By Thomas Goldsmith
State health officials say North Carolina nursing homes that have had COVID outbreaks should test all residents and staff, including people who aren’t showing signs of the disease.
Some government officials, doctors and academics are strongly recommending universal testing for COVID-19 in every long-term care facility. That advice accompanies the increasing realization that patients can have the disease, but show no symptoms for as long as two weeks. Even these asymptomatic people can pass on the potentially deadly disease.
Michael “Dee” Gunn, a professor in immunology at the Duke University School of Medicine, said at a recent Duke seminar on testing for COVID that it wouldn’t be necessary to test every resident and staff member every week.
The practice is gaining favor as state figures showed that as of Sunday, of the 299 people who have died of COVID-19 in North Carolina, 122 people have been nursing home residents along with 25 residents of other congregate living centers. That amounts to just about half of the death toll.
However, even some proponents cite the expense and logistical difficulties of achieving such widespread testing. More than 1,300 cases of COVID-19 have been diagnosed among the state’s nursing home population of about 38,000.
It appears that DHHS only recently came out in favor of testing all residents in COVID-19-occurring facilities. As recently as early last week, their emphasis remained on testing staff and residents who displayed symptoms of the virus, leaving to counties and facilities the decision of whether to take that further.
Some have virus, but no symptoms
An April 3 CDC report found that as many as half of COVID-19-positive patients in a Washington state nursing home showed no signs of the infection at the time of testing, but most developed symptoms later.
“If asymptomatic or presymptomatic residents play an important role in transmission in this population at high risk, additional prevention measures merit consideration,“ the report said.
North Carolina’s Department of Health and Human Services says it’s behind the practice of testing nursing home residents, but notes that its hard-pressed State Laboratory of Public Health won’t be able to handle all the tests necessary under that approach. Chris Mackey, director of the DHHS office of communications, said long-term care facilities and public health departments should try commercial labs instead.
“There is currently excess capacity in some of our commercial labs with short turnaround times (commercial labs have resolved delays and now have capacity to run more tests),” Mackey said in an email. ”And so therefore we are encouraging health departments and nursing facilities to use those capabilities as appropriate. In facilities with a large number of residents or staff that require testing, it may be necessary to use more than one lab to meet the demand for testing.”
The practice of universal testing for COVID-19 drew national attention when West Virginia Gov. Jay Justice chose to take that approach in his state’s facilities beginning April 20. This move goes beyond North Carolina’s, as West Virginia nursing homes are being tested even if no residents have tested positive. Officials have even called in the state’s National Guard to test nursing home residents.
“As a general matter, yes. More testing capacity is needed for patients and residents of skilled nursing facilities. This includes those transitioning from hospitals to nursing facilities, whether or not those individuals have symptoms of COVID-19. Our residents are extremely vulnerable to this disease and it has proven elusive to contain. The fact that it can be spread by people who show no symptoms makes the testing of residents even more important.
“If there is a COVID-19 outbreak in a skilled nursing facility, we believe that all residents in that facility should be tested unless state and local health officials working with the facility determine that less extensive testing is appropriate. This may happen, for example, when a newly admitted patient, isolated on a dedicated unit for new admissions, tests positive. In that case, it may be more appropriate to test those other residents on the same unit. State and local health officials, as well as facility leaders, are in the best position to make these decisions.”
— Adam Sholar, President, NC Health Care Facilities Association to the Governor’s COVID-19 Task Force, April 24, 2020
Marty Wright, chief executive officer of the West Virginia Health Care Association, said two days after the kickoff that the state’s long-term care facilities are willingly taking part.
“In a lot of the positives that come up, a large majority are asymptomatic,” Wright said on the phone. “The test is helping to identify them so that you can do appropriate cohorting.”
The term cohorting here refers to the practice of separating residents and staff who have tested positive for COVID-19 from those whose tests have shown they don’t have the disease. The complicating factor is the number of residents who may have the disease, with the ability to transmit it to others, without showing any symptoms.
‘Work out in rings’
North Carolina grassroots advocacy groups for older people generally favored universal testing, while recognizing potential obstacles.
“We think that testing everyone would be an ideal scenario, but we understand that there are funding limitations that have to be taken into consideration,” said Allison Constanza, executive director of the North Carolina Coalition on Aging. NCCOA favors federal backing of an extended testing program.
Some states are continuing on their own. In Oregon, the state is putting up $3 million for universal testing of state health-care workers following a request from the legislature’s Emergency Board.
“We need to test everyone. That’s the most bare-bones response,” emergency department physician Sharon Meieran told the Willamette Week. Meieran is on the front lines of medicine and government as both a doctor and a commissioner in the Portland-area’s Multnomah County.
“Every single nursing home should be testing everyone. There is no excuse. These are the most vulnerable and at-risk people.”
The news that NC DHHS is in favor of testing all residents may come as a surprise to some facility operators and public health leaders, who had heard previously that the agency did not want specimens being sent to the state lab instead of an outside provider. That was the word given to public health officials at an April 17 meeting.
“I didn’t think the state would want to get tests from us,“ said Mike Zelek, health promotion and policy division director at Chatham County Public Health Department.
County Public Health Director Layton Long has directed staff to have everyone tested at any nursing home with a COVID-19 outbreak, Zelek said. Chatham County ended up getting its testing done through a relationship with UNC Health, he said.
Thomas Denny, CEO of the Duke Human Vaccine Institute, said instituting comprehensive testing will require strong national support.
“This is going to be costly,“ Denny said. “It’s going to take a lot of people to execute these plans. I do believe at the end of the day, the testing part of it has to be very local. You go into each local community and you work with your public health teams and you try to identify those within each setting, who are at the most risk, and work out in rings.“
Starting with high-risk groups such as those at low income levels would follow the same pattern used to administer new vaccines when they are scarce.
“All this is going to take time,” Denny said. “You can’t get it done overnight.”
Chain of priorities
In the early phases of the pandemics, health officials put a premium on testing health care workers and early responders. Older people with underlying conditions should also get attention as systems put together the discrete elements that testing requires, Denny said.
“Those that are in nursing homes, I would put them in a high priority,“ he said.“You can’t do it all at one time, you have to grow into this and get the capacity.
“And then you have the laboratory infrastructure, but do you have the equipment? Do you have the people trained to run the test at the quality that it needs to be run at?” he asked. “And then you have the supply chain related to all the reagents that you need. And we’ve had challenges with each one of those.“
The state’s public and private laboratory capacity will remain an issue as the need for testing will continue, inside facilities and in public.
“One of the things that determines the tests we need is, what is the level of infection when we eliminate social distancing?“ Gunn said. “If there are still a lot of infections going around, we’re going to need a lot of tests.
“If we can really tamp down our ongoing rate of infection, it’s much easier to track the hot spots. But if you’re not doing it, if you don’t get that baseline down, it becomes a game of whack-a-mole.”