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When Maine triples testing capacity for COVID-19 at its laboratory early next week, medical providers will no longer have to prioritize tests for the most vulnerable patients, putting Maine among the first states to “completely throw open the doors,” on testing, said Nirav Shah, the director of the Maine Center for Disease Control and Prevention.
“We are definitely among the first states to say, ‘If you send it, we will run it,’” Shah said in an interview on Thursday afternoon.
The goal is for the state laboratory to be ready by Monday to triple the number of tests it has historically performed, allowing it to turn out 7,000 test results per week, he said, and put Maine on a surer path to reopening its economy. Hospital-based and commercial laboratories are able to perform even more tests.
If all goes according to plan, the state will alert physicians Monday about the new lack of criteria for testing. While the details are not yet complete, the Maine CDC will also provide recommendations for who should be tested, including patients transferring to nursing homes from the hospital and people who have been in close contact with those with confirmed cases of COVID-19.
“Those will not be prioritizations. They will not be exclusionary criteria or inclusionary criteria. If you send it to us, we will run it. But we want to make sure people know who should really be tested, according to the science,” Shah said.
The Maine CDC plans to base guidelines for health care providers on information from the U.S. Centers for Disease Control and Prevention and the Infectious Diseases Society of America, which has created an algorithm to help clinicians decide when to order tests.
For example, when there are enough tests, asymptomatic people should be tested if they have been exposed to someone with COVID-19, if they’re going to have major, time-sensitive surgery, or if they’re going to have an aerosol-generating procedure that might expose health care workers to pathogens, the infectious disease group states.
There are several situations in which someone who originally tests negative for COVID-19 should be retested, it says. Those decisions mostly rely on clinical judgment.
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Boosting Maine’s testing capacity is particularly important given that Johns Hopkins University ranks Maine as last in the nation for its per capita rate of testing, pointed out Peter Millard, the former medical director of Seaport Community Health Center in Belfast, who has a background in epidemiology.
As the state gradually reopens, “there will be more cases for sure,” he said, and the increased testing will be a “basic tool” to know where COVID-19 is spreading.
Having increased testing capacity is “a safety net that underlies reopening,” Shah said. As Maine finds more cases, it can then trace their contacts to have them tested, too.
“We want to make sure we have the robust testing architecture in place, so that if people get a call that says, ‘Hey, you know what? Turns out you were in close contact with a confirmed case five days ago, and we need you to come in and get tested,’ we have the capacity at the state lab to do that test,” Shah said.
The forthcoming recommendations from the Maine CDC will represent a stark reversal from the current testing strategy, which has limited testing due to a low national supply of laboratory materials.
In March, Maine prioritized tests at its laboratory for the most at-risk patients with symptoms, such as a fever. First priority went to people who were hospitalized, health care workers, first responders and people living in congregate settings such as nursing homes. Second priority went to people older than 60 and those with underlying medical conditions.
But COVID-19 doesn’t just spread from people showing symptoms. While a definite estimate is unknown, public health officials have stated that 25 percent of all cases may be asymptomatic. People may have the virus for days before they show symptoms, if they ever show symptoms at all, making detection — and knowing when to test — difficult.
“That’s what complicates all of it so dramatically,” said Dr. Noah Nesin, chief medical officer for Penobscot Community Health Care.
The recent COVID-19 outbreak at the Hope House Health and Living Center in Bangor, overseen by PCHC, illustrated the challenge of catching asymptomatic spread. Once the homeless shelter had three confirmed cases, meeting the definition of a cluster, it tested everyone who had visited within the previous two weeks, ultimately finding a total of 20 residents and staff with the virus who were then quarantined.
“In the quarantining stage, there were people who developed symptoms — late, into two weeks,” Nesin said. “More than half of the people who were asymptomatic when they tested positive never did develop symptoms.”
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So while he wishes Maine had been able to test far more people earlier, which would have helped control the spread of the illness, he said it is difficult to know, still, how to best detect asymptomatic carriers.
The Hope House would like to test new admissions to the shelter, he said, but it’s not clear how frequently testing — and retesting — should be done.
“It probably has to be customized,” Nesin said. “What’s the regimen, in what setting, that helps us mitigate the impact of an outbreak?”
