19 estimates were strongly correlated with institutionally reported COVID-19 infections (Pearson correlation of r=0.96; p=1.8 e-12) from April 2020 to January 2022 (50-state correlation average of r=0.88, SD = 0.073). This was before the government-led mass distribution of at-home rapid tests. Following January 2022, correlation was diminished and no longer statistically significant (r=0.55, p=0.08; 50-state correlation average of r=0.48, SD = 0.227). In contrast, survey COVID-19 estimates correlated highly with SARS-CoV-2 viral concentrations in wastewater both before (r=0.92; p=2.2e-09) and after (r=0.89; p=2.3e-04) January 2022. Institutionally reported COVID-19 cases correlated (r = 0.79, p=1.10e-05) with wastewater viral concentrations before January 2022, but poorly (r = 0.31, p=0.35) after, suggesting both survey and wastewater estimates may have better captured test-confirmed COVID-19 infections after January 2022. Consistent correlation patterns were observed at the state-level. Based on national-level survey estimates, approximately 54 million COVID-19 cases were unaccounted for in official records between January 2022 and January 2023. Conclusions and RelevanceNon-probability survey data can be used to estimate the temporal evolution of test-confirmed infections during an emerging disease outbreak. Self-reporting tools may enable government and healthcare officials to implement accessible and affordable at-home testing for efficient infection monitoring in the future. Trial RegistrationNA Key PointsO_ST_ABSQuestionC_ST_ABSCan non-probability survey data accurately track institutionally confirmed COVID-19 cases in the United States, and provide estimates of unaccounted infections when rapid at-home tests are popularized and institutionalized tests are discontinued? FindingsThe proportion of individuals reporting a positive COVID-19 infection in a longitudinal non-probability survey closely tracked the institutionally reported proportions in the US, and nationally-aggregated wastewater SARS-CoV-2 viral concentrations, from April 2020 to February 2022. Survey estimates suggest that a high number of confirmed infections may have been unaccounted for in official records starting in February 2022, when large-scale distribution of rapid at-home tests occurred. This is further confirmed by viral concentrations in wastewater. MeaningNon-probability online surveys can serve as an effective complementary method to monitor infections during an emerging pandemic. They provide an alternative for estimating infections in the absence of institutional testing when at-home tests are widely available. Longitudinal surveys have the potential to guide real-time decision-making in future public health crises.