Allegheny County is set to move into the yellow phase of Gov. Tom Wolf’s reopening plan on Friday. In its plan to restart the economy amid the novel coronavirus pandemic, the Wolf administration said that in order for an area to reopen, there must be sufficient capacity for both testing and case investigation, including contact tracing.
Officials say Allegheny County is in a good position to meet the latter requirement, in large part because it has its own health department and isn’t dependent on the state, unlike most Pennsylvania counties. Health Department director Dr. Debra Bogen said the county’s contact tracing program has been very successful thus far.
“We have been able to reach most of the people we try to, which has been fantastic,” Bogen said during a press briefing Wednesday. “If we're seeing an increase and we need more contact tracers, we will be prepared to increase the number … We have a very flexible and responsive plan right now and [do not] foresee a problem of meeting those numbers.”
In terms of testing, the state’s plan said there must be “enough testing available for individuals with symptoms and target populations such as those at high risk, health care personnel, and first responders.” According to state Health Secretary Dr. Rachel Levine, “high risk” includes senior citizens, particularly people with co-morbid medical conditions, such as hypertension, heart disease or lung disease.
On Tuesday, the state Department of Health announced that all residents and staff at nursing homes and personal care homes will be routinely tested for coronavirus.
“What we’re trying to do is to find people who are asymptomatic,” Levine said during a press briefing. “As we’re learning, in terms of this novel coronavirus … many patients have no symptoms, or they might be transferring virus before those symptoms develop. By testing them when they start to develop symptoms, we’re missing people.”
The same logic holds for the broader population. The U.S. Centers for Disease Control and Prevention has not given a recent estimate for what proportion of infected people might be asymptomatic, but testing in Iceland showed that about 50 percent of carriers were asymptomatic. At one New York hospital that instituted universal testing in its labor and delivery unit, 88 percent of people who tested positive did not show symptoms. One study out of China, published in the journal Nature, found that 44 percent of COVID-19 cases were linked to asymptomatic carriers.
Bogen said during this week’s Board of Health meeting that she would like to see studies conducted to determine the prevalence of COVID-19 in the county, even among people without symptoms. However, she said limited availability of testing supplies prevents widespread testing of asymptomatic people.
“Right now, we're still only testing symptomatic people, but we are asking their contacts – whether they have symptoms or not – to act as if they've been exposed and to stay home and stay out of the community,” Bogen said. “I'm hopeful that that ... our recommendations will change as testing becomes more available.”
The Trump administration’s Opening Up America Again plan recommends testing symptomatic individuals and urges states to establish sentinel surveillance sites meant to identify asymptomatic cases within particularly vulnerable groups, such as older individuals, low-income communities and communities of color. CDC Director Dr. Robert Redfield said on Tuesday during Senate testimony that a plan to implement surveillance testing in vulnerable communities is in the works.
It’s unclear during which phases of the Trump administration’s three-phase reopening plan these sentinel sites are recommended. Further complicating the issue is the fact that the Wolf administration’s plan differs substantially from the federal plan; the White House plan is more lenient, allowing gyms, movie theaters and restaurant dining rooms to reopen during phase one.
State Health Secretary Levine said on Wednesday that sentinel surveillance sites are “perhaps something like the mass testing sites that we have done in Montgomery County, in Luzerne County, and then the previous one in Philadelphia.”
There are currently no sentinel surveillance sites in Allegheny County, and the Pennsylvania Department of Health does not have any plans to do broad surveillance testing of both symptomatic and asymptomatic individuals, due to limited laboratory capacity.
“What would be best to be able to do that would [be] rapid, simple point-of-care tests … maybe even a home test … that had very good accuracy,” Levine said. “That's not available yet, but I know that there are laboratories and companies working on that, [which] would aid that type of population-based screening greatly.”
Rite Aid has opened up its testing to people without symptoms, as part of agreement with the U.S. Department of Health and Human Services and the CDC, according to a company spokesperson. Allegheny Health Network is testing only symptomatic individuals with and without a provider’s recommendation, depending on the site.
UPMC is testing “select, symptomatic patients” and people who are entering its facilities for in-patient procedures, even if they are asymptomatic. The latter testing effort has revealed limited community spread in Western and central Pennsylvania, according to UPMC Chief Medical and Science Officer, Dr. Steven Shapiro.
“Having done over 2,000 viral antigen tests on asymptomatic patients, to date, we have four positives: three in central Pennsylvania and one in western Pennsylvania. So right now, in our areas, the … infectiousness of this is extremely low,” Shapiro said during state senate testimony on Wednesday. He also said the majority of COVID-19 admissions at UPMC facilities are nursing home residents.
Harvard University’s Roadmap to Pandemic Resilience report, released in April by the university’s Edmond J. Safra Center for Ethics, recommends testing 2 to 6 percent of the population each day. In Allegheny County, that would amount to testing between 24,000 and 72,000 people daily. By contrast, the Wolf administration has set a goal of testing 2 percent of the population each month, or about 800 people a day. As of Thursday morning, Allegheny County reported that 22,545 total tests had been administered.
Still another Harvard report, this one from the university’s Global Health Institute, recommends a testing at least 500,000 people per day across the United States. That’s about 0.15 percent of the population daily, or about 4.5 percent over the course of a month.
“If we can’t be doing at least 500,000 tests a day during May, it is hard to see any way we can remain open,” the authors wrote on April 18.
By any of these metrics, testing numbers in Allegheny County fall short.
Reopening the economy “really comes back to testing,” said Democratic Rep. Conor Lamb during a media briefing hosted by the county on Tuesday. “More testing is more business and it’s going to mean a quicker economic recovery, so that’s what we’ll be focused on.” Lamb later said via e-mail that he supports broad, surveillance testing of the population, including both symptomatic and asymptomatic individuals.
The latest federal coronavirus relief bill, introduced by House Democrats, includes $75 billion for testing, contact tracing, isolation measures and treatment. Of that sum, $25 million would go toward the type of rapid COVID-19 test Levine said would make broad surveillance possible in Pennsylvania. The bill would also require the Trump administration to develop “specific plans for broadly developing and implementing testing for potential immunity in the United States” through serological, antibody testing. However, GOP response to the bill has been tepid, and it’s likely to face an uphill battle in the Senate.
A recent poll from the Pew Research Center finds 61 percent of Americans believe the federal government should be responsible for testing. On Monday, President Trump claimed that soon, every American who wants a test could get one. However, the CDC website cautions that “although supplies of tests are increasing, it may still be difficult to find a place to get tested.”
Meanwhile, on Friday, Allegheny and 12 other counties in Southwestern Pennsylvania moved in the yellow phase of Gov. Wolf’s reopening plan. Previously shuttered daycares, churches and retail stores are allowed to open, gatherings of fewer than 25 people are permitted, and the stay-at-home order has been lifted. This will likely result in an increase in transmission of the coronavirus, but at the state Senate hearing on Wednesday, UPMC Chair of Emergency Medicine Dr. Donald Yealy appeared confident that focusing testing efforts on “the elderly, the sick and the poor” will save lives and allow the economy to reopen.
Still, Allegheny County Executive Rich Fitzgerald admitted during a press briefing Wednesday that he and other officials are nervous about reopening, even though they believe it’s the right move. Health Department Director Bogen said the county is prepared for an increase in cases.
“We are tracking data at the Health Department very closely. We look at emergency department visits. We look at hospitalizations. We look at bed availability. We look at our cases. We look for clustering in those cases, and that data will help drive our decision-making,” Bogen said. “So, yes, we are prepared.”