The Deeper Dig is a biweekly podcast from the VTDigger newsroom, hosted and produced by Sam Gale Rosen. Listen below, and subscribe on Apple Podcasts, Google Play, Spotify or anywhere you listen to podcasts.
When the Department of Health in March announced the first Covid-19 cases resulting from “community spread,” it represented more than just an increase in the total caseload — it meant the state’s ability to contain the coronavirus using testing and contact tracing had failed.
Now, with cases leveling off and small steps to reopen businesses underway, the department is focused on preventing a second wave. And thanks to an increase in testing capacity, a containment strategy is back on the table.
“It’s like a chicken-and-egg thing,” said Health Commissioner Mark Levine: Gov. Scott’s recent moves to allow some Vermonters back to work would not be possible if the public health strategies implemented so far hadn’t been effective. Moving forward, Levine’s team plans to widen testing in facilities or communities that show signs of a potential outbreak.
But the commissioner is stopping short of recommending a more widespread testing strategy, like those that have worked to slow the disease in countries like Iceland and South Korea. Testing enough Vermonters to get a large enough sample size would be a “huge challenge,” Levine said. “You can’t just test a little here, test a little there. You need to have a strategy that samples enough of the population that you’re getting an accurate look.”
It may also be too late for widespread testing to have an effect. “It would have been a wonderful strategy for us to use back in early March,” Levine said. “Too bad we didn’t have testing.”
[Related: Testing for the coronavirus in Vermont: What’s next?]
**Podcast transcript**
This week: The Scott administration has loosened restrictions on some workplaces for the second week in a row, as part of a plan to slowly reopen Vermont’s economy. Now, public health officials are getting a second chance to try a containment strategy that didn’t work the first time around.
Gov. Phil Scott: Good morning, everyone.
At a press conference on April 8th, Gov. Phil Scott signaled that he would be extending Vermont’s stay-home order – but that the administration was also planning for how the state could reopen.
Phil Scott: This may get harder before it gets easier. But as soon as the data shows a leveling and downward trend, then and only then will we open the spigot, a quarter turn at a time, to get folks back to work in a way that’s responsible and safe.
It was the debut of a metaphor we’ve been hearing a lot since then.
Phil Scott: And just as soon as we possibly can, working closely with public health experts, we’ll open up the economic spigot, a quarter turn at a time.
Phil Scott: As I said the other day, there’s no one who wants to open up the economic spigot more than me.
Phil Scott: But if we have a false start, if all of a sudden we open up the spigot, and people go back to work, and then all of a sudden everything spikes and gets out of control, and we have to shut the spigot off again, there’s going to be a lack of confidence in government.
Now, that spigot is opening. Last week Scott announced that two-person crews at some businesses could go back to work. As of this week, certain businesses can staff up to five people, and other changes might be on the horizon.
Scott says these decisions are based on the data that shows the spread of the virus in Vermont leveling off. But in order to maintain that progress, public health officials will need a lot more data. And right now they’re figuring out how they’re going to get it.
Our health care reporter Katie Jickling has more.
Katie Jickling: Vermont has peaked in the number of coronavirus cases statewide. And right now it’s a time where the state government as a whole, and the governor, is changing their strategy and thinking about the long term. Like, how do we bring down the number of cases long term, and how do we prepare for the future so that we don’t see another uptick in the number of cases, so that we can start to safely reopen the economy?
That’s something that the state is thinking about broadly. Testing is an important part of that. Because as that happens, we need to know who has the virus, how it’s spreading, and how many people have already had it and become immune.
Got it.
Mark Levine: Can you hear me?
Katie Jickling: I can, indeed. Thanks for talking. How are you?
Mark Levine: Good. Busy. [laughs]
What exactly were you looking to find out from our Health Commissioner, Mark Levine?
Katie Jickling: Around the country, we’re hearing that a lot of states really don’t have enough tests. They’re asking the federal government for more testing materials and for more capacity to be able to process those tests. Some states are saying that they don’t have enough personal protective gear that they need to conduct those tests.
Vermont really isn’t in that situation at all. In fact, the state has about four times more tests than they are running. We are running about 500 tests a day on average. And we could be running as many as about 2,100 tests. That’s a big discrepancy. Our big question for Dr. Levine was, why? Why aren’t we using these tests? And what is the strategy that has led us to have so many extras?
Mark Levine: If testing is pretty much determined by outbreaks in facilities, or by people like you and I, who might develop symptoms and call our doctor and say, ‘Gee, I think I might have something’ and the doctor would say, ‘let’s test you’ — you can see that we’ve reached a point in time where there aren’t that many complaints.
