As Vermont loosens restrictions on work and movement in a step-by-step manner, state health officials are gearing up for an expected increase in COVID-19 cases by beefing up testing and tracing capacity. If they stay on top of new cases, they hope to be able to keep the spread to a minimum.
This hour, we get a health information update and take a deeper dive into the state's approach to testing and contact tracing.
Our guests are:
- Tracy Dolan, deputy commissioner for the Vermont Department of Health
- Patsy Kelso, state epidemiologist for the Vermont Department of Health
Broadcast live after Gov. Phil Scott's press conference on Monday, May 4, 2020; rebroadcast at 7 p.m.
The following has been edited and paraphrased for brevity and clarity.
Jane Lindholm: The Scott administration has announced a goal of reaching a testing capacity of at least 7,000 tests per week. How did the state choose that number?
State Epidemiologist Dr. Patsy Kelso: We want to be testing more people than we have so we can get a more accurate picture of COVID-19 here in Vermont. We know people can be in the incubation period and spread the virus, and that some people have mild-to-no symptoms and can spread it.
There are some studies that show you need to test about 150 people per 100,000 in the total population to have what is considered enough testing. When we did that math, it comes out to just about 1,000 per day, or 7,000 per week.
You really have to be capturing enough of the population to be able to say that you have a robust picture of what is going on.
We want providers and Vermonters to think about ordering one of these tests or health care with even the mildest of symptoms.
How sensitive are the tests we have?
Kelso: There are several different technologies out there that are being used to test for COVID-19, and they all likely have slightly different levels of sensitivity. The data I have seen suggest that the sensitivity and specificity for pretty much all of the tests we are using in Vermont is around 95%. They’re pretty good
But the predictive value of a positive test result is impacted by how many people truly have what you are testing for. That can give misleading results if very few people have it because with a test that is not 100% accurate all of the time, if you test a ton of people who don’t have it, you are going to get some positives, and those may be false positives.
With regards to contact tracing, the state has said that, under a plan announced last week, it will increase its capacity for contact tracing this month from 500 new cases per week to 300 to 900 cases per week. How did you arrive at those numbers?
Kelso: We currently have about 50 people trained and working on our Case Follow-Up Team. They are largely people from other health department programs we have trained up to do this work. To come up with our capacity, we figured that each staff person could conduct two full contact tracing protocols per day — so if you had two new cases, that would mean interviewing each case to find out who their contacts are then following up to interview each contact. With people working 5 days a week, we think we have enough staff to trace about 500 new cases per week.
That is the capacity. I certainly don’t hope we get to point where we have 500 new cases a week. As we ramp up testing and open up the economy, we do expect to see more positive tests than in the past weeks with more social interaction in work places. As a department, this is our highest priority right now.
What sorts of apps is the state planning to use to track cases, and will they be using those that track and aggregate data about where a person has been?
Kelso: Our goal is really keeping in touch with people to help them monitor their health. There are a number of apps out there that allow people to enroll and choose how they keep in contact with us – you don’t need a smartphone or even a cell phone. You can sign up to communicate by email or landline as well.
That’s not the type of app we are looking to use— that would be a location or proximity tracker app. In order for that type of technology to be effective, you really need 60% of the population or more to be using that technology. We are proposing a more basic system that allows us to reach people with a confirmed case every day to check in and see if their symptoms have improved, they’re getting sicker. For a contact, we’d check in daily to see if they are developing any symptoms of COVID-19.
There’s been talk nationally about the possibility of self-administered tests, or tests that are less invasive and so require less risk and PPE for those who administer them. Do you see us getting that technology here in Vermont?
Kelso: We are moving towards a nasal swab test rather than nasal pharyngeal swab test, which is what we’ve been doing so far. The latter is invasive and requires the person administering the test wear extensive PPE because it can trigger a cough or sneeze in some people. We are moving now towards a nasal swab, just at the front of the nose, which is much more comfortable and doesn’t require the person administering it to wear as much PPE.
We expect to roll out that out later this week. That will really help us to expand access to testing, perhaps even at primary care providers.
A self-administered saliva test is emerging, but it’s not as simple as spitting into a cup. It requires saliva be collected first thing in the morning and in a fairly large volume, but we’ll continue to look into that.
Jane Lindholm: Do we have enough testing capacity to meet this new goal of testing as many as 7,000 people per week? If so, how did we get there?
Deputy Health Commissioner Tracy Dolan: There are a variety of people in the state that have been working on securing medical supplies through federal and private vendors.
We have a fairly good supply chain of testing materials right now, and plenty of capacity to conduct tests both within the state and outside. We feel like we are in a good place, and it appears that we will have a good enough supply to support ourselves. Together with UVM, we have the laboratory capacity to ramp up testing as needed. Rutland is also doing some of their own testing.
Is the state stockpiling testing supplies?
Dolan: I don’t really like the term stockpiling. We have an adequate number of tests. We have a buffer, and we continue to keep orders coming in.
As we open up more, why aren’t more people in the general public being tested? Can we test everyone?
Dolan: We are following CDC guidelines and looking first at more vulnerable populations. We can’t get every single asymptomatic person tested, so we are prioritizing the more vulnerable people.
We may get to the point where if we test enough people, we are able to say, “This is what the state looks like, on average.” However, it may not be feasible that we test everyone on a regular basis.
You’ve said that the Vermont Department of Health now has a contact tracing capacity of 500 new cases per week. If we reached that level, wouldn’t that be a crisis, considering we just saw 900 cases total in Vermont?
Dolan: We established that capacity to be prepared, but hope we don’t get there. In the event we do, we will have to look at whether the measures we have in place are sticking. If we see cases spike versus rise, we may stop and reassess and impose some more stringent regulations again. We would likely do
something before we ever get to that point.
Now that workplaces are starting to reopen, how should people who may have had COVID-19 or another respiratory illness determine that they are symptom free and ready to return to work, knowing that even a benign cough can linger for many weeks?
Dolan: The CDC has embraced a symptom-based strategy rather than a test-based strategy here. We follow that here in Vermont. The language from the CDC says to look for improved symptoms and no fever for at least 72 hours, but there is some subjectivity involved there.
We know that COVID-19 is primarily passed through respiratory droplets, so it may not be advisable to return to work with a lingering cough.
As Vermonters return to work and are required in many cases to wear a mask in their workplace, who is going to provide them? What is the latest guidance about when and where to wear one?
Dolan: You should wear a mask anytime you are around other people. It’s a good idea, even if you’re outside, to bring one with you in case on your walk or hike you find yourself in a place where there are a lot of people around. If you are exercising around others, it’s a good idea to wear a mask – though social distancing is still of the utmost importance here.
With regards to work, masks are going to become a necessary for everyone in Vermont and the United Sates. It is part of the way we need to live our lives. I think Vermonters should assume that it’s their responsibility, not their employers’ to obtain a mask.
Now that elective outpatient care is opening up again in Vermont, who will pay for the personal protective equipment (PPE) required to make that happen?
Dolan: The state is not going to provide that PPE; health care facilities will be responsible for sourcing their own, through their own vendors. We will see a higher burn rate of PPE now that this sector has reopened, but the market is picking up and meeting that demand.
Why is inpatient care not open? Will dentistry open soon?
Dolan: Emergency dental care is currently available, and we expect some other procedures to be back very soon.
We didn’t reopen inpatient care yet because of the risk. We are trying right now to roll out extensive health surveillance. It’s difficult, but we are going to do it step by step. We’ll see first how it goes with outpatient care.