Public health experts caution not enough resources to test, trace COVID-19 patients as Nevada eyes reopening economy
Nearly 40,000 tests for the novel coronavirus have been performed in Nevada over the last month and a half, but to safely begin reopening portions of the economy, the Silver State may need to be running that many tests each day.
A new Harvard University report produced by 45 experts across several different disciplines estimates the country needs to be running 5 million COVID-19 tests a day by early June to begin allowing some businesses to reopen; to fully open the economy, it will need to run 20 million tests a day by late July. Extrapolating those numbers out to each state by population, Nevada will need to run 47,000 tests a day by early June and 188,000 tests by late July.
Another, more conservative projection by Dr. Ashish Jha, director of the Harvard Global Health Institute, estimates the country should be conducting a minimum of 500,000 tests per day. That’s about 4,700 tests a day in Nevada. Nobel prize-winning economist Paul Romer puts the figure at 20 million to 30 million tests a day nationally.
While there haven’t been any projections looking specifically at how many tests should, ideally, be run each day in Nevada, public health experts, health care providers and other scientists agree that the number of tests being run in the state isn’t enough. Over the last week, Nevada reported an average of about 920 new people tested each day.
Providers and labs do, however, say they have the resources they need for testing under the status quo under the Centers for Disease Control and Prevention’s current guidelines, which include three different priority groups for symptomatic patients.
In some clinics, that means testing only patients who present with symptoms of COVID-19 and have other risk factors, such as age or underlying conditions. In others, the protocol is more broad; at HealthcarePartners Nevada’s COVID-19 clinic, for instance, all patients exhibiting symptoms of the virus are tested, as well as asymptomatic family members of confirmed positive cases.
“We’ve been able to keep up. At first, we just tested the highest-risk patients and within two weeks, we were testing anyone with symptoms,” said Dr. Warren Volker, HealthCare Partners Nevada’s chief clinical officer. “We’ve been in really good shape.”
But public health experts would like to have even more testing capacity in place before reopening the economy. In an ideal world, all of the close contacts of people who test positive for COVID-19 would be tracked down by public health officials — in what’s known as contact tracing — and tested, whether or not they live with the positive patient or are showing symptoms. But that will take both time and resources, including scores of workers, that public health officials do not currently have.
“I think we know that what we have available now is not sufficient,” said Washoe County District Health Officer Kevin Dick on a press call with reporters on Monday. “I could tell you that would mean that we would have to at least double, maybe triple or more, that capacity of the testing that we’re doing.”
The current testing situation
COVID-19 testing, under the status quo, serves a few different purposes. In a hospital setting, patients are tested so that health care providers can best care for them while also taking the proper precautions to prevent other patients and themselves from getting infected. In a community setting, testing can help doctors provide the right level of treatment for ill individuals so their condition doesn’t worsen and land them in the hospital.
Hospitals initially relied on the state’s public health labs in Las Vegas and Reno to run their COVID-19 tests. Then, they switched to the private labs, such as Quest Diagnostics and LabCorp. Now, many have switched to in-house testing, providing them results in a matter of hours instead of days.
University Medical Center, the county-run hospital in Las Vegas, was the first to switch to in-house lab testing. The hospital is now partnering with a technology company in Abu Dhabi, G42, to develop a high-volume testing laboratory to process samples from hospitals, doctor’s offices, curbside testing locations and other health care providers across the state.
“We are proud of UMC’s ability to build upon our extensive laboratory capabilities, to work with G42 and our other partners in Clark County and throughout our state to collectively strive to keep our residents and visitors safe and healthy,” Mason VanHouweling, UMC’s CEO, said in a statement announcing the partnership.
Dignity Health’s St. Rose Dominican Hospitals Siena Campus is now running rapid tests for the company’s three Southern Nevada hospitals, with results available in about two hours. Hospital spokesman Gordon Absher said in an email that the tests are used for acute patients admitted to the hospital, in part to help staff determine whether they need to use personal protective equipment in caring for the patient.
“A positive test means staff must wear full PPE when caring for the patient,” Absher said. "A negative test allows us to use standard precautions while caring for the patient’s condition, thus conserving PPE.”
However, Absher noted that rapid tests are limited and the hospitals are also relying on outside testing, which can take about 24 hours to get results.
The three Las Vegas hospitals run by HCA — MountainView Hospital, Southern Hills Medical Center and Sunrise Hospital — began running tests on-site last week, with results expected in a matter of hours instead of days, and Renown Regional Medical Center in Reno is also running on-site testing. The six hospitals in the Valley Health System are outsourcing all COVID-19 tests to private labs and the Southern Nevada Health Public Health Laboratory.
The CDC designates hospitalized patients as priority one for testing. Priority two and three patients, however, are often tested in a community setting, where the protocols for who to test are more uneven.
UNLV’s School of Medicine, for instance, has been running a drive-through COVID-19 testing clinic since March 23. It started with two tents, testing about 240 patients a day. Now, it’s operating four tents, with the hope that additional support from the Nevada National Guard will allow it to ramp up to 400 tests per day.
