Thousands more Oregonians could get tested for coronavirus right now but state leaders aren’t ready to ease restrictive screening guidelines that could help them identify additional infections and better understand the breadth of the disease.
The tight controls on who should get tested have frustrated people who have symptoms but aren’t part of the highest-risk groups. Some sick residents are left to fend for themselves and risk infecting others, unsure if they actually have the virus, even as tests sit unused.
Oregon’s limited testing criteria have created an access imbalance. Doctors and nurses generally follow state advice but exercise discretion, allowing some people with symptoms to get tested at one place after being turned away by another.
One Oregon county with the highest rate of infections statewide is doing fewer total tests than a county with a smaller population and a fraction of the total infections. The state lab isn’t using its largely untapped testing capacity to fill that gap.
Seven weeks into the state’s coronavirus outbreak, testing remains a confounding puzzle to the average Oregonian. There appears to be pent-up demand for more widespread testing – and the ability to provide it – yet the state’s per-capita testing rate ranks in the bottom half nationally.
Chunhuei Chi, director of the Center for Global Health at Oregon State University, said testing more people in Oregon now could help prevent the spread of the virus among people within a household or when someone who’s infected but has mild or no symptoms visits a grocery store.
That in turn could help reduce the number of active cases and speed up the timeline for trying to reopen parts of the economy.
“In the absence of increased contact tracing, the second best we can do is to ramp up testing by loosening the criteria,” he said.
Relaxing testing constraints to allow doctors to include mild symptoms will likely happen eventually, said Dr. Dean Sidelinger, the state’s epidemiologist and health officer.
But first, Sidelinger said, the state needs to build the capacity to test up to 15,000 Oregonians per week – not necessarily to actually test that many people – to soften social-distancing restrictions. Sidelinger said officials don’t know how close they are to that goal.
It appears Oregon may already have reached it.
The state has reported an average of 1,300 test results a day over the past three weeks. The Oregonian/OregonLive found in a sampling of about a half-dozen hospital systems and health care providers that their staff and labs could handle at least 1,000 more tests each day.
Add them together and that tops 2,300 a day or more than 16,000 tests a week.
Sidelinger said it makes sense for the time being to reserve testing for people who have symptoms and fall into certain categories. Those include first responders or health care workers, nursing home residents, people 60 years old and over, Oregonians whose symptoms are getting worse and those with underlying medical conditions.
Testing people with mild symptoms risks exposing medical workers to the virus and uses supplies that may become scarce, according to guidance from the Oregon Health Authority. But limited access to tests or supplies is no longer an impediment, Sidelinger acknowledged.
“If we made an explicit recommendation to test all mildly symptomatic individuals and asked them to go in for testing, yes, it would likely increase testing,” he said. “But I don’t know if that would change the situation here in Oregon.”
It remains to be seen whether Oregon’s capacity goal of 15,000 tests a week, or the equivalent of 60,000 tests a month, is an adequate benchmark, however. Oregon is one of about only a dozen states nationwide that lacks the ability to test at least 100,000 people a month, according to data collected by federal officials.
On a per-capita basis, Oregon’s capacity looks even worse -- drawing a direct mention by Dr. Deborah Birx, the White House coronavirus response coordinator, during a briefing Friday in Washington, D.C.
“Those are the three states that we’re working on building capacity in,” she said, referencing Oregon, Montana and Maine by name.
To be sure, Oregon has not been hit as severely by the coronavirus as many other states. The stay-at-home order announced by Oregon Gov. Kate Brown on March 23 has unquestionably helped bend the curve of infections, preventing a surge in hospitals and a rapid increase in deaths.
And expanded testing has shown the rate of infection is low when Oregon is compared nationally, with just one out of every 20 Oregonians tested finding they’re infected. Officials don’t expect that to dramatically change with more testing.
But more infected Oregonians could be found – and other states, such as Utah and New Mexico, have loosened criteria to do just that.
A 36-year-old teacher who lives in Northeast Portland is among those left dismayed by Oregon’s mixed messaging on testing.
The teacher developed a dry cough in the center of his chest April 6. Over the Easter weekend, his fever reached the low 100s and he felt fatigued. He wondered if it could be coronavirus but doubted whether he could get tested.
An online assessment through Kaiser Permanente told him that, despite his symptoms, he was at low risk for coronavirus. He called a nurse, pre-emptively hoping to get his name on a list in case his symptoms worsened.
“The big message was, you don’t qualify for testing, don’t come in,” he said.
A spokesman for Kaiser said people with coronavirus symptoms are screened for testing under nine defined criteria, none of which included non-essential workers or those without underlying health conditions.
The teacher asked for anonymity to shield his family from possible social reprisal. Given the uncertainty of his illness, his wife has still been leaving the house for work or to pick up groceries for the couple and their two kids.
He eventually found a different provider who tested him Thursday and is awaiting results.
“If you don’t know, you don’t know what to do,” he said. “It’s really hard to be in the gray area.”
