Maine reopening despite missed benchmarks, inadequate testing regime

Gov. Janet Mills has continued to lift lockdown measures that have slowed the pandemic in Maine even though the state has failed to meet key reopening prerequisites and other essential benchmarks and guidelines established by public health experts.

The missed targets include downward trends in new cases, minimum levels of daily tests performed, and the establishment of a regime to routinely test asymptomatic individuals in exposed roles such as health care providers, supermarket clerks, ambulance crews and factory employees.

“If we are really going to bring our society back to normal and have a major reopening, we need to be having much broader testing for all people in public-facing roles so you can detect the asymptomatic folk,” said Sen. Geoff Gratwick, D-Bangor, a retired physician who co-chairs the Legislature’s Health and Human Services Committee. “If you can’t test a second-grader in their class, a grocery clerk and a fireman, I think we’re running a danger.”

Dr. Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, agreed. “If the criteria you use to decide whether it’s time to open up are case counts and ICU occupancy and deaths, those are fairly late indicators, and if you wait to see changes in those numbers, it could be too late to take action,” she said. “You want to spot the problem as early as possible so you can implement changes in the community so you don’t have to revert to closing things down again.”

Maine is by no means the only state that is reopening without meeting key benchmarks or building a comprehensive testing regime. Faced with unemployment rates not seen since the Great Depression and pressure from President Trump, dozens of states are coming out of lockdown, many with metrics much worse than Maine’s. But experts say this approach risks an economic disaster as well as a public health one, as a second wave of outbreaks would force new shutdowns and prolong the damage.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told a U.S. Senate panel Tuesday that states that skipped federal guidelines were running “a real risk that you will trigger an outbreak that you may not be able to control, which in fact, paradoxically, will set you back, not only leading to some suffering and death that could be avoided, but could even set you back on the road to try to get economic recovery.”

“My feeling is that OK is not good enough,” said Dr. Thomas Tsai of the Harvard T.H. Chan School of Public Health. “What’s at stake are lives and livelihoods and the way to restore the economy is really about restoring confidence in society, and the way you restore confidence is by widespread testing.”

REOPENING WITHOUT MEETING BENCHMARKS

Facing heavy pressure from business and industry, Mills announced April 28 that Maine would take its first steps toward reopening on May 1, when barbershops, hairdressers, auto dealers, doctor’s offices and golf courses would be allowed to reopen statewide. But at the time, Maine had not met key thresholds laid out by the White House in mid-April: a “downward trajectory” of cases for at least 14 days or, failing that, a reduction in the positive share of coronavirus tests compared to 14 days earlier.

On April 28, Maine’s new-case trend had been going up for nearly a week, and it has ascended more steeply in the two weeks since, growing from 21.7 a day on April 28 to 33.6 a day on May 14, according to a Portland Press Herald/Maine Sunday Telegram analysis of the Maine Center for Disease Control and Prevention’s data.

Because the number of cases often bounces around from day to day, public health officials measure trends by looking at seven-day moving averages of the daily data. The number of cases over the previous seven days is averaged each day, dropping the oldest day in favor of the newest one, revealing the underlying trajectory. “Having a moving average, that really smooths out the random variability of the day-to-day data,” said Dr. Patrick Remington, professor emeritus of the University of Wisconsin-Madison School of Medicine and Public Health, who said it is the standard practice.

When Mills announced the reopening decision, the moving average of new cases had been gently growing each day, from 20.1 a day on April 23 to 21.7 on April 28. Though it was lower than it had been the week before that, when it was in the low 30s, it clearly did not meet this primary White House benchmark, developed by the Trump administration’s public health experts.

On April 28, there was no way for the governor to evaluate whether the percentage of positive cases had increased or decreased over the previous 14 days, because Maine is the only state in the country that has decided to compile and release negative testing numbers on a weekly, rather than a daily basis. The agency releases cumulative testing data each Wednesday because, according to spokesman Robert Long, it “has met our needs to date.”

