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Maine reopens with “bare minimum” testing strategy

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Maine’s gradual reopening plan relies on the detection and isolation of people infected with the coronavirus, but public health experts say the state’s proposed testing regimen is probably too small to achieve it.

Governor Janet Mills’ four-step plan, announced Tuesday, carefully opens parts of Maine’s economy step-by-step, with state officials ready to halt the process or re-impose restrictions if they see signs. spread of the virus rather than withdrawal.

But the testing regime that supports it is much less extensive than many public health experts recommend, and it continues to focus on people entering or residing in healthcare facilities or gathering places who experience active epidemics.

Dr. Nirav D. Shah, Director of the Maine Center for Disease Control and Prevention Derek Davis / Staff Photographer

This testing strategy – described by Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, in an interview with the Portland Press Herald / Maine Sunday Telegram – plans to increase Maine’s testing capacity from two to three times over the next few weeks, from about 1,000 tests per day to 2,000 to 3,000. The increase – which he and other lab operators say is achievable, despite shortages of reagents, samples and other critical test items – would greatly expand testing within the healthcare system.

“We are starting to work on testing patients who may be in the hospital before returning to a nursing home and vice versa, every patient who has to undergo elective surgery, every pregnant woman near childbirth,” said explained Shah. “The types of people I think would need to be tested to control the epidemic.”

The state would also be able to extend its testing to clustered settings such as industrial factories, homeless shelters and long-term care facilities. Currently, anyone living or working in such a setting is tested if there are three or more confirmed cases, the technical definition of an epidemic. The increased capacity would allow everyone to be tested once there was a single case.

But Maine’s testing capacity – which corresponds to an ability to test 0.15 to 0.22% of the population each day – would not be sufficient to test asymptomatic people more widely, as is done in Los County Angeles, where every citizen is offered a free test.

Shah said this testing strategy parallels the recommendations set out in a widely circulated April 18 article by Dr. Ashish Jha of Harvard Global Health Institute and Dr. Thomas Tsai of Harvard T.H. Chan School of Public Health. They calculated the minimum number of tests needed to detect most new infections, allowing authorities to quickly isolate these people and those they came into contact with, rather than being forced to isolate everyone when the an outbreak breaks out. The article, which was Featured According to the New York Times, the nation needs 500,000 tests a day, or 1 in 152 people, which means Maine would need about 8,800 a day.

In an interview, Tsai said the number is “the bare minimum”.

“I don’t think it’s enough,” said Tsai, who is also a surgeon at Brigham and Women’s Hospital in Boston, at The Press Herald / Sunday Telegram. “We have to test 5 million if we can or 20 million a day (nationally) if we can. Originally, the United States was so constrained by the supply chain that we could only test very sick and front-line healthcare workers. But now this testing ability is slowly improving. “

“Maine doesn’t have to wait for people to come to the hospital,” he added. “Because it is a less densely populated state, it has the ability to build this surveillance infrastructure to be able to track individual cases and trace them in a way that is not possible if you are in the midst of an epidemic . “

One more detailed interdisciplinary report hosted by the Edmond J. Safra Center for Ethics at Harvard argues that a much larger testing network will be required if Maine and other states are to avoid shutting down their economies repeatedly until a vaccine available. To test widely enough to detect asymptomatic carriers of the disease – estimated at 20 to 40 percent of the total infected – it would be necessary to be able to test 2 percent of the population per day in May, increasing to 5 percent in August, when more restrictions are removed.

This translates to 27,000 and 67,500 tests a day in Maine – an order of magnitude more than what the Maine CDC plans – as well as a small army of contact tracers who can determine who each positive case may have already infected. . A system should be in place, the study argues, to support each infected person while in isolation.

“We think that doing enough testing to ward off a second wave should be the goal, and it requires even more growth than what Maine is offering here,” said Safra Center director Danielle Allen, about the map of Maine by email.

Dr. Edison Liu, president and CEO of the Jackson Laboratory, which developed the COVID-19 testing capability in March, said large-scale screening of asymptomatic people is essential.

“We need to be able to know, in the workplace, which is contagious and which is not,” said Liu, who led Singapore’s scientific response to the 2003 SARS pandemic. “Just like you would prevent someone from carrying a loaded weapon in your workplace, you should be able to prevent someone shedding the virus from entering the workplace because it poses a danger to co-workers. ”

“Health care workers, people in grocery stores, nursing home guards, first responders – these people need to be tested now,” he added. “Test call centers, paper factories and everyone in prison.”

THREE CAPACITY

The good news is that, despite shortages of swabs and reagents, Maine lab directors believe they can reach double or triple the state’s analytical capacity envisioned by the Mills administration.

Shah said Maine’s own CDC lab has a capacity of 300 tests per day and, with the arrival of two test instruments in the coming days and weeks, plans to reach 500 tests daily . He said the agency is hiring two other laboratory staff.

The biggest challenge in achieving these goals remains the lack of reagents – chemicals needed to perform the tests but the new instruments will help alleviate the problem, as they require a reagent pack that is less difficult to secure.

Scarborough-based NorDx can handle approximately 250 COVID-19 tests per day, most of which come from healthcare providers who share their membership in MaineHealth, the state’s largest hospital network. Laboratory medical director Robert Carlson said NorDx is looking to double this capacity to 500 over the next few weeks as the national shortage of reagents eases.

“At this point it is mainly a restriction of reagents, but once we reach 500 or 700 tests per day, we will also have reached the capacity of our current instrumentation,” said Carlson.

If Maine is looking to increase testing more widely, it’s not clear how difficult it would be.

An unknown amount of additional testing capacity is already being drawn from out-of-state labs like New Jersey-based Quest Diagnostics and North Carolina LabCorp, although these options often have long lead times, which limits their usefulness.

‘TELL US WHAT YOU NEED’

Jackson Lab already processes 700 tests a day at a test site it set up in March on its Farmington, Connecticut campus, said Liu, and is growing to be able to process 20,000 a day in the six to the next eight weeks20. times Maine’s current capacity.

“I have no doubt that I can reach 20,000. It’s a question of time and money,” said Liu, who has partnered with Connecticut Public Health and two hospital systems, UConn Health and Hartford HealthCare, on the project. Reagents were not a problem for Jackson, he said, due to a relationship with their instrument manufacturer, ThermoFisher.

Most of Jackson’s increased capacity will go to Connecticut, but Liu said the Bar Harbor-based institution could also create large-scale capacity for Maine, if state officials commit to it.

“For a state of 1.3 million people, we can get the number of tests that would be needed very, very soon,” he said. “It’s not a ton of people; it just depends on how you deploy it. It’s a matter of will and organization.”

“Don’t ask us what we can do,” added Liu. “Tell us what you need, and we’ll do it.”


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