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After 'wasted time,' coronavirus testing poised to increase in Arizona

Loosening COVID-19 test bottlenecks will mean jumps in reported cases, officials say

New guidelines, private labs coming online, and access to more testing kits should soon ramp up the number of patients who Arizona health authorities can diagnose for the COVID-19 virus, officials said.

That will inevitably mean an increase in the number of cases reported here, they said, as previously undiagnosed people are tested and added to the count.

Anxiety & fear for patients, frustration for doctors & local officials

While the pandemic has worsened around the world, Americans have seen strict limits on who can be tested and a lack of testing capacity, leaving those who are worried they have the disease — or remain especially vulnerable — in limbo.

People with severe flu symptoms have been unable to qualify for testing, including some who traveled to Arizona for large public events such as the Gem Show in Tucson. Many local doctors have been confused about the procedures for ordering tests. And public health officials have had to ration tests because not enough physical supplies were available.

Now, instead of needing to deal with bureaucratic approvals by public health authorities, doctors can order the tests and have them processed by private commercial laboratories.

The limited testing regime led to frustrations among both those potentially carrying COVID-19 and medical professionals.

"I still don't understand these delays," said a top Pima County official, Dr. Bob England.

Many residents have being unable to get a coronavirus test, despite serious health concerns. A 70-year-old Tucson man said his doctor's office hung up on him when he asked about getting a test.

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The wife of a Colorado man who came down with the flu after traveling to the Gem Show here said she and her husband have been "living in this limbo," unable to get a test despite many requests.

While a declaration by President Donald Trump a week ago that "anyone who wants a test can get a test" remained largely untrue, a shift in federal policy and the distribution of more testing kits will mean a dramatic expansion in the number of Arizonans who have symptoms who can be tested for the virus, officials here said.

'Completely wasted time China bought us' — Local officials 'don't understand' delay in tests

"I welcome any resources that make it down to the states and the locals, that will help us out," Dr. England, interim director of the Pima County Health Department, said Friday evening. "The health care system is going to need all the help they can get, because they're going to be really, really busy in the coming months."

England earlier in the week criticized the delays, saying "we've completely wasted the time that China bought us" in limiting the spread of coronavirus.

Since the outbreak began two months ago, restrictive testing procedures and logistical issues — including a small number of testing kits and materials already depleted by a heavy flu season — limited the number of people able to be tested in the state.

Just 183 people have been tested in Arizona, with 12 positive results and 50 pending tests here, as of Sunday morning. A case just announced by Pima County officials adds to that total. So far, 121 Arizonans have been ruled out. Across the United States, just 18,417 people have been tested, with 2,450 diagnosed with the virus. At least 60 people are known to have died in this country. Other countries, such as South Korea, are testing upwards of 10,000 people every day, with the disease affecting more than 150,000 and nearly 6,000 deaths reported.

As of Sunday, three positive cases have been reported in Pima County.

Despite the relatively low number of reports here, many public health experts are concerned that the very slow response in the United States will mean many more people will contract the virus, as so few measures to limit its spread were undertaken early.

More tests will mean more infection reports

With new guidelines from the Centers for Disease Control that remove stringent restrictions on who can be tested, officials here expect the number of Arizonans being diagnosed to jump in the coming days as more tests are run.

That means people should be careful to not misinterpret a quick increase in the number of cases, said Chris Minnick, a spokesman for the Arizona Department of Health Services. More tests being performed next week will almost surely mean a leap in reported cases, he said Saturday.

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As of Saturday, the state health lab has testing kits that will allow the diagnosis of about 800 more people here, Minnick said. The federal Centers for Disease Control sent a substantial number of new testing supplies to the state just before the end of the week.

"We can run about 450 per day," Minnick said. The private labs that are coming online "can run probably thousands per day."

While testing has been limited to just the State Public Health Laboratory previously, several private labs are beginning to run tests, he said. They include Sonora Quest, Mayo, ARUP Laboratories and Labcore.

In places where the outbreak has hit a critical point, such as in New York, some public health experts have said that it's too late for widespread testing to slow the impact of coronavirus.

Arizona may still have time to slow its spread. "Flattening the curve" is vital so that hospitals and officials aren't overwhelmed with a crush of patients, officials have said. Stemming the rate of infection, so that everyone who ends up catching the virus doesn't come down with it all at the same time, has officials encouraging "social distancing" and advising that anyone feeling ill stay home.

