Does the swab have to go as far down the nose for the COVID-19 test?

One Canadian reported that he felt something like a painful pinprick in his brain. An American heard a kind of cracking sound in her head. A French woman suffered a profuse nosebleed. Others had headaches, cried, or were shocked.

All were tested for COVID-19 with deep nasal swabs. While many people don’t complain about their experience, for some, the hyssop test – a vital tool in the global battle against coronavirus – instinctively dislikes, squirms, or feels unresponsive to their knees.

“It felt like someone was pressing the reset button in my brain to change something,” said Paul Chin, a music producer and DJ in Toronto, of his nasal swab test. “There really is nothing like it.”

“Oh my God,” he added, “the swab went deeper into my nose than I ever imagined or thought. It is a very long, sharp and pointed thing ”.

Since the coronavirus emerged, millions of swabs have been inserted into millions of noses to detect a pernicious virus that has claimed the lives of millions of people around the planet. One of the ways to fight the virus, according to the authorities, is to do frequent tests and in wide sectors. The bottom line has been to use a test that people are willing to take repeatedly.

Swabbing is usually appropriate.

In some parts of the United States, healthcare workers give people the swab to test themselves, ensuring a certain level of personal comfort. For many South Africans, the only test for COVID-19 is painful: you see little stars or gag because the swab goes down the throat.

Swab range raises questions: who gets it right? How deep should the swab be inserted into the nostril? How long should you spend there? Does an accurate test have to be uncomfortable? Unfair or not, some countries have a reputation for brutal testing.

First, a short anatomy lesson: no, they are not poking your brain with a cotton swab.

The swab goes through a dark passage that leads to the nasal cavity. This is inside a bone covered with soft and sensitive tissue. At the back of this cavity — roughly aligned with the earlobe — is the nasopharynx, where the back of the nose meets the top of the throat. It is one of the places where the coronavirus is actively replicating and is where a satisfactory sample of the virus is likely to be obtained.

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Suspicion about the test may be due to a very simple fact: most people cannot bear to have something shoved so far down their nose. Plus, the tests evoke some of our darkest fears: those of things that can get into our orifices and burrow into our brains.

“People are not used to feeling that part of their body,” Noah Kojima, a resident physician at the University of California, Los Angeles and an infectious disease expert, said of swabs that touch the nasopharynx.

Pain occurs when the swab – a nylon ball attached to a stick that looks like a paddle – is inserted at the wrong angle, said Yuka Manabe, a professor of medicine specializing in infectious diseases at Johns Hopkins University School of Medicine.

“If you don’t tilt your head back, you don’t reach your throat,” he said. “You hit someone’s bone.”

Chin, the music producer, described his test as a “prick to the brain” and compared the burning sensation to the effects of breathing spices.

“Your whole face is kind of ready to overflow,” he said, adding, “I really don’t know if there’s any way to be ready for it.”

There are three main types of nasal swab tests for COVID-19: nasopharyngeal (the deepest), mid-turbinate (the middle), and anterior nasal (the shallow part of the nose). Early in the pandemic, deep nasal swabs were widely and aggressively applied to adults as the method worked for influenza and SARS testing. Although science is evolving, experts tend to agree that the deepest swab is the most accurate.

According to a review of studies published in July in the scientific journal PLOS One, nasopharyngeal swabs are 98 percent accurate; shallow swabs are 82 to 88 percent effective, and mid-turbinate swabs perform similarly.

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In South Korea, nasopharyngeal swabs remain the gold standard for COVID-19 testing, said Seung-ho Choi, deputy director of risk communication at the Korea Agency for Disease Control and Prevention.

“Depending on the skill of the medical staff, it may or may not hurt,” he said. But he added: “The nasopharyngeal test is the most accurate. That is why we continue to do it ”.

WHO has guidelines on the best way to test; complications have been rare. Australian guidelines say that the swabs should rise a few inches up the nostrils of adults. The US Centers for Disease Control and Prevention states that swabbing the middle part of the turbinate should generally be inserted less than an inch or a half or until resistance is met. Some examiners swab both nostrils.

Guidelines from the Korean Prevention and Control Agency allow examiners some leeway to scrape the nasopharynx (by moving or twisting the swab or both). Choi says the experience depends on the brand of the swab, the patient’s tolerance for pain, the anatomical structure of the nasal cavity, and the skill of the examiner.

Lee Jaehyeon, a professor of laboratory medicine at Jeonbuk National University who helped develop the Korean government’s guidelines for testing for COVID, said the test posed as little risk as drawing blood.

But when leaving a Seoul clinic this month, some people sneezed, rubbed their eyes or blew their noses. One or two were crying.

“I felt as if the hyssop was scraping my brain,” said 19-year-old Chu Yumi.

28-year-old Kim Kai, who had bloodshot eyes, said, “I think my nose is about to bleed.”

Lee Eunju and Lee Jumi, both 16, said they did not want to be tested again. Eunju explained that she felt as if chili powder had been poured into her nostrils. Jumi said, “It hurt a lot.”

Lee mentioned that discomfort is the price of precision. “This does not mean that we can ignore the pain that each patient feels,” he said.

Many people tolerate the test well. Paul Das, a family physician at St. Michael Hospital of the Unity Health Toronto network, said children tend to have a worse time.

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Some people attribute their experiences to the technique or personality of the examiners.

“Itchy, it’s a bit awkward, but I think the person was very nice,” said Kim Soon Ok, 65, leaving a clinic in Seoul.

Issa Ba, a 31-year-old soccer player, recalled: “I got tested for COVID-19 in Conakry, Guinea, in August, before coming to Senegal. I felt a bit of pain when they shoved the stick up my nose, but it wasn’t that bad. And I have endured much more intense pain. I’m a man”.

Some countries seek to standardize testing and eliminate human error. Developers in Denmark, Japan, Singapore, and Taiwan have invented robots to do this job.

Manabe, the Johns Hopkins physician, insists the tests shouldn’t hurt.

However, painful stories abound.

Studies show that women tend to feel more pain than men, but this could be due to a design bias – some swabs may be too large for women’s facial anatomy.

Briana Mohler, 28, suffered a nose swab in Minnesota in 2020 so excruciating she heard “cracking sounds.”

Audrey Benattar, who recently moved to Marseille, France, recalled visiting a Montreal hospital in May to give birth. There, a nasal swab for covid left her with burst blood vessels and with balloon catheters in both nostrils to stop the bleeding.

“I’ve never seen so much blood in my life,” said Benattar, 34.

Some argue that nasal swabs rank relatively low on the scale of the most sensitive coronavirus tests.

This year, China required some foreign travelers, including diplomats, to undergo anal tests for COVID-19, enraging foreign governments.

Aurelien Breeden, Lynsey Chutel, Ruth Maclean, Mady Camara and Vjosa Isai contributed to this report.

Livia Albeck-Ripka is a New York Times reporter currently living in California. Previously, she was a reporter at the Times bureau in Australia. @livia_ar

John Yoon reports from the Seoul newsroom of The New York Times. He joined the Times in 2020. @johnjyoon