BY ALEX HOEFT AND BECCA LOUX | Moonshine Ink
Knowledge is power. And when it comes to the novel coronavirus, with the U.S. having tested roughly 1% of the population (about 3.2 million Americans) and Tahoe Forest Health System locally having tested, according to its CEO, about 1.2% of our much smaller population, we’re still all but powerless when it comes to ending the pandemic.
At this point, almost a month since California Gov. Gavin Newsom’s “stay at home” order, the scarcity of COVID-19 testing has been constant. According to local health officials, prioritization for use of Tahoe-area tests comes down to a very specific checklist: First priority is yours if you’re experiencing COVID symptoms harsh enough that you need to be hospitalized, the next tier of tests go to you only if you’re a health-care worker.
“I think in an ideal world we would like to know about everybody who actually has it,” reasoned Cindy Wilson, director of public health nursing for Nevada County. “… [But] we have to live with the reality rather than the ideal in this moment because testing is limited and is being prioritized in a way that makes sense with the limited capacity.”
TFHS CEO Harry Weis, who also referred to testing availability overall as “in short supply,” explained that the Centers for Disease Control’s current stance in light of that is “that we should basically consider every person out there [as] potentially a positive COVID-19 patient.”
In the absence of that perfect world where tests are available for anyone experiencing symptoms, Weis said TFHS, along with most hospitals, is in the business of improvising. In addition to keeping count of positive-tested cases, Weis’ team tracks what they refer to as “rule-out” COVID-19 cases, those who did not receive a test or the results of a test yet, but show symptoms consistent with the disease and require hospitalization.
Rule-out patients “look in every way like a COVID-19 lab test-confirmed patient,” Weis continued, so the hospital counts these patients alongside officially determined positives for a current total inpatient COVID-19 count of six — as of April 16, two were confirmed with COVID-19, the other four were rule-out patients. TFHS’s cumulative total of COVID-19 positive tests taken on site is 49 (which has remained consistent for a few days), 41 of which were tested at the Truckee location and eight at the Incline Village hospital branch.
Weis said he believes it’s common practice to treat such rule-out patients assumptively as suffering from COVID-19: “The patients that are hospitalized in different hospitals across the country, I’m not sure how many of them really differentiate, [or think], ‘Well, this one has a positive lab test and this one doesn’t.’” He estimated that half of an average hospital’s inpatient count might be rule-out cases.
TFHS follows the same testing triage guidelines Nevada County’s Wilson described, Weis having explained to Moonshine in a former interview that as per CDC recommendations, inpatients and emergency room visitors with COVID-19 symptoms take first-available tests. Following those priority patients, healthcare workers are next in line for testing to quickly stop spread among them and “make sure that we can rule that out quickly because it’s critical that we maintain a healthy health-care workforce,” Weis said.
As of publication, Weis said 11 TFHS employees had contracted the novel coronavirus, over half of which had recovered and all of which are still self-isolating at home. The number of employees confirmed to have COVID-19 has remained consistent for a week.
Testing triage, in practice
A local resident who asked not to be named, but we’ll call Mary, experienced the prioritization of COVID-19 test administration firsthand as the disease swept through her body in March.
“I went down like a ton of bricks on March 18 all of a sudden in the afternoon,” she told Moonshine Ink. “And had the worst chills I’ve ever had, freezing immediately. And you know when you feel like you have the flu and your skin starts to hurt?”
Everything hurt, she continued — her back, scalp, eyeballs, eye sockets; symptomatic of a really bad flu. This woman (who has no underlying conditions) said her temperature fluctuated between 99.8 and 101 degrees in the days to follow, and the symptoms remained; she was “really not getting out of bed except for to go to the bathroom and get back into bed. Not oh, laying in my bed, I don’t feel good, I’m gonna watch movies; like moaning, miserable plain. It was awful.”