Dr. Jabbar Fazeli has been performing what he calls “smart testing,” which largely means assessing each person individually in the two long-term care facilities in southern Maine where he is medical director, as opposed to routinely testing everyone once a week or once a month.
Otherwise, “You could have that test become a false security,” he said.
He has been testing asymptomatic people based on their situation, regardless of whether they’re showing symptoms, despite the state not yet encouraging that more preemptive level of testing, he said. (Physicians can order tests for patients regardless of whether they are in a prioritized group and have results processed at outside laboratories.)
For instance, it had been more than a week since one hospitalized patient’s last negative COVID-19 test, Fazeli said, so he ordered another test before the person entered the facility. Despite not having any symptoms, the results were positive.
In April, one of his facilities had an employee whose partner tested positive. The facility then tested the employee, who wasn’t showing symptoms. The result was positive. Retesting the employee later revealed she remained positive for three weeks, he said, longer than the recommended quarantine time of two weeks.
“We dodged the bullet multiple times so far through this process of smart testing,” Fazeli said.
In addition to making sure patients being transferred from hospitals are tested, he follows up with additional testing five days after their admission. That’s because the average incubation period — the time from exposure to development of COVID-19 symptoms — is five days. Relying on an average isn’t ideal, he said, but more research needs to be done to figure out “the most optimal testing intervals” to catch the most cases.
Even increased testing can’t uncover every case. One of his facilities, Durgin Pines in Kittery, became the site of an outbreak after confirming its third case on Friday. A resident tested negative in April before being admitted to the facility, Fazeli said. The nursing home tested her again five days after her admission. The results were negative. When she developed a low-grade fever on May 13, the facility tested her again. This time, the results were positive.
The Maine CDC is planning to recommend that patients be tested upon discharge from a hospital to a long-term care facility, Shah said.
“Medically, epidemiologically, public health-wise, it is the right thing to do,” Shah said. But the details of how and when to test matter.
“We want to make sure we provide good guidance around that. If they’re supposed to be discharged from the hospital at 2 p.m., on Tuesday, well then, is the system in place such that we can test them and have a small enough window where we’re not worried they’re going to get exposed?” he said.
It will be up to local operators of facilities to decide when it makes the most sense to retest residents, Shah said. The state laboratory doesn’t charge patients for COVID-19 testing.
“It’s ultimately their judgment call. But we’re here for them,” Shah said. “We’ll weigh in with what we think is appropriate.”
In some instances, the state might suggest that a laboratory other than its own conduct the tests, especially if an entity wants to test a lot of people. “We may say to them, ‘We recommend that you test all 2,000, but doing so at Maine CDC may be tough. Maybe you want to call Quest or LabCorp,’” Shah said.
In addition to giving providers leeway to order tests, the Maine CDC intends to conduct randomized testing of residents and staff who volunteer for a sentinel surveillance program in long-term care facilities, Shah said.
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It’s also planning how to make tests more available for out-of-state visitors traveling to Maine, who have been asked to self quarantine for two weeks.
“We’re actually actively working with a major national retail organization to make such testing more available. It’s been a part of our strategy. We’re in favor of it. We want as much testing for visitors and Mainers alike. But what next?” Shah said. “If you test positive, where do you go from there? It’s one of those things where we’ve got to think it through.”
Asked if the Maine laboratory might hit its maximum of 7,000 tests per week quickly, Shah said it was possible.
“That’s not a bad outcome. It means we just need to continue to work to expand our capacity,” he said. “Our projections don’t suggest that will happen. But we’re ready for it if it does.”
Shah said his thinking is guided by the work of South Korea, which has achieved a positivity rate of approximately 2 percent with a strategy of expansive testing and tracing contacts.
Maine’s positivity rate — the percentage of total cases that test positive — is currently around 5.9 percent, he said. While favorable when compared with other states, it implies that doctors are still testing too many people with a higher probability of having the infection and missing those with milder or no symptoms.
“In order to get to that 2 percent we would mathematically need to roughly triple the amount of testing,” Shah said. “That was part of the metric that we used when planning for our expansion at our laboratory.”
That expansion is possible because of a partnership with IDEXX Laboratories, which loaned a testing instrument to the state laboratory.
Watch: Why Maine is tracking number of tests instead of people tested