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On March 29, pilot Kirk Walters got a call from Department of Public Safety Commissioner Mike Schirling with bad news: A flight from Logan airport to Minnesota had been canceled.
It wasn’t any flight; it was supposed to carry Covid-19 test samples from the University of Vermont Medical Center to the Mayo Clinic Laboratories in Minnesota for processing.
“This is about saving lives,” Schirling told Walters.
At Schirling’s request, Walters and Martti Matheson, co-owners of JV Air, agreed to fly their private plane from Burlington to Minnesota that Saturday, then again each day for the next 10 days, carrying a total of 4,000 test kits to the lab.
“It filled the gap,” Gov. Phil Scott said, as he praised the duo at a press conference last week.
It wasn’t the first — nor would it be the last — unorthodox work-around Scott would use to run Covid-19 tests. His administration has increased Vermont’s testing capacity with wide-ranging efforts that include tapping the services of the state police, and fast-tracking approval for the UVM Health Network to process its own tests.
Now, as other states have reported testing shortages and backlogs, Vermont has the capacity to conduct four times more Covid-19 tests a day than it is currently running.
The apparent paradox comes down to timing: When aggressive testing would have been ideal early in the pandemic, Vermont didn’t have access to enough kits, according to Health Commissioner Mark Levine. Now that the state has the tests, fewer people with symptoms are requesting them.
But some experts warn that as the state reopens, a lack of testing could lead to a resurgence of infections.
In the U.S., and in every country, “You’ve got this vast amount of susceptible people and once you lift the lid off … the virus is still out there lurking and it’s going to start infecting people,” said Tim Sly, an epidemiologist and professor emeritus at Toronto’s Ryerson University.
Expanded testing capacity and infrastructure could give Vermont a second chance to combat the disease, said Easton White, a biologist at the University of Vermont.
“Early on, the outbreak happened because we couldn’t test people,” he said. “Now we should be able to prevent a second wave.”
State officials say they’re considering new testing strategies as they evaluate what will work best to prevent another outbreak.
A ‘Herculean effort’
The federal government failed to ramp up Covid-19 testing in the U.S. early in the pandemic. The series of setbacks included technical failures, an entanglement of bureaucracy, and a faulty test. Vermont was no exception. At the start of the state’s coronavirus outbreak in early March, the state lab could only process 97 tests a day.
“There were a number of pinch points,” said Debra Leonard, the chair of the Department of Pathology and Laboratory Medicine at UVM’s Larner College of Medicine who was tapped to coordinate the state’s testing efforts. The “trickiest part” has been obtaining enough reagents — the chemicals needed to run tests — from vendors facing exponentially more demand than normal.
But while states including Michigan and Maryland have continued to report shortages and ask the federal government for more tests, Scott and his administration found ways to circumvent the red tape and logistical challenges.
“At the beginning of the crisis, we were pulling every lever and turning every knob in the public sector, in the private sector… to get machines, to get swabs, to get reagents, to get anything and everything our lab experts were telling us would be helpful,” said Jason Gibbs, Scott’s chief of staff.
At one point in mid-March, when the state was down to two days worth of supplies, the governor called Vice President Mike Pence to ask for more. Pence obliged, and sent shipments to both Vermont and New Hampshire.
Leonard got access to the Cambridge-based Broad Institute, a Massachusetts Institute of Technology and Harvard University lab that had converted equipment typically used for DNA sequencing to run Covid-19 tests for New England states. Vermont can now send up to 1,500 collection samples by courier to Broad each day.
When the state had no way to get the samples to Broad, Scott enlisted the Vermont State Police to drive them down.
As Vermont officials built up testing capacity, the state has also allowed hospitals to experiment on their own. Copley Hospital became one of the first hospitals in the country to offer thus-far unproven antibody tests. UVM Health Network has developed its own tests that use more readily available reagents used for lab research, and received emergency approval from the Food and Drug Administration to begin testing in-house for Covid-19.
“We’ve been building up capacity at our labs from those dark days when we had two days of supplies,” said Agency of Human Services Secretary Mike Smith.
Vermont can now conduct up to 2,185 tests a day.
But the state has been running an average of 419 tests a day since the start of April — about a fifth of its total capacity.