Michael Gardner, the medical school’s vice dean of clinical affairs and strategy, said the National Guard is providing eight medics who will help the school’s medical assistants collect nose swabs, as well as military police through the Army National Guard to help UNLV police with traffic control.
The clinic also has a new web-based triage tool, which Gardner said was developed by a local software company at no cost and screens people for COVID-19 symptoms; if they require testing, they’ll receive a call from the school’s call center, which is run by medical students and residents, to set up an appointment to come in for drive-through testing. He said the tool has decreased demand on the call center, which he described as a “choke point” in the process.
“Using this new system right now we’re only one day out,” Gardner said, of the wait-time for appointments. “One to two days.”
Results, he said, typically come back in three or four days. The school has partnered with the private lab Clinical Pathology Laboratories, which flies the samples to Austin for testing.
The Washoe County Health District has a similar drive-through-style operation at the Reno Livestock Events Center, with patients triaged either through an online-risk assessment form or by phone. The drive-through clinic tested 216 people on Sunday, and officials projected it would test another 230 on Monday.
Patients can also get tested at a private health care provider. For instance, HealthCare Partners Nevada has centralized its COVID-19 testing operation at its Wynn Urgent Care Clinic. Volker, the company’s chief clinical officer, said that all patients who call with respiratory symptoms, fever and body aches are directed to that location for drive-up testing.
Early on, the company gathered as many test kits as it could and tested just the highest-risk patients, Volker said. Since then, they have been able to expand testing to not only all symptomatic patients but their asymptomatic family members as well.
“We had a mother come in who tested positive for COVID with symptoms. We tested the whole family, including a nine-year-old child, and everybody was positive, including the nine-year-old child,” Volker said. “The good news is everybody stayed home. Everybody is doing well.”
Volker said that the longest the clinic has ever had to wait for results from one of the three private labs it sends samples to is four days but that test results have generally been coming back the next day.
“We’ve been able to literally test everybody that’s met criteria,” Volker said, adding that the clinic has more than 500 kits available on hand. “We are in really good shape right now.”
In fact, Volker said the clinic gifted some test kits to the hospital in Pahrump when they ran out last week.
But not all clinics have had the same resources. Nevada Health Centers, which runs 18 federally qualified health centers across the state, only receives about five to 10 testing kits per week per clinic from its private testing company, LabCorp, on top of the 50 kits it received from the state. As of Friday, they had tested 372 patients, with 35 positive results.
Dr. Ali Shahin, Nevada Health Centers’ chief medical officer, said that because of limited resources, they have had to prioritize testing older individuals and those with underlying conditions, such as heart and lung disease.
“We do screen also younger folks, if really the symptoms very much are indicative of COVID-19, but the challenge that we’re having all in all is we don’t have enough testing kits to really screen everyone who comes with a cough,” Shahin said. “That’s why we have to make some prioritizations.”
Shahin said that Nevada Health Centers is collecting around 25 to 30 samples per day as an organization, but, in an ideal world, they would be able to test four times that.
“If we just go with symptomatic patients, at least, I would say four-fold that, quadruple that number we would like to be collecting,” Shahin said. “Symptomatic patients, people who are close contacts of patients who have COVID. We should be testing the critical infrastructure workers, restaurant, et cetera. So it’s difficult for me to say, but at least four fold.”
Clinics and hospitals are also starting to roll out rapid testing. The Southern Nevada Health District received eight Abbott ID Now rapid testing machines; three will stay at the health district’s clinic, one will go to UMC and the rest will go to other federally qualified health centers in the community. The Washoe County Health District received four; three will go to Northern Nevada hospitals, Saint Mary’s Regional Medical Center, Renown, Northern Nevada Medical Center, while one will go to the Community Health Alliance, a federally qualified health center.
"The reason we deployed them with the hospitals is to be able to provide that 15-minute turnaround for people that they need to be admitted to the hospital, to be able to determine whether they have COVID-19" so they can be "separated and cohorted with other COVID-19 patients,” Dick, Washoe’s health officer, said.
Oscar Delgado, the Community Health Alliance’s CEO, said that the organization is currently deciding how it will implement rapid testing, as it is not currently conducting any COVID-19 testing. The hope, he said, is that the clinic will eventually receive 120 tests a week, though it only received eight to begin with — meaning only eight people can initially be tested.
“We’re going to be a trusted place to go,” Delgado said. “And hopefully we’ll get a rapid turnaround and response for those in the community.”
Implementing contact tracing
But testing is only half the battle. Even if there were enough tests available for every close contact of every positive patient, the state and local health agencies still would need enough staff to be able to find all of those contacts and make sure they get tested. By all accounts, the local health districts are far from having enough staff to implement that kind of a robust testing and surveillance operation.
Dick has estimated that Washoe County will need about 140 people to do full-time contact tracing, when the health district right now has fewer than 160 full-time employees in any position. He said that the CDC has talked about sending their staff into the field, but said it was unlikely that the federal agency would be able to solve the staffing shortages.