Indeed, I was on a phone call today with the Vermont Medical Society — because I hold a call every week, and they have 100, 50 physicians on the line at the same time. And no matter where they were in the state, they all said that there was a dramatic drop in phone calls about illnesses, people they were seeing for these illnesses. They were reducing their testing facility times in half because people just weren’t needing to come use them. And there was even a pediatrician who said he hadn’t heard from a mother about a febrile infant in a month. Those kinds of diseases just had stopped happening.
If I could be so bold, I would certainly say that a lot of what’s happened with “stay home, stay safe,” social distancing, masking, all of that — those interventions have reduced the level of Covid illness in the population. So that explains why lately we’ve had less tests per day, because there’s less going on.
Why aren’t we using all those tests?
Katie Jickling: There are a few reasons. First, having that number of tests is a relatively new thing. In March, we didn’t have enough tests. The states did everything they could to try to get more. Governor Phil Scott called Vice President Mike Pence to try to ask for more tests. The state enlisted a private pilot to fly test samples to Minnesota so that we could run them. They asked the state police to drive the test samples down to a lab in Massachusetts so we could run the tests.
They really were employing every possible resource and part of state government to get as many tests as possible and then to be able to run those tests. And now we’re at the point that we have a lot. We can test at UVM Medical Center. Previously, we could only run the tests at the Department of Health. Or we can also test at a lab in Boston that’s run by MIT and Harvard. So now that we’re at this point, things are changing for the Department of Health. And they are really looking at the testing strategy.
Mark Levine: Because we reached a point where we actually have succeeded in reducing — you know, flattening that curve. Now, going forward, it’s going to be important, as we enter a period of suppression of the virus, to really try to do containment anytime outbreaks erupt, whether it be in a community, whether it be in a long term care facility or what have you.
Katie Jickling: To that point, how does the reopening of the economy change that testing approach?
Mark Levine: I don’t think it changed it at all. It’s like a chicken and egg thing. One begets the other. You couldn’t get to the reopening of Vermont unless all the strategies to date had worked. And now that they’ve worked, and there is a period where we hope we can view it as very low level activity, or suppression of the virus, containment is an ideal strategy to really move forward. Which means testing whenever you have the opportunity to help, in terms of: disrupting an outbreak, finding it quickly, ascertaining it’s Covid, and going through that cycle again of test, isolate, contact trace and quarantine.
Katie Jickling: So far, Commissioner Levine has said that what we want to do is, we want to test everybody who has symptoms of the virus. That includes people who feel sick and then call the doctor and are referred to get a test, and are then approved by the Health Department. It does not include people who maybe were exposed to the virus but don’t have symptoms. It doesn’t include the frontline workers, such as cashiers or pharmacy workers, that have been prioritized in other places or countries. And it doesn’t include regular testing, random testing of the population and people without symptoms, so we can get a sense of what proportion of the population maybe has the coronavirus, but isn’t showing symptoms of the disease.
Right, and we’ve heard a lot about how even asymptomatic people can spread this. So if we have that testing capacity, why wouldn’t we use it for those things?
Katie Jickling: We basically don’t know about how many people might get the coronavirus but not show symptoms. We heard recently that 60% of the people who tested positive for Covid-19 on the US aircraft carrier Theodore Roosevelt didn’t show any symptoms. So there’s a chance that a very significant percentage of the population has gotten this disease and just never knew it. The challenge comes when you decide who to test and how many people, because it takes a significant number of resources to be able to test enough people without symptoms that you’re getting a big enough sample size to have a good sense of the spread of the virus.
Mark Levine: Bottom line is, there are strategies that involve testing asymptomatic people that work really well early in an epidemic. So you could, say, do that now when we think we’ve suppressed the disease and find any remnants of it. That would involve testing a lot of Vermonters, and that would be very challenging but could be done, I suppose. As opposed to waiting for some of them to become symptomatic.
Katie Jickling: The other thing is, once you’re tested, you could come in contact with someone and contract the virus in 10 minutes, or just after you are tested, and then you would need to be tested again. And so I think it’s difficult for the Department of Health to have a clear strategy on how many folks to test and whether it’s worthwhile.
Mark Levine: Sure, you can test. But then you’d have to keep repeatedly testing the same people to find out if they were going to be positive. Or you could just have a quarantine in place, because that’s what we do in public health for those kinds of people.
What do we know about how these strategies have worked, or not worked in other places? And is that informing the decisions that Dr. Levine and his team are making here?
Katie Jickling: One thing that’s particularly notable about Vermont is that it does have so many tests — many more than other places. That’s partly because our population is so small. So Vermont is in the minority in the U.S. in terms of places that have excess capacity of tests. Really, it’s not that comparable to other places in the U.S.