The day after Mills’ announcement – Wednesday, April 29 – the new testing data showed the positive rate had actually increased from 4.8 percent to 5.1 percent since the previous report, which covered the period from April 16 to 22. This was lower than the rate earlier in the month – 8.1 percent for the period April 8 to 14 – but also failed to meet the White House criteria. (The rate has dropped dramatically with a large expansion in testing, falling to 1.8 percent in the period ending May 13.)

The governor’s office did not respond directly to a set of specific written questions about falling short of the White House benchmarks and other guidelines, instead sending a general statement about her use of the criteria she had laid out for evaluating the reopening.

“It is a review of these metrics in their totality and in context, as opposed to the daily change of a single metric itself, that informs decisions,” her spokesperson Lindsay Crete wrote. “This includes taking into account the insight of Maine CDC epidemiologists; for example, into whether an increase in cases is related to an outbreak in a congregate living facility or to spread among close contacts of a previous positive case.”

The Maine CDC did not respond to written questions for this article, instead referring to the governor’s statement, which did not address them. Since May 5, the Portland Press Herald/Maine Sunday Telegram has been asking to interview the Maine CDC director, Dr. Nirav Shah, about the testing regime and the reopening plan but has been repeatedly told he is unavailable.

FURTHER LOOSENING AS METRICS WORSEN

Mills established key metrics for evaluating whether to advance with reopening measures. Although several of those metrics are going in the wrong direction or falling short of expert advice, the governor has moved ahead with further loosening of the lockdown.

On May 11 most retail activity was allowed to resume in 12 of Maine’s 16 counties, home to small cities like Augusta, Waterville, Topsham, Presque Isle and Ellsworth. In those counties – which exclude harder-hit York, Cumberland, Androscoggin and Penobscot – sporting camps and restaurant dining rooms will be permitted to open Monday.

On Thursday, the administration also made the surprise announcement that from June 1 hotels and other lodgings would be allowed to have reservations from any out-of-state resident who claimed to have undergone a 14-day quarantine since arriving in the state.

Meanwhile, one of the key metrics established by the governor that can be definitively tracked by the public – the trajectory of documented cases – has been going up, not down. The moving average of active cases grew from 413 a day on May 1 to 506 on May 14.

The other metric, new hospitalizations, was more encouraging, going from 3.57 a day to 2.14 in the same period. Hospitalizations generally lag new case numbers because the disease has a long incubation period and there is typically a week delay between the onset of symptoms and when a severely affected patient becomes sick enough to be admitted.

Another of the governor’s benchmarks, “a downward trajectory of influenza-like illnesses and COVID-like syndrome cases,” cannot be evaluated by the public because the Maine CDC does not release the information. Asked in writing whether the agency intends to begin providing this information, the Maine CDC did not reply.

STATE LACKS ROBUST TESTING REGIME

Another of the governor’s metrics is “the ability of the state to engage in a robust testing program,” but the state’s program and future strategy both fall short of what public health experts say are and will be required to ensure that a phased reopening is successful.

Even with significant new capacity thanks to a partnership between Maine CDC and Idexx Laboratories, leading public health experts say Maine still isn’t testing nearly enough people to allow for a safe and successful reopening.

The new partnership, announced May 7, nearly tripled the Maine CDC’s daily in-house testing capacity from 350 to 1,000, according to agency spokesman Long. As a result, the overall tests performed on Mainers by the CDC and outside labs jumped from the equivalent of 363 a day during the week ending May 6 to 1,563 a day the week ending May 13, the most recent the CDC has available.

But the same day the partnership was announced, Harvard’s Global Health Institute released estimates for the minimum testing targets each state would need to achieve by May 15 to properly contain its outbreak by detecting new infections quickly enough to contain them and avoid a universal lockdown. For Maine the researchers set a bar of 1,805 tests a day.