“In our future scenarios, once we are reducing the social distancing requirements, we're reopening additional businesses, et cetera, that will increase the potential for the spread of the disease, and therefore it becomes even more important that we're able to very quickly identify positive COVID-19 cases to have those individuals isolated, to identify their close contacts, and have those individuals quarantine for that 14-day incubation period as soon as possible to prevent the additional spread,” Dick said. “That's going to take additional resources.”
The Southern Nevada Health District is in a similar situation. Health district officials estimate that they have about 50 people from their Office of Epidemiology and Disease Surveillance working on contact tracing, in addition to others who have been pulled in from other roles to assist.
“As you might imagine, we're really overwhelmed with the amount of contract contact tracing that we have to do,” said Michael Johnson, director of the health district’s community health division. “We, like many other health departments around the country, are really in need of additional disease investigators to keep up with all the contact tracing.”
John Packham, associate dean for the Office of Statewide Initiatives at the UNR School of Medicine, noted that other countries, including South Korea and Singapore, have robust testing and contact tracing operations that allow them to quickly identify and quarantine people who may have been exposed to the virus. Without contact tracing, the increased testing is less helpful, he said.
“The testing is a key part of it, but then what do you do on the basis of that test?” Packham said. “It’s a kind of detective work.”
Packham also noted the yearslong underfunding of public health in Nevada. Among the 50 states and Washington, D.C., the Silver State ranks 50th in the nation in public health spending per capita.
“To do the testing and surveillance and contact tracing and disease investigation is pennies on the dollar for what we’re going to pay for this crisis,” Packham said. “That’s public health though. It’s not a huge amount of money or resources we’re talking about, but we’re paying for it right now.”
What happens next
The question, then, is with limited testing and contact tracing resources, when and how, exactly, can businesses begin opening up again in Nevada? Gov. Steve Sisolak is expected to address that question this week as governors across the country continue to release their own frameworks and timelines for reopening their economies.
There are some dates to work off of, though. The University of Washington’s Institute for Health Metrics and Evaluation’s COVID-19 projections now includes a forecast for when states can start thinking about relaxing social distancing measures with appropriate containment strategies, including testing, contact tracing, isolation, and limiting gathering size. For Nevada, that’s May 18.
But others are even more cautious. Packham said it might be more like June 1.
“It looks like things in Washoe County and the state as a whole are leveling off — but that leveling off looks like less than a week,” Packham said. “I’m looking at every piece of data I can.”
Southern Nevada Health District officials, during a press call with reporters last week, wouldn’t put their finger on a particular timeline or a number of cases that would make them feel comfortable about reopening the economy.
“It’s really about when we have people we want to test, even people with milder symptoms, do we have the capacity to test those people?” said Vit Kraushaar, medical investigator for the health district. “But we can't put a specific number on that.”
Health care providers are similarly cautious.
“We’re not even testing all the symptomatic patients let alone the asymptomatic ones. We really don’t know what the prevalence of this disease is,” Shahin said. “I think we should be cautious about opening or loosening the stay home orders too soon.”
They are, however, making preparations for more and new kinds of testing becoming available in the coming months. Volker said that HealthCare Partners Nevada is continuing to test patients and is looking forward to the availability of antibody testing, which will help determine who has already contracted COVID-19 and therefore may have immunity from it, though it’s not clear how widely available such testing will be.
“There are a lot of coronaviruses we’ve known for years, but this COVID version, we’re going to have to follow and learn from this,” Volker said. “It’s going to be a little bit of a starting lifting restrictions and holding our breath a bit.”
Dr. Robin Titus, who is Lyon County’s health officer as well as the head of the Assembly Republican Caucus, is hoping to see restrictions beginning to lift, particularly in some rural communities with few cases, soon. She believes that ramping up testing can happen even as some businesses are allowed to reopen.
“What we need to do is ask people the question, ‘Did you have an illness that was undiagnosed? Did you seek medical care?’ And then we’ll have antibody testing. That’s important. We need to start that now,” Titus said. “But that doesn’t prohibit us from very consciously and very carefully opening businesses. I’ve said from the start if a business believes they can maintain the appropriate social distancing, sterility, and the safety of their employees and their clients, we should give them a chance.”
Assembly Republicans on Monday released a four-point plan for reopening the state, which includes Nevada joining a previously announced Western states compact with California, Oregon and Washington and establishing regional plans to modify or ease the state’s stay-at-home order based on testing and hospital readiness. Titus said that what may make sense for rural Lyon County is going to be different than what’s best for Clark County.
“Unfortunately Clark County is a different issue, which is why I’ve pushed for identifying hotspots and hot zones,” Titus said. “I feel so bad for the Strip and the folks down there, but opening the casinos and allowing airport traffic to come back in would be a mistake initially. That’s why we have to do it in a wise, wise manner.”
Brian Labus, an assistant professor of public health at UNLV and former senior epidemiologist for the Southern Nevada Health District, noted the push and pull between public health and the economy.
“Of course there are all sorts of economic considerations we have to think about. There’s all kinds of things that go into a decision about when to open,” Labus said. “If there’s a way to reopen a lot of those things without causing problems, great, go for it. If opening that business is going to create a bunch of cases of disease, obviously the public health approach would say don’t do that. You have to think about those things: Is there a way to open it safely?”
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