It is worthwhile to look at other countries. We’ve seen places around the world — Iceland, for instance, has not shut down its economy. And it has instead taken a very aggressive approach to testing its population. They, I think, had tested about 5% of their population recently, and were hoping, it’s been reported, that they want to test everyone in their population of 364,000 people. That certainly would not be possible in Vermont or anywhere in the U.S. South Korea has also taken a very aggressive approach in testing. They basically identified everybody who had had the virus and contacted everyone who had come in contact with the people who are infected, and then tested all of them. And that really halted the spread of the virus across the country.
Vermont’s in a really different situation than South Korea because the virus has already spread. And so that approach is less effective at this point in the disease.
Mark Levine: It would have been a wonderful strategy for us to use back in early March. Too bad we didn’t have testing. But social distancing is a sound strategy. Avoiding mass gatherings is a sound strategy. Closing workplaces and having people telework is a sound strategy. And then of course, closing schools. But all of these things are a package — they are all timed. So there’s a “too early” time to do them, and there’s a “why did you wait so long?” time to do them. Every decision we’ve made along the way, we’ve had equal sets of praise and criticism along those lines.
You want to be on the right part of the ascending curve, if you will, when you start implementing these things — not too early, but not too late — if you’re going to have this impact on flattening that curve. And then you need to be courageous enough to do everything, and not just do one or two things, thinking, “well, we’ll see what happens.” You need to actually make it a package, if you will, a suite of initiatives, because that’s what it takes.
Katie Jickling: We would use widespread testing for a very specific purpose, and that is: knowing who is being infected and how the disease is spreading. And it’s a different stage of public health response than they did in South Korea, where they’re mainly just trying to stop the spread of the disease in a population that hasn’t come into contact with it. Now it’s more preventive in the future.
Mark Levine: The biggest question in testing is, do you just test a whole bunch of people who have no symptoms or not? And then what do you do with that information? That’s a huge challenge for any state, because you can’t just test a little here, test a little there. You need to have a strategy that samples enough of the population that you’re getting an accurate look at that.
Most places haven’t been able to get even close to that because they could barely test the people who had symptoms, nevermind the people who are out there without them. So I think that’s a real challenge. And that’s something we’ve debated forever, because you have to then decide what are you going to do with the information.
Katie Jickling: And you just haven’t found a way to use that? Because it seems like Vermont has the tests and the capacity to be able to do that, and the small population, to potentially get a significant sample size.
Mark Levine: We think so. You know, then you have to have issues of equity. Like, did you test one community and not another community? Or did you test a certain number of people in each community? You have to really think it through very clearly, in a population, again, that might not want to be tested. If you have no symptoms, why would you want to be tested? You may just want to know if you’ve got the virus or not. But at the same time, in a state like ours, where the curve I’ve shared with you gets as low as it gets, I’m not sure it helps at that point. It probably helped way back on the left side of the graph, more than it would help now.
So what does that look like going forward? What does Dr. Levine say about what he thinks the next several months look like under this strategy that he’s laid out?
Katie Jickling: The state is rolling out a new testing plan, which they plan to unveil next week. That plan will include a new testing approach. Dr. Levine announced on Monday that pediatricians could start testing kids and teens with flu-like symptoms, a group that wasn’t previously being tested. He also wants to start doing antibody testing, which is a different kind of test to identify not just people who have the virus now, but people who have already recovered from it and are now immune. So he hopes by May or June, we’ll have enough of those antibody tests, which are also called serologic tests, to be able to test up to 10% of Vermonters to see if they’ve already contracted the virus.
That plan could include testing health care workers more regularly, or testing frontline workers such as pharmacy workers or cashiers or postal workers. And then there’s also the option that Vermont could start testing people in congregate workplaces, such as manufacturing facilities or factories where you have a lot of people working together at the same time. And that would start to allow some of those people to come back to work, and at the same time to track the spread of the disease.
I know there’s a lot of pressure on the state generally to try and get as many people back to work as possible. The governor has said over and over again that, nobody wants to get people back to work more than me. How big a factor is this component of it? How big a deal is the testing strategy to that ability to open things back up?
Katie Jickling: I think that’s the fundamental question. And I think this virus is so new that different experts and public health officials disagree on that point.
Certainly as you start to open up the economy, people will be walking around more, they’ll be going back to work potentially, they will be infecting other people more quickly and easily. So testing can be a really key way to know who has the disease and to stop those outbreaks immediately.
So far, Governor Scott has really focused on keeping people home, keeping people from getting the disease in the first place, and that has been very effective. Vermonters have stayed home, and they really have flattened the curve. So I think the question remains, to what degree you can continue to halt or slow the spread of the disease while still starting to open up the economy?
I think we just don’t know yet. That’s the balance of: how much do we want to invest in this testing that yields some good information and some useless information? But it also could be potentially lifesaving in preventing a second peak.
Thanks, Katie. I appreciate it.
Thanks, Mike.
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