"We are in a mitigation phase," said Pima County's Dr. England during a public meeting in Midtown Tucson on Wednesday.

"Tests are in short supply," he said then. "I do not understand why it has taken long to produce these tests."

Each test previously required a swab from the mouth and a swab that goes up through the nose and down the back of the throat. The samples must be stored in a sterile container and kept cool until they arrive at a lab, where researchers use a process called Polymerase Chain Reaction to create thousands of copies of the virus. This is compared against other samples, and control samples are also processed to make sure the test works correctly.

Friday, the CDC changed its recommendation from collecting multiple nasopharyngeal and oropharyngeal (throat) swabs to a single swab from the upper nose tract.

"The testing procedure is not as simple as it might appear," said Minnick, describing the requirement to swab the back of the nasophyrngeal tract as "extremely unpleasant."

"Take your finger and place it right between your eyes, at the top of your nose," he said, emphasizing that he was speaking of his own personal experience, and that he doesn't have a medical degree. "Now imagine a point two inches or so back from that, inside your head. That's where the swab needs to collect from." The swab must be left in place for several seconds to absorb material.

"I can still feel it on my brain," he said of a previous flu test.

As the number of cases in China spiked, the medical community moved quickly to develop a reliable test for the novel coronavirus—or SARS-CoV-2. While researchers have identified coronaviruses — named for their "crown" or "halo" — since the 1960s, COVID-19 is a new virus similar to the disease that caused the 2002 SARS outbreak. Within weeks of the first outbreak in China last year, researchers were able to identify the disease, far faster than researchers were able to identify the disease that caused the 2002 outbreak. And, by late January, researchers isolated the newest coronavirus, and this allowed the World Health Organization to began shipping out test kits around the world.

ADHS's Minnick said that "not everyone should get the test," to avoid overburdening testing facilities, even with the expanded access.

"The testing criteria were so narrow" that people who perhaps should have been tested were not, he said. Now, "if a physician feels it's necessary, they can have that patient tested."

'Flat-footed' response, defective tests

However, a cascade of problems kept the U.S. from implementing the test, including problems with the testing kits that were sent to Arizona health officials.

As U.S Rep. Greg Stanton put it in a letter to VP Pence, who was assigned to lead the White House's response to COVID-19, test kits sent to Arizona on Feb. 11 were "defective," and Arizona officials had to send samples to the CDC lab in Atlanta.

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"In my district, there has already been one confirmed case of the novel coronavirus, and local public health officials are working to stop it from spreading," Stanton wrote earlier. "But the flat-footed response and lack of transparency from this administration continues to make their jobs more difficult."

Delays because the Food and Drug Administration didn't process emergency use authorizations, known as EUAs, and a lack of virus samples also hindered the government's ability to build test kits.

'Completely wasted time China bought us'

"I still don't understand these delays, with the length of time that we've spent getting testing barely operating, we've completely wasted the time that China bought us," England said.

Dr. Francisco Garcia, the county's chief medical officer, said that up until last Friday, the total number of tests for Arizona was about 300, allowing the state to test about 100 people. Each test requires multiple specimens, he said.

"We have to run controls too to make sure that the testing platform works," he said.

England said previously that some patients had up to 8 controls run with their tests, with each separate test using up a kit.

Officials in Arizona, he said, have been "super-responsive, and were turning tests around in about 48 hours, far faster than the previous rate of testing when tests where sent to the CDC and took almost 10 days for a result.

On Wednesday, Dr. Cara Christ , director of Arizona's Department of Health Services, said that at the time the state was "anticipating 150 samples that we can test" and that her office was in "ongoing communication with the CDC."

"And it's hard to determine how many patients that is because there's so many different factors that play a role in how many samples are getting utilized for each patient," she said then.

People with tests run at the public health laboratory will be either high-risk or those who "fall under that risk category," she said..

"But as we continue to increase capacity with those diagnostic labs, that's when everyone is going to have access," she said. "So right now, you might have trouble, we are working with healthcare providers to ensure that they know how to get those samples, where to send them, what to do with them, so that we can increase that."

ADHS's Minnick said Saturday that the CDC had provided enough kits to test about another 800 people in the state, with more tests promised.

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"We've never had a problem with (the number of) supplies," he said, telling TucsonSentinel.com that there was not a case of any patients not being tested because of the limited number of testing kits.

Rather, the previous strict criteria on who could be tested was the limiting factor, he said.