Oregon Gov. Kate Brown announced Tuesday that schools will remain closed for the rest of the academic year. April 8, 2020 Beth Nakamura/Staff
‘NOT RECOMMENDED FOR TESTING’
Coronavirus testing has expanded immensely since Oregon became one of the first states in the country to identify its first infection.
When a Lake Oswego elementary school janitor tested positive for the virus Feb. 28, his test went to the state health lab – the only place in Oregon with the necessary technology. In the two weeks that followed, the state lab remained essentially the only game in town and the Oregon Health Authority reported fewer than 100 test results a day.
But then national labs and hospital systems came online. Oregon, like the rest of the nation, saw a seismic shift in how many people could be tested – although the United States still lacks the per-capita capacity of other countries.
Oregon’s governor was clear not every resident could get tested but emphasized the importance of getting more tests.
“It’s critical for us to increase our capacity so that we can fully assess the spread of COVID-19 in Oregon,” Brown said March 18, a week before the state regularly began reporting test results for more than 1,000 people a day.
Coronavirus testing increased quickly but has since appeared to plateau, with daily averages between 1,200 and 1,400 results in each of the past three weeks. It’s possible testing has inched up recently, but it takes time for results to get reported to the state health authority.
As of Saturday, the state reported 72 deaths and 1,844 infections out of 37,583 Oregonians tested. Oregon’s ranking a day earlier stood at 31st nationally, including Washington, D.C., with 8.6 people tested per 1,000 residents.
The state’s instruction continues to discourage the testing of everyone with fever, cough or shortness of breath – three hallmark signs of coronavirus.
In bold letters, the health authority’s guidance to doctors and nurses says: “Asymptomatic persons and those with symptoms that do not necessitate medical evaluation are not recommended for testing at this time.”
Sidelinger said he realizes hospitals and other private labs could handle additional tests “if they were received.”
But confirming additional mild cases now through testing may have little value in how doctors would otherwise treat presumed infections, he said, given that Oregonians are all under stay-home orders to prevent the spread of coronavirus.
“Clinically, if it’s not going to change what the provider tells them to do, or how they treat them, that provider might not be ordering that test,” he said. “And we’re hearing that from multiple providers.”
‘TEST ALL INDIVIDUALS WITH SIGNS AND SYMPTOMS’
Some states comparable to Oregon are far more aggressive at testing for infections.
Utah and New Mexico stand out. Both match Oregon’s low rate of infections, finding about one in 20 tested residents have the virus.
Both are testing about twice as many people per capita as Oregon.
It’s not only that Utah and New Mexico have large laboratories that almost immediately boosted testing availability. They also have relaxed restrictions.
Officials in New Mexico on April 1 greenlighted testing for people without symptoms who had close contact to a known COVID-19 case or those who live in nursing homes or homeless shelters. The state also said people with a fever, cough or shortness of breath who didn’t necessarily need a doctor’s care could be considered for testing.
“I don’t want to make it sound like we’re geniuses here. We’re not,” said state spokesman David Morgan. “The math has worked for us, as well as the desire to pursue aggressive testing.”
New Mexico now has the capacity for more than 21,000 tests per week, he said. Through Friday, it had tested about 35,000 people.
TriCore Reference Laboratories is processing more than half of all tests in New Mexico and the state public health lab is taking about one-quarter. The rest of the tests have been analyzed by private companies such as Quest Diagnostics and LabCorp, according to state data Morgan shared.
Utah, meanwhile, welcomed tech entrepreneurs who developed a website to assess residents’ symptoms and direct them to testing locations. Public health officials also launched an aggressive media campaign to encourage testing as capacity increased.
“Healthcare providers and testing sites should test ALL individuals with signs and symptoms (fever, cough, or shortness of breath), no matter how mild the symptoms may be,” the state’s official Twitter account for coronavirus news announced last week.
By Tuesday, the guidance had been revised again to include any of those three symptoms, plus three more: muscle aches and pains, decreased sense of taste or smell or sore throat.
“Have a symptom?” a catchy graphic asked. “Get tested.”
Nearly 60,000 people in Utah have now been tested. More than half of the state’s tests have been analyzed at a local lab, ARUP Laboratories, while a large hospital chain has completed about a quarter, according to data provided to the newsroom.
Officials loosened restrictions when they realized many tests weren’t being used each day.
“The fact that we have this unmet demand is concerning for everyone,” said Tom Hudachko, a state spokesman. “If we can test 5,300 people, we’d like to test 5,300 people.”
Dana Pharr tests for coronavirus at Providence Health & Services drive-thru COVID-19 testing. The testing is conducted by appointment. March 30, 2020 Beth Nakamura/Staff
‘Really restrictive guidelines’
Health care professionals across many parts of Oregon say they have coronavirus tests that aren’t being put to use.
It appears easing restrictions could increase screening, although other factors may be at play, including the possibility that fewer Oregonians are sick or overarching confusion among residents about whether they should seek testing.
In southern Oregon, the hospital system Asante helped propel testing in Jackson County to enviable levels by opening a drive-through location in mid-March, where more than 2,100 people have now been tested.
