Ross D. Franklin | AP
Dr. Sabrina Solt asked a few questions before scheduling an appointment only with a COVID-19 coronavirus test on Monday, May 4, 2020 in Scottsdale, Arizona. The Maine CDC plans to triple testing capacity starting next week.
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When Maine triples COVID-19 testing capacity in its laboratory early next week, medical providers will no longer have to prioritize testing for the most vulnerable patients, placing Maine among the first states to “open completely the doors “of the tests, said Nirav Shah, 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 execute it, “said Shah in an interview Thursday afternoon.
[Our COVID-19 tracker contains the most recent information on Maine cases by county]
The goal is for the state lab to be ready Monday to triple the number of tests it has historically performed, allowing it to produce 7,000 results per week, he said, and put Maine on a path. safer to reopen its economy. Hospital and commercial laboratories can perform even more tests.
If all goes according to plan, the state will alert doctors on Monday of the new lack of criteria for testing. Although details are not yet complete, the Maine CDC will also provide recommendations on who to test, including patients transferred to nursing homes from hospital and those who have been in close contact with those who have confirmed cases of COVID-19.
“These will not be priorities. They will not be exclusion criteria or inclusion criteria. If you send it to us, we will execute it. But we want to make sure that people know who really should be tested, according to science, “said Shah.
Maine CDC plans to base guidelines for healthcare 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 are going to have major and urgent surgery, or if they are going to have an aerosol – generating procedure that could expose health workers to pathogens, says the infectious disease group.
There are several situations in which a person who initially tested negative for COVID-19 should be retested, he says. These decisions are based primarily on clinical judgment.
Increasing Maine’s testing capacity is particularly important given that Johns Hopkins University ranks Maine the lowest in the country for its per capita testing rate, said Peter Millard, former medical director of the Seaport Community Health Center at Belfast, who has a background in epidemiology. .
As the state gradually reopens, “there will certainly be more cases,” he said, and the increased testing will be a “basic tool” to find out where COVID-19 is spread.
The increase in testing capacity is “a safety net behind the reopening,” said Shah. As Maine finds more cases, it can then find their contacts to have them tested as well.
“We want to make sure that the robust test architecture is in place, so that if people get a call that says,” Hey, you know what? You happen to be in close contact with a confirmed case five days ago, and we need you to come for a test, “we have the capacity at the state lab to do this test,” said Shah.
States like New Mexico and California have already relaxed certain guidelines for testing people without symptoms.
The forthcoming recommendations from the Maine CDC will represent a sharp reversal from the current testing strategy, which has limited testing due to a small national supply of laboratory equipment.
In March, Maine prioritized testing in its lab for those most at risk with symptoms such as a fever. The first priority went to hospitalized people, health care workers, first responders and people living in gathering places such as nursing homes. The second priority went to people over 60 and those with underlying health problems.
But COVID-19 is not spread only to people with symptoms. Although a definitive estimate is not known, public health officials have said that 25% of all cases may be asymptomatic. People can be infected with the virus for days before they develop symptoms, if they do develop symptoms, which makes detection – and when to test – difficult.
“This is what makes it all so dramatically,” said Dr. Noah Nesin, chief medical officer of Penobscot Community Health Care.
The recent COVID-19 outbreak at the PCHC-supervised Hope House Health and Living Center in Bangor illustrated the challenge of countering asymptomatic spread. Once the homeless shelter had three confirmed cases, meeting the definition of a group, it tested all those who had visited in the previous two weeks, ultimately finding a total of 20 residents and members of the personnel infected with the virus who were then quarantined.
“At the quarantine stage, there were people who developed symptoms – late, within two weeks,” said Nesin. “More than half of the asymptomatic people who tested positive never developed symptoms.”
So, although he wished that Maine had been able to test many more people earlier, which would have helped control the spread of the disease, he said that it was still difficult to know how to best detect asymptomatic carriers.
The Hope House would like to test new admissions to the shelter, he said, but it is unclear how often the tests – and the new tests – should be done.