Beyond testing kits, other medical supplies have played a role in hampering testing, Minnick said.

The swabs used for influenza tests as well as COVID-19 tests have been in short supply because of an already active flu season.

"We'd see 15,000 (flu) cases in a normal year, and we've had 30,000 cases already this year," he said, noting that many of those sick with the flu this winter have been children with influenza B.

Pima officials point to lack of testing ability

The previous limits on kits and the proper chemicals needed to process them have hampered efforts to diagnose more people in Southern Arizona as being positive or negative.

While federal officials have touted the availability of thousands of tests, that doesn't matter on the ground, Garcia said. "The numbers from the administration are not fiction, but they do not reflect my ability to get a test on a patient in my office," he said.

Meanwhile, a ProPublica report found that the U.S. Food and Drug Administration required the Centers for Disease Control and Prevention to retest every positive coronavirus test completed by a public health lab to confirm its accuracy, duplicating efforts and wasting limited resources as thousands of Americans are waiting to get a COVID-19 test.

Under new protocols, CDC no longer has to confirm tests done by state labs, ADHS's Minnick said Saturday.

The American Enterprise Institute, a conservative think-tank, estimated the total capacity of U.S. coronavirus testing at 25,175 patients per day. This includes not just the nation's public labs, but also private labs.

One, LabCorp, said that it began testing for COVID-19 on Thursday, March 5.

"LabCorp is working 7 days a week, 3 shifts a day to perform COVID-19 testing and to increase capacity. We are now able to perform several thousand tests per day and are rapidly adding new equipment and staff to create additional capacity," said Pattie Kushner, a spokeswoman for LabCorp.

Those private labs are running tests from multiple states.

A third diagnosed case of coronavirus in Pima County, announced Sunday morning, was tested by a private lab, officials said.

But the expansion of testing now hasn't eased previous weeks of worries and near-panic from some very ill people — some of whom may have been spreading the virus.

Sick Gem Show visitor can't get coronavirus test

Around Feb. 25, days after he returned from the Tucson Gem Show, a Colorado man who asked to be publicly known only as "Jacob" started feeling "kinda' rough."

At first, he felt like he was suffering from a normal chest cold, and he left work and went home with a plan to stay there and "watch cartoons" until he felt better, but each day he kept feeling worse, he said. Struck by a sore throat that was mitigated only by codeine cough syrup, Jacob also felt phlegm building up in his chest.

In a Medium post, Caitlin described her husband's illness — which his doctor thinks may be a COVID-19 infection.

"His throat got progressively worse and worse that he was no longer able to sleep as simply breathing was painful. At the same time, the dry cough was getting worse. He would cough so hard he would vomit and get bloody noses," she wrote.

In an interview with TucsonSentinel.com, the couple described the details of Jacob's illness, but asked that their last names be withheld to help protect their privacy.

As Jacob got sicker, Caitlin said they joked about coronavirus, and that she "went a little nuts at the pharmacy" and bought "literally everything" that she thought would help her husband's sore throat.

"When he first got sick, I did the usual when someone in the house gets sick, I bought jello, Sprite, soup. I wanted to make sure he was all set up, but he just kept getting worse and worse, he couldn't eat, and he couldn't sleep for more than 45 minutes because of the pain," she said.

"Anything carbonated hurt more," said Jacob. After two days, Caitlin took Jacob to urgent care, where he was tested for strep throat and given liquid Lidocaine to mix with liquid Benadryl and gargle.

"It didn't touch the pain at all, but did make his mouth numb. He said his throat felt like hamburger meat, and could feel how raw it was at the back of his mouth," Caitlin wrote.

After his condition continued to get worse, they made a medical appointment online, and as they came into the doctor's office, someone demanded he put on a mask.

"They almost tackled him to get a mask on," said Caitlin.

"Well, that's maybe hyperbole," said Jacob, but he said that as he approached the counter, people working at the clinic were "very insistent on wearing a mask."

A doctor tested Jacob for the flu, as well as several other diseases, but while his wife told officials in Colorado and Arizona about the case, they refused to test Jacob for COVID-19.

"He wasn't hospital-level sick, and he had not traveled to a high-risk country, and had no contact with a person known to be positive for coronavirus," said Caitlin. Not getting tested was "simply frustrating," she said. "We still cannot get tested; we were denied the drive-thru test too."