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Fewer people seeking tests
Countries that have had the most success in combating the coronavirus have relied on early, aggressive testing, among other measures. Iceland, which is now offering tests to anyone who wants one, drew praise for slowing the spread of the virus without shuttering its economy by testing 10% of its 364,000 residents.
South Korea contained the disease by offering widespread testing early on to about 10,000 people a day. Once officials identified a case, they tested everyone who came in contact with the infected person, and imposed a strict quarantine — a strategy epidemiologists call “containment.”
“Early in an epidemic, that’s a great strategy,” Levine said.
But adequate testing supplies came too late for states like Vermont to rely on a containment strategy, Levine said. State officials instead focused on a “mitigation” approach, prioritizing social distancing to reduce the number of new cases each day, while ramping up testing and contact tracing to contain outbreaks.
Initially, the state told healthcare providers to ration tests by prioritizing immunocompromised people, healthcare workers, and people who had recently traveled to certain regions. Vermonters with Covid-19 symptoms reported they were unable to get tested in March.
“I think, early on in March, and maybe even the end of February, there were people who had Covid-19 disease, and never got tested, because they had all the systems and everything but there wasn’t testing readily accessible,” said Leonard.
Now the state is urging physicians to order tests as needed. In late March, state officials relaxed testing criteria so that anyone with Covid-19 symptoms could get tested. Officials have also started broad testing at facilities where positive cases have been identified, including 11 elder care facilities and one state prison.
While the capacity has increased, the number of tests run each day hasn’t. The reason? There simply aren’t that many sick people in Vermont, according to Levine.
The portion of tests that come back positive has also declined to about 6%, significantly lower than the national average of 18% since the start of the outbreak. A lower rate indicates that the virus is less widespread.
The state has likely peaked in the total number of cases, according to Levine. As of Friday, 851 people had tested positive for the virus since the beginning of the outbreak, and 46 have died. Earlier on, state officials feared much higher numbers.
“We got this disease down, really, to a degree that I wouldn’t have even imagined possible,” said Joshua White, Chief Medical Officer at Randolph’s Gifford Medical Center.
Doctors and hospital administrators also report fewer people are seeking tests.
Joe Woodin, CEO of Copley Hospital, said he estimates that cases in Lamoille County peaked around April 1. The hospital tested 460 people for the virus, 27 of whom tested positive, and continue to test everyone who has symptoms. Copley hasn’t hospitalized a single Covid-19 patient, he added.
Paul Reiss, a doctor at Evergreen Family Health in Williston, said his practice has cut testing from six days a week to three. Now, he’ll go a week without seeing a positive test, he said.
Asymptomatic people in close contact with someone who has Covid-19 can get a test — the spouse of someone with the virus, say, or a health care worker — at a doctor’s discretion.
A more widespread policy could involve testing people without symptoms, as well as frontline and health care workers, people who came in contact with someone with Covid-19, or blanket testing of vulnerable populations such as nursing homes even when there hasn’t been a reported case in a facility.
So far, the state’s strategy of instituting mitigation efforts like the governor’s “stay home, stay safe” order appears to have promising results. The data proved encouraging enough for Scott to begin to ease economic restrictions last week, and the governor announced on Friday that up to five people will be allowed to return to work in indoor construction, manufacturing, or outdoor work settings.
‘Chicken or the egg’
Experts and doctors alike question whether the current level of testing will be aggressive enough to quickly catch the outbreaks that will inevitably emerge as more people start to venture from their homes. A lot is still not fully understood about how long someone can be contagious, how many people will contract the virus without showing symptoms, and whether people can be reinfected.
Reiss saw a patient who had tested positive in the military on April 3, even though he felt healthy. After he self-quarantined for two weeks, he came to Reiss for a second test. The patient tested positive again on April 15. He never had any symptoms, Reiss said. Those are the cases that could prove to be problematic, he predicted. “Until we can figure out who’s walking around asymptomatic positive, who’s presumed to be immune, antibody-wise, it’s going to be very hard to be safe out there,” Reiss said.
Infectious disease researchers have cautioned about the role “silent spreaders” are playing in the pandemic. Sixty percent of the individuals who tested positive for Covid-19 on the U.S. aircraft carrier Theodore Roosevelt, for instance, didn’t show symptoms.
“That’s nightmare stuff for public health people who are trying to control the spread of highly infectious pathogens,” said Sly, the Toronto epidemiologist.