“It probably needs to be personalized,” said Nesin. “What is the diet, in what setting, that helps us mitigate the impact of an epidemic? “
Dr. Jabbar Fazeli performed what he calls “smart tests,” which means largely assessing each person individually in the two long-term care facilities in southern Maine where he is medical director, instead of systematically testing everything the world once a week or once. a month.
Otherwise, “you could make this test false security,” he said.
He has tested asymptomatic people based on their situation, whether or not they have symptoms, although the state is not yet encouraging this more preventative level of testing, he said. (Doctors can order tests for patients, whether or not they belong to a priority group and the results are processed in external laboratories.)
For example, it has been over a week since the last COVID-19 negative test from an inpatient, Fazeli said, so he ordered another test before the person entered the facility. Despite the absence of symptoms, the results were positive.
In April, one of its establishments had an employee whose partner was positive. The establishment then tested the employee, who had no symptoms. The result was positive. The employee’s re-test later revealed that she had been positive for three weeks, he said, longer than the recommended two-week quarantine period.
“We have avoided the bullet several times so far thanks to this intelligent testing process,” said Fazeli.
In addition to ensuring that patients transferred from hospitals are tested, he performs additional tests five days after admission. This is because the average incubation period – the time between exposure and the development of symptoms of COVID-19 – is five days. Relying on an average is not ideal, he said, but more research needs to be done to determine “the most optimal test intervals” to catch the most cases.
Even an increase in tests cannot reveal all cases. One of his facilities, Durgin Pines in Kittery, became the site of an epidemic after confirming his third case on Friday. A resident was tested negative in April before being admitted to the facility, said Fazeli. 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 hospital tested her again. This time the results were positive.
The Maine CDC plans to recommend that patients be tested after discharge from a hospital to a long-term care facility, said Shah.
“Medically, epidemiologically, in terms of public health, it is the right thing to do,” said Shah. But details on how and when to test the material.
“We want to make sure we provide good guidance on this. If they’re supposed to be out of the hospital at 2:00 p.m. Tuesday, well, is the system in place so we can test them and have a small enough window where we don’t fear they’ll get exposed? ” he said.
It will be up to local facility operators to decide when it makes more sense to retest residents, said Shah. The state lab does not charge patients for COVID-19 tests.
“It is ultimately their judgment. But we are there for them, ”said Shah. “We will weigh with what we think is appropriate. “
In some cases, the state may suggest that a laboratory other than its own perform the tests, particularly if an entity wishes to test a large number of people. “We can tell them, ‘We recommend testing every 2,000, but it can be difficult at Maine CDC. You may want to call Quest or LabCorp, ”said Shah.
In addition to giving suppliers flexibility to order tests, the Maine CDC intends to conduct randomized tests on residents and staff who volunteer for a sentinel surveillance program in health care facilities. long term, said Shah.
He also plans to make the tests more available to foreign visitors to Maine, who have been asked to quarantine for two weeks.
“We are currently actively working with a large national retail organization to make these tests more available. It is part of our strategy. We support it. We want as many tests for the visitors as for the Mainers. But what to do next? Said Shah. “If your test is positive, where do you go from there?” This is one of those things that we have to think about. “
When asked if the Maine lab could quickly reach its maximum of 7,000 tests per week, Shah replied that it was possible.
“It is not a bad result. It means that we just have to keep working to increase our capabilities, ”he said. “Our projections do not suggest that this will happen. But we’re ready for it if that’s the case. ”
Shah said his thinking is guided by the work of South Korea, which has reached a positive rate of around 2% with an expansive testing and contact tracing strategy.
Maine’s positivity rate – the percentage of the total number of positive cases – is currently around 5.9%, he said. While favorable compared to other states, it implies that doctors are still testing too many people with a higher likelihood of getting the infection and missing those with milder symptoms or no symptoms.
“To reach that 2%, we would mathematically need to roughly triple the number of tests,” said Shah. “It was part of the metric we used when planning our expansion in our laboratory. “
This expansion is possible thanks to a partnership with IDEXX Laboratories, which loaned a test instrument to the state laboratory.
Watch: Why Maine Tracks Number of Tests Instead of People Tested