"We can't get permission from the state, and while the doctor thinks he has it, the doctor keeps being told no," she said. "We're just trying to be good citizens. We need the results to be able to take time off from work if he has it, or work from home. If he gets tested and he's negative, then life goes back to normal," she said. "If he'd been tested and it was positive, I never would have gone back to work, but since I don't have anything official, I keep going and hiding in my office, and people are nervous."

"Living in this limbo, wondering if you probably have it is hard, but that doesn't fly when you're trying to make a living," said Caitlin.

Jacob was sick for nine days before the first case in Colorado was announced, she said.

"I was livid," she said. "They're not testing anyone, not enough test going around. And until we get to the point where lots of people are tested, it's going to keep spreading. And the scary thing is that people are going to keep dying."

Tucson man hung up on

In Tucson, Steve Zupcic, 70, said that he was trying to get in touch with his doctor at Iora Health, but after he requested a coronavirus test during a phone call, the office hung up on him. Zupcic, a former public relations professional for 40 years with the University of Pittsburgh who helped coordinate the university's response to public health issues, is worried about his health.

"I'm really concerned about this," he said. Zupcic has a series of conditions, including congestive heart failure and pulmonary hypertension that makes coronavirus especially dangerous. And, he's worried about his increasing fatigue, joint pain, and other issues are signs of the virus.

"It would just help to have my primary care doctor help me," he said.

Caution, dealing with 'scarcity'

England, the Pima County health official, cautioned people against worrying that some symptoms were indicative of coronavirus.

"There are way more flu and other respiratory diseases out there than this," he said. "As for a particular individual who didn't get tested or seen here, I'm not sure, but we have had numerous requests from individuals and from providers that did not meet testing criteria, and whom we could not test," he said by email.

"It worries me that we have not had broad testing, but in lieu of that, we have been tracking ICU admissions, and thinking about how to track those," Garcia said.

"That's where you would see a blip," he said, because patients who were in the ICU for respiratory problems qualify for COVID-19 testing. "It's an unknown, but we would see a lot more ICU-related infections," he said.

Garcia said that people were seeking "on demand" testing, but that like other areas of medicine, a doctor shouldn't just test someone because they think they have a disease, rather doctors and other health professionals should evaluate patients.

"On demand testing works if you have a lot of product to test, but it doesn't work if you have a scarcity," he said.

"We're trying to be consistent in our messaging here: if you're sick have the kind of symptoms that would have kept you home before you heard about coronavirus, then do the same thing – stay home, take Tylenol and drink fluids. We don't want folks clogging up the system of care," he said.

"We have people showing up to ERs because they have the sniffled and ask for a COVID test, and we're not sure it makes sense," he said. "And, in many cases, we wouldn't change our actions based on the results of that test when it comes to treatment."

"There's no vaccine for coronavirus, so we treat this by monitoring and treating symptoms, and if things change, call the doctor, come on in, and we will reassess," Garcia said.

England noted Wednesday that one result from South Korea's testing has been data that shows that coronavirus is not as deadly as initially suspected, killing approximately 0.6 percent of patients diagnosed with the disease, and that number was likely lower because they weren't finding all the mild cases, said England. A study of COVID-19's spread on cruise ships showed that many people were asymptomatic, meaning they didn't have any outward signs that they had the disease.

People can be cleared 7 days after a swab, or 72 hours after signs of a fever or acute symptoms are gone, said England. That period may be long, but is a "conservative, but reasonable standard," he said.

He also noted that even after the virus has died, a person can still test positive for COVID-19 because the small genetic markers will still be replicated in the PCR test. Sometimes people may also experience a secondary infection, from a different disease, which will also make people feel as if they've gotten better, and then later showed new symptoms.

Additionally, while the flu "spreads like mad," in schools, COVID-19 acts differently with kids, England said. The infection rates for children has been far lower, and while adults can give the disease to kids in a home setting, England cautioned against closing schools.

Nonetheless, England still cautioned older people, especially those over 60, to avoid big public events, and "for God's sake, wash your hands."

He added that he was also in his 60s, and that he has asthma, but he was not going to "hunker down."

"So, lots of decisions about getting made about events, some of those are logistical, and some are on the part of the organizer," said Garcia. "If you're going to have an event, you're telling people medical frail, older, 65 to stay home. So, no AARP convention, but there's no reason why other stuff doesn't go forward, so long as we protect the vulnerable."