Mary called TFHS’s COVID hotline on March 19, shared her symptoms, and was invited to go through their drive-thru testing clinic. There, healthcare professionals listened to her chest, took her temperature, checked her oxygen … and decided to give her a flu test.
“They got the results back and I was negative for flu A and B,” she recalled. “Then I was like, okay, I’ll take my [COVID-19] test now, and they’re like, ‘Yeah, no, you don’t meet the criteria … even though you have a lot of the symptoms, frankly, we don’t have enough tests so you’re not going to get tested.’”
Then a close, local friend tested positive, and Mary’s symptoms didn’t abate, so the hospital finally administered a test on March 25. Mary was told it would take two to nine days to get results. “At the time,” she recalled about why she scored a test, “I [felt] like one of the big crux questions was, have you been exposed to anybody who’s tested positive?”
By that Friday, March 27, however, her friendship with a positive case didn’t matter anymore for testing purposes when she started experiencing difficulty breathing. Her hospitalization followed shortly thereafter.
“They gave me a chest X-ray which showed I had pneumonia in my lungs, and then they tested my oxygen and it was at like 87%,” she said. “They were like, we would recommend that you stay. We generally keep people that are under 90[%].”
The nurses told her she was the first person hospitalized overnight with COVID symptoms. Or, rather, the first of Weis’ rule-out patients presumed to be experiencing COVID-19. Because she ended up in the hospital, she was granted two more tests — one the day she arrived, the other, the day she left.
Of the three COVID-19 tests she received, one she never heard back about (the March 25 test); one tested negative (taken the first night she entered the hospital, March 27); only the last one tested positive for the disease, taken the day she left (March 29).
“I ended up with three tests where other people can’t get any,” she said.
Investigating contact cases
After she went home, Nevada County stepped in to investigate the case of Mary and the people she’d been in contact with. The patient connected with Wilson, who was assigned to document the woman’s recovery. This procedure is standard for communicable diseases, Wilson said. There’s actually a list of 90 diseases (for example, gonorrhea) that must be reported to the county’s clinical disease program nurse, and followed up on from there with two goals in mind: first, to make sure the person who’s ill is getting necessary care and treatment; second, containing the spread.
“With COVID-19, that process is in place,” Wilson explained. “Healthcare providers, hospitals, [or] labs report to us if they have a positive result. Then that person becomes a case and we reach out to them. They are placed in isolation per our health officer’s order and that means they have to stay away from everybody for at least seven days from the time their symptoms started, and at least three days from the time their symptoms resolve.”
Mary said it was determined her date for clearance was April 3, meaning she could re-enter the community then.
At TFHS, monitoring inpatients both confirmed by test or presumed based on symptom rule-out to be COVID-19-positive is a priority. Yet they do not have a formal system to track those who have had contact with known or presumptive cases, symptomatic or not, as long as they are not in need of ER or hospice.
“[That level of tracking detail is] not physically feasible with any reasonable timeframe or amount of resources,” Weis told Moonshine.
Plus, case tracking is the responsibility of the counties, though Weis did say that “the infection rate is so widespread, I think most counties have stopped that.”
In reality, for Nevada County at least, investigations into contact spread are still happening (like with Mary), but the data is not being consolidated or publicly presented at this time.
Each nurse under Nevada County’s clinical disease program touches base with a number of positive cases and confirms the people each person came in contact with. It’s a tiered system, Wilson said: close household contacts, people in a congregate care setting (homeless shelter, nursing home, jail), then employment or large gatherings. (The last tier isn’t a large concern right now due to the stay at home order.)
Close household contacts of an infected person are placed in quarantine, and aren’t allowed to go out in public at all for 14 days from the last exposure to the sick person.
“If I have a case I’m talking to, I might know that they have seven contacts, and out of those seven contacts, four of them were symptomatic and three of them were not over the course of time they were in quarantine,” said Wilson, providing an example. She explained that another nurse would personally have the same information about her cases, but they have not put the numbers together.