Even that is a minimum measure, according to the institute’s director, Dr. Ashish Jha. “For states that look like they’re meeting their testing goals, I wouldn’t take that as too much comfort, because the number of cases will start going up,” he said in a recent statement. “This is not the goal you want to hit and then say, ‘OK, good, we’re done.’ This is the goal you want to hit and say, ‘OK, now we can start.’”

A May 12 follow-up to a detailed interdisciplinary report organized by Harvard’s Edmond J. Safra Center for Ethics estimated Maine would have to cast a wider testing net to avoid having to shut down its economy over and over until a vaccine is available. To test broadly enough to detect asymptomatic carriers of the disease – based on the state’s daily COVID-19 deaths and epidemiological indicators as of May 8 – the researchers advised that Maine would daily need to test between 2,500 and 5,000 people, and have an army of 300 to 500 contact tracers to quickly identify people who came in contact with the infected.

Two of the report’s lead authors, Safra Center director Danielle Allen and Divya Siddarth of Microsoft Research India, said in a joint statement that Maine’s souped-up plan was too small. “Given Maine’s current load of cases, this is not a sufficient volume of testing to suppress the spread of infection,” they said. “The risks in this approach are that prevalence may flatten or rise, rather than declining, and this also leaves Maine vulnerable to large-scale outbreaks.”

The researchers said that based on current prevalence in the state, they would advise Maine to seek to test 10,000 people a day. “While this may seem like a heavy lift, the payoff will be in suppression of the disease upfront, protection of life, and safety for economic activity,” they said. “Investment in 10,000 tests/day now is far preferable to the loss of life, and much higher testing needs, that will likely result from acting too late.”

The Press Herald/Sunday Telegram asked the governor’s office and the Maine CDC about the wisdom of reopening without meeting stronger testing levels. Gubernatorial spokesperson Crete wrote back that “the Administration will continue its efforts to secure more testing and the Governor believes more testing is needed.” The CDC declined to answer.

ROUTINELY TEST ASYMPTOMATIC

Tsai, a co-author of the Harvard Global Health guidelines, said it’s important to remember that reaching the testing benchmarks isn’t the ultimate goal. “The goal is to get ahead of the pandemic and save lives and livelihoods, and the tests are just a means to that end,” he said. “People want to know that it’s safe to go back to the grocery store, back to school, and back to work and the only way you know it’s safe is if they are testing you and your neighbor and your colleagues.”

Several experts interviewed by the Press Herald/Sunday Telegram emphasized the importance of setting up a system to routinely test asymptomatic health care workers, grocery store clerks and other exposed individuals. In announcing the expanded testing partnership with Idexx, Gov. Mills and Dr. Shah have indicated the tests will be focused on those ordered by health care providers for patients suspected of having the disease; on universal testing of individuals in nursing homes and other congregate facilities where an outbreak has taken place; and for patients entering hospitals for surgeries and other procedures.

“Widespread and repeated testing will be critical for the safe reopening of any state’s economy, even in states with a relatively low prevalence of COVID-19 to date,” Dr. Jennifer Horney, founding director of the University of Delaware’s epidemiology program, said via email. “The only way to move towards a relaxation of social distancing is testing.”

Sen. Ned Claxton, D-Auburn, a retired physician, said that while Maine has a number of advantages compared to many other states – a low population density, substantial available ICU capacity in hospitals, and a low prevalence of the disease – expanding testing is essential.

“Until we have adequate testing in place, it’s going to be very hard for us to safely open up as much as we would like or maybe could,” Claxton said.

Asked in writing if Dr. Shah has concerns about reopening without a system to test asymptomatic individuals, the Maine CDC declined to respond.

Dr. Lani Graham, a former director of the Maine CDC, said that if she had as much testing capacity as she wanted, she would “go where the money is, whether or not symptomatic,” starting with front-line health care workers.

She said she thought the governor has been doing a good job walking the fine line between economic and public health impacts.

“The toughest decision may be when the metrics look off,” she added. “Cases are increasing as more testing is done. At one point might the governor say, ‘We have to ratchet back.’ Absolutely no one will like that.”