Who - and why - Montana tests for COVID-19

HELENA - Jim Murphy, Montana's chief epidemiologist, has heard the same stories most everyone in the state has heard about residents who've made unsuccessful attempts to get themselves tested for COVID-19. But even as national headlines worry over testing backlogs in some parts of the country, he says testing constraints haven't hampered Montana's coronavirus response.

"I'm not aware of what I would consider valid access issues," Murphy said in an April 7 interview. "I think the providers in Montana are testing the right people."

That distinction - targeting sometimes-scarce test kits for the "right people," as opposed to attempting blanket sampling - is key to understanding the strategy state officials say they're employing to fight the pandemic in Montana.

The state's anti-coronavirus efforts, Murphy said, are focused on what's known as contact tracing, which amounts to identifying COVID-19 cases with testing, tracking down anyone a confirmed patient could have infected, and then getting those people into quarantine. The goal is to hunt down and contain transmission vectors before the virus spreads so widely it becomes untraceable.

Contact tracing is a battle-tested method for fighting infectious disease, responsible for the ultimate eradication of smallpox in the 1970s. However, running down each potential case is a time-intensive task, and one that can end in futility if exponential spread of the disease moves faster than public health efforts can keep up, as has happened with COVID-19 in some parts of the U.S.

"That's where the resources are being put," Murphy said. "And that's the best thing we can do right now to stop the spread of this illness."

Montana Gov. Steve Bullock has at times expressed concern about maintaining a reliable supply of COVID-19 tests for Montana's state laboratory, telling President Donald Trump in a leaked conference call March 30 that the state was "one day away" from running out of testing supplies necessary to support contact tracing efforts if its supply chain was cut off.

However, Bullock and other officials have maintained that Montana hasn't yet had a day when it hasn't been able to process every sample sent to the state lab, where most of the state's tests have been processed. Officials also said this week that they're feeling more confident about the state's testing capacity.

While the U.S. as a whole has struggled to contain the coronavirus, spurring criticism that the federal government moved too slowly in ramping up monitoring programs, South Korea has been cited for the comparative speed at which it rolled out massive testing programs.

The first U.S. coronavirus case was confirmed the same day as South Korea's, Jan. 20, but according to reporting by Reuters, South Korea swiftly approved a diagnostic test and set up programs like drive-through screening centers.

As of mid-March, South Korea had tested more than 290,000 people, conducting 1 test for every 176 South Korean residents, Reuters reported. At the same point, the U.S. had run about 60,000 tests, one for every 5,453 Americans.

In Montana, as in most parts of the U.S., decisions about whether to administer a COVID-19 test to an individual are generally made by frontline health providers, guided by criteria published by the U.S. Centers for Disease Control.

The current version of the CDC testing criteria, last updated March 24, calls for clinicians to assess whether patients have symptoms compatible with COVID-19, specifically fever and respiratory problems such as coughs or difficulty breathing. The CDC also encourages providers to test for other respiratory illnesses, consider whether the disease is being transmitted in the patient's community, and assess whether their jurisdiction has adequate testing capacity.

The CDC also articulates three priority tiers in the event that testing capacity is limited, prioritizing first hospitalized patients and symptomatic health care workers; secondly symptomatic patients who are elderly, have an underlying condition, or live in long-term care facilities; and thirdly other symptomatic patients, health care workers without symptoms, and people with mild symptoms in hard-hit communities.

At a March 31 press conference, Bullock responded to a question about people being denied testing by noting that providers are assessing whether symptomatic patients have had direct contact with a positive case or traveled somewhere with community coronavirus spread.

"In an ideal world maybe we would be testing everyone," Bullock said. "But by the same token, I and others are working every day to make sure we even have a sufficient testing supply."

As recently as April 8, the Montana Department of Public Health and Human Services has issued official guidance notices asking health care providers to "be judicious with ordering" tests from the state lab. The department cited high demand, limited supplies, and the need to accommodate "high priority patients within a reasonable turn-around time."

Even so, Bullock on April 9 encouraged any Montanan with COVID-19 symptoms to seek testing.

"The more testing that we can receive, even if it ends up increasing the numbers, the better we have our hands around the impact of this virus," he said.

Bullock's comment underscores another key point: that the official COVID-19 case counts published daily by Montana officials - a total of 365 as of April 10 - reflect both the disease's prevalence and the number of people tested.

With perhaps 80% percent of COVID-19 cases manifesting as cold-like symptoms, Murphy said, it's likely there are Montanans with mild cases that have gone undetected because they haven't been ill enough to seek out the medical care that could trigger a test.

"The numbers we see always reflect the surface. How deep below the surface this goes, I don't think we know yet," he said. "That's something at the national level they're still struggling with."

It's common, he added, for contact tracing efforts around serious cases to turn up less serious cases that otherwise would have likely escaped notice. He pointed to an outbreak tied to an assisted-living facility in Toole County as an example.

"It's a very small, localized outbreak," Murphy said. "Even though those numbers are much higher than we would like, those numbers are so high because they've done a great job identifying close contacts."

On April 7, Bullock said the Toole County outbreak was responsible for 20 cases there and in a handful of surrounding counties. At that point, half of Montana's six deaths from the virus were in Toole County.

While local health departments in some of Montana's 56 counties have released information about how many of their residents have been tested, state officials have said they don't have county-level testing data compiled in reliable form, making it difficult to gauge how many people have been tested in different parts of Montana.

At a state level, Montana appears to have a per-capita testing rate on par with peer states. The state had conducted a total of 7,860 COVID-19 tests as of April 9, equivalent to one test per 136 residents. Wyoming, in comparison, has conducted roughly one test per 139 residents, and Oregon one per 158, according to a Montana Free Press analysis of data compiled by the COVID Tracking Project.

Anecdotes about people who've been unable to get tested circulate regardless.

For example, a website run by former state Rep. Nick Schwaderer, untestedmontana.com, had collected approximately 75 self-reports as of April 10 from Montanans who purportedly made unsuccessful attempts to get tested for COVID-19 in different parts of the state. In an interview, Schwaderer said he was passing that information on to state health officials.

Murphy said that when the state has investigated stories of people who've been turned away from testing, they've generally found that it's been for valid reasons.

"In a lot of these instances, when we talk with the health care provider, we'll find that they didn't test the person because they didn't really think the person had signs or symptoms consistent with COVID," he said.

"We don't encourage testing of people that are absent of symptoms," he added. "That's really not what this test is intended for."

This article was originally published by Montana Free Press. For more information please visit http://www.montanafreepress.org