At its height, nurses were collecting nasal specimens from about 200 people per day, said Lauren Van Sickle, an Asante spokeswoman. Now it’s about 60 people.
“I would say the novelty wore off pretty quickly,” she said of the buzz over the drive-through, set up in a strip-mall parking lot.
Van Sickle couldn’t pinpoint what caused the drop off but suggested the number of county residents seeking testing may have dropped because fewer people have symptoms.
Oregon’s largest health care system, Providence Health & Services, is also seeing a slowdown.
The in-house lab has processed about one-quarter of all tests for Oregonians, according to data provided by spokesman Gary Walker.
But Providence could run samples for about 600 people a day collected from tests at its hospitals and drive-through clinics. Instead, it’s about half that a day on average.
Walker said Providence would like to get much closer to its full capacity “and we’re looking for the ways to do that,” including “how to loosen” the criteria for testing.
Legacy Health can process about 750 coronavirus tests a day between its in-house lab and using new Abbott ID Now rapid tests at urgent care locations. But over the past week, total tests have averaged about 270 a day, spokeswoman Sarah Ericksen said.
It’s a similar story for the Virginia Garcia Memorial Health Center, albeit on a much smaller scale. Drive-through locations in Washington and Yamhill counties are testing about 20 people a day, below the goal of 28. Officials have now taken out targeted advertisements hoping to encourage testing among their mostly Latino clientele.
“That is something we discuss every day,” spokeswoman Kasi Woidyla said. “How do we get the word out to everybody?”
Same goes for Oregon Health & Science University. Two drive-through locations could each accept samples from 100 patients a day, spokeswoman Tamara Hargens-Bradley said. Instead, it’s been averaging about 35 people daily.
“We’re trying to make it available to as many people as we can without getting overwhelmed,” she said, adding that some non-OHSU network patients have even been accepted.
Erik Vanderlip, chief medical officer for ZOOM+Care, said the company’s clinics in Oregon are sitting on under 1,000 test kits that could be put to use at a drive-up collection site.
Loosening guidance on who should be tested would enable the company to test more people, he said, expressing optimism that changes would come soon.
“We are under really restrictive guidelines as to who can get tested,” he said.
State epidemiologist Dr. Dean Sidelinger fields questions from local journalists during a tour of the Oregon Health Authority's newly configured operations center in Portland. March 3, 2020. Beth Nakamura/Staff
‘MORE INDIVIDUALS SHOULD BE GETTING TESTED’
As Oregon looks to reopen parts of its business sector, perhaps as early as next month, it appears even more testing options will be available.
This past week, the University of Oregon announced it would soon run tests for McKenzie-Willamette Medical Center in Lane County, beginning with 100 tests a day and ramping up to 300.
Oregon State University’s veterinary lab has launched a partnership with WVT Laboratory in Benton County to run up to 1,000 tests per day, according to The Lund Report.
Oregon State is also launching a four-week effort to collect samples at random from nearly 1,000 residents in Corvallis. The study will gauge the spread of the virus and get a baseline for the rate of people who are infected without symptoms – which will be a major, eye-opening finding.
State officials also say they, too, are looking to improve testing capacity at the public health lab, which now has the ability to test up to 200 people per day. One day this week, state officials completed just 20 tests.
Extra testing by the state could conceivably help address testing challenges across the state, such as in Marion County.
Data show that one out of every 10 people tested there has the coronavirus – the highest rate in the state – although some of that is due to outbreaks in nursing homes. Marion County has identified 335 infections but fewer residents have been tested there than in Jackson County, which had only 49 infections through Saturday.
Marion County health officials didn’t agree to be interviewed or address what challenges local providers are facing in expanding testing.
“We do think more individuals should be getting tested in Marion County and the state as a whole,” county spokeswoman Jenna Wyatt said in a statement.
Oregon Health Authority officials said they’re not aware of inadequate testing availability in Marion County but would evaluate how to help if the county makes a request.
Sidelinger said testing capacity will play a key role in when and how the state eases Oregon’s stay-home order. He acknowledged that the 15,000-per-week testing capacity figure is a rough estimate of what state officials believe is needed.
“Some of that is back of the envelope, but it is also our goal,” he said. “Part of our planning now is to see how close we are and see what additional capacity we need.”
Public health officials would like to see the number of active infections and hospitalizations decrease before unwinding stay-home restrictions, so there’s fewer people at risk of spreading the virus. The latest modeling suggests that may not happen until the end of May at the earliest.
The plan is to have a more robust effort in place to test not only people believed to be infected, but also do a much better job identifying their close contacts for testing and quarantine.
“That’s why we want to have the testing capability,” Sidelinger said, “… so that we can identify people early, do the contact tracing, hot spot analysis, and see who’s potentially exposed and keep them home – so we can limit the spread.”
Mark Friesen contributed to this report.
-- Brad Schmidt; email@example.com
This article was originally published by The Oregonian/OregonLive, one of more than a dozen news organizations throughout the state sharing their coverage of the novel coronavirus outbreak to help inform Oregonians about this evolving health issue.