The data could be compiled at some point in the future, she continued, but right now, each positive case is simply one individual with X-number of contacts; it doesn’t go further than that.
“But we also know that in addition to the people that are testing positive and are becoming our confirmed cases — that’s right now at 34 [in Nevada County] — there are people out there who have it and have not been tested because testing has been limited and we know that,” she said. “Our 34 is not everybody who has it.”
The future of testing?
Testing for the disease was initially limited to the CDC, then headed to state public health labs, followed by county public health labs. Because neither Nevada nor Placer counties have such labs, they utilized Sacramento, the closest testing option. Private labs were next on the list to offer COVID-19 tests, Nevada County’s Wilson explained; places like Quest and LabCorps. Hospitals came last.
“Now it’s come to where you can do point-of-care testing, rapid testing that takes about five minutes for a positive and about 15 for a negative,” she said, explaining the process of new rapid tests made by Abbott Laboratories, which are being rolled out regionally so far only at Grass Valley’s Sierra Nevada Memorial Hospital. “That’s still limited as to how many of those can be done, but at least for the people who are being prioritized, the answer is fairly quick and immediate rather than waiting for three to four days — and if the lab is backlogged, sometimes even longer than that.”
Tahoe Forest Health System does not yet have rapid testing capabilities. Sierra Nevada Memorial Hospital scored access to such testing because it falls under the Dignity Health System, part of what TFHS’s Weis described as “a cluster of five or six hospitals that are sharing a small allotment of the Abbott Rapid COVID-19 lab tests.”
Weis has reached out to that hospital’s CEO to discuss sharing equipment TFHS may have that Sierra Nevada Memorial might need and vice versa, with hopes they may share Abbott tests. No such luck so far.
He has also approached the California Hospital Association, the state assembly and senate, as well as the company itself, to ask to be placed at the top of the list to receive the Abbott rapid tests that he calls “gold standard.” Another newly developed COVID-19 test is on Weis’ radar as well, which takes between one and two hours to display results, made by a company called Cepheid and is also “in super high demand from the federal government.”
He concluded, in summary, that when it comes to rapid testing, “We’re aware of it, we’ve been asking for it, we don’t have it.”
Rapid COVID-19 testing availability still applies the aforementioned prioritization (those needing hospitalization, followed by health-care workers). Close household contacts, while the number one tier when investigating case contact, are left to their own quarantine devices.
“[My daughter] had symptoms for like three days,” said Mary. “Mild, but a headache, the same low-grade fever, and a back ache, and then she was fine.”
Her husband, on the other hand, hasn’t shown any symptoms, though she’s convinced there’s no way he couldn’t have been infected, what with sharing a home with one positive case and one presumed case.
“[My husband] is a little bit of an OCD clean guy, but it’s very hard for me to believe he has not gotten it — not that he doesn’t have antibodies at this point,” she said. “ … But there’s no way … knowing what we know about how contagious it is, I can’t imagine that he actually managed to not get it.”
Her husband ended up having an antibody test done through a private source — by who, she wouldn’t say — and the test confirmed that her husband was positive for the antibodies, which indicates, according to the CDC, that he had an immune response to COVID-19.
Weis has also alluded multiple times to the power of having antibodies, whether naturally or after fighting off the disease, saying that the TFHS healthcare workers who have recovered from COVID-19 will prove “very important.”
Wilson, however, said her knowledge of antibody tests is that they’re mostly still in research phases, and urged people to be wary of antibody tests that aren’t from a reputable source or ask for money — “There’s lots of people out there who are trying to figure out how to scam other people and make payments out of this current situation.”
But overall, the antibody tests, once finalized and available for broader use, can play a role in how we kick-start the economy, according to Wilson.
“If somebody has antibodies can we consider them to be immune?” she asked. “That’s a question that still needs to be answered. If they’re considered to be immune, perhaps they can get back to work before somebody who doesn’t have those antibodies. It’s an important piece of research, but at this point I still believe it’s research and not patient care, per se.”