The more testing a state does, the farther they’ll realize the disease has spread, said Easton White, the UVM biologist. “It’s a bit of a ‘chicken or the egg’ thing,” he said. “If we’re testing less, we’re going to miss people.”
He suggested that the state should test aggressively, running tests for everyone who comes in contact with someone with Covid-19, those who are returning to work, and randomized testing for people without symptoms. This week, California health officials said asymptomatic people working in “high-risk” settings like nursing homes should be a priority for testing.
Such an approach would require “enormous resources,” said Catherine Antley, a pathologist at Copley Hospital. But, she added, “it’s necessary and it works.”
In mid-March, Antley urged Senate Pro Tem Tim Ashe to open the state’s checkbook. “You’ve got to invest in a test, you’ve got to invest in an army of social workers who are going to be tracking and helping to isolate and you need to write a check to Mark Levine today to help him do that,” she recalled telling him.
But state officials only order institution-wide testing at long-term care facilities and prisons if a resident or staff member exhibits symptoms and tests positive for Covid-19, a stance that has come under fire from some prisoners’ rights advocates. On Wednesday, the state moved to test all residents in a Brattleboro nursing home after initially not fulfilling the home’s request to test an employee whose family member had tested positive.
More universal testing isn’t always useful, according to Levine. A person who tests negative may become infected minutes after receiving the results — or anytime in the future, he pointed out.
The tests also have a relatively high false negative rate, leading public health experts to caution that a negative test result does not mean someone is Covid-19 free.
Besides, Levine said, the disease doesn’t appear to be prevalent in Vermont. He spoke with 150 doctors from the Vermont Medical Society, and “no matter where they were in the state, they all said that there was a dramatic drop in phone calls” and visits about Covid-related illness. People “just weren’t needing” testing, he said.
New testing strategies
As the number of cases levels off and businesses slowly start to reopen, the state is launching new testing initiatives to contain the spread of the virus long-term. Levine announced Monday that pediatricians should start testing kids and teens with flu-like symptoms. Vermont was also selected for a pilot project with the CDC for multiple rounds of testing at elder care facilities with positive cases to get a better understanding of those outbreaks.
Levine expects an upcoming step for the state will be antibody testing — identifying not just people who have the virus, but those who have recovered from it and are now immune. Those tests are unreliable now, he said, but by June, that may change.
Nationally, public health leaders say improved technology will be key to mitigate new outbreaks going forward. Dr. Deborah Birx, the coordinator of the White House Coronavirus Task Force, said on Meet the Press Sunday that as states begin to reopen, the country needs to develop testing technology to be able to detect who has had the virus — expanding beyond the current tests for the live virus.
In what could be a major breakthrough in better understanding who contracted the virus in Vermont, Levine said he’d like to test up to 10% of Vermonters in a statewide “seroprevalence” study.
And, despite earlier reluctance to test asymptomatic people, the state may yet expand its active infection testing, according to Gibbs, Scott’s chief of staff. The administration will unveil an expanded testing plan this week to set forward new priorities. The plan may include “aggressive and frequent testing” of health care workers or testing on a rolling basis for pharmacy workers, cashiers or postal workers, he said.
The state is also considering testing people in congregate workplaces such as manufacturing facilities, as well as patients who go to the hospital for non-emergency appointments. This week, UVM Health Network started testing expectant mothers who come in for labor and delivery.
“The idea is to expand the amount of intelligence we have coming in about our enemy, if you will,” Gibbs said.
The U.S. House of Representatives approved Thursday a $484 billion Covid-19 response package that includes $25 billion to expand nationwide testing capacity for the infection.
Rep. Peter Welch, D-Vt., who has been advocating for the federal government to foot the bill, said in an interview Thursday that the decision to fund testing demonstrates an acknowledgement that it is integral to safe reopening of the country.
He and four other Democrats have also proposed making federal money available to states for keeping infection rates under control as they reopen businesses.
“My view is we should be supporting state efforts,” Welch said. “Turning that economic spigot, but have contact tracing, testing, and quarantining as we do that.”
Regardless, Levine is playing the long game when it comes to testing, The virus may rebound, he said, and if it does, he plans to have a stockpile of tests on hand.
Vermont needs to be sure “we’ve got all the capacity we need to really help our population,” he said. If Levine has anything to say about it, he added, the state will be “primed and ready to go.”
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