After the president made his remarks about testing, Health and Human Services Sec. Alex M. Azar tried to tamp this down, telling the New York Times and others during an off-camera briefing, "You may not get a test unless a doctor or public health official prescribes a test."

"That is our medical system in the United States, in the same way that you may not get a cardiac medicine if your doctor doesn't prescribe that," Azar said.

On Friday, the president declared a national emergency, and said that he would grant new authority to Azar to waive regulations and give doctors and hospitals more flexibility to deal with the virus, and giving up to $50 billion in federal funds to states and territories to combat the spread of coronavirus.

"I am officially declaring a national emergency, two very big words," the president said. And, ignoring his statements at the CDC, said that testing everyone was "unnecessary."

"We don't want everybody taking this test," he said. "It's totally unnecessary."

City plans for COVID-19

Charles Ryan, the new chief of Tucson Fire Department, said Wednesday that firefighters and ambulance personnel are used to managing people who have an infectious disease, and had protocols in place to disinfect vehicles and equipment when needed.

"Nothing changes from our perspective, and we have the same protocols in place that we had with the Ebola crisis," Ryan said. "This is a very different animal," he said, "but it's business as usual for us." The outbreak of COVID-19 "allowed us to refresh our protocols," when dealing with infectious disease, Ryan said.

And, city officials said that they would move to add hand-washing stations at key locations in the city to help homeless, who are also highly vulnerable to the disease. Meanwhile, homeless shelters and soup kitchen managers asked how they could help mitigate infections, and what to do if someone had coronavirus.

"Neither myself or any of my family have been tested, nor is there any plan to get tested," said Garcia. "There's a sense that if I know the right guy, and say the right password, or the right handshake, you'll get the tests, but that just does not exist."

Late Thursday night, Garcia also questioned the closures of public forums and events, including classes at the state's three universities. "You have to ask, how are these thresholds being created? And, how effective are things like this?"

England made this same argument Wednesday, asking if it made sense to close some things for days or weeks. "I wouldn't cancel an outdoor street fair, while leaving Costco open," said England.

"It's really important when we take a public health action that it's based on some rational fact," Garcia said. "We're giving people the best, most up-to-date information that we have. We are pledged to be transparent, and we're pledged to be data-driven. And, that's what we try to do every day."

"It's important that people know this," he said.

City, towns call off events, school leaders planning for closures

Despite England's downplaying the necessity of limiting public gatherings, many local venues have halted live concerts, sporting events and other large groups. The city of Tucson, and towns of Marana, Oro Valley and Sahuarita, have said they're halting municipally sponsored events, with Tucson Mayor Regina Romero calling for a halt to all events with crowds of more than 50 people.

School leaders said the state must plan for a "longterm inevitable shutdown" of schools in the state, with the state teachers union calling for a student strike if plans are not announced. The University of Arizona joined Pima Community College and the other state universities in halting in-person classes and moving online.

Even the county itself announced Sunday that is was closing the Southern Arizona Heritage and Visitor Center, located in the Historic Courthouse, until further notice to discourage any "unnecessary social gatherings during the COVID-19 epidemic."

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Paul Ingram/TucsonSentinel.com

Dr. Bob England speaks during a press conference at the Pima County Board of Supervisors meeting room on Monday.

Preventing the spread of coronavirus

From the Pima County Health Department: COVID-19 spreads through the air when an infected person coughs or sneezes. Symptoms are thought to appear within 2 to 14 days after exposure and consist of fever, cough, runny nose, or difficulty breathing. Those considered at highest risk for contracting the virus are individuals with travel to an area where the virus is spreading, or individuals in close contact with a person who is diagnosed as having COVID-19.

The best ways to prevent the spread of respiratory viruses, including COVID-19, are to:

  • Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.
  • Avoid close contact with people who are sick.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then immediately throw the tissue in the trash.
  • Clean and disinfect frequently touched objects and surfaces.

Public health officials advise residents that flu and other respiratory diseases are circulating in the community, and are recommending everyone get a flu shot and follow basic prevention guidelines.

If you have recently traveled to an area where COVID-19 is circulating, and have developed fever with cough or shortness of breath within 14 days of your travel, or have had contact with someone who is suspected to have 2019 novel coronavirus, please stay home. Most people with COVID-19 develop mild symptoms. If you have mild symptoms, please do not seek medical care, but do stay home and practice social distancing from others in the household where possible. If you do have shortness of breath or more severe symptoms, please call your health care provider to get instructions before arriving.


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