Author: Bill Stamey, M.D.

A neurologist trained in movement disorders, Dr. Stamey has no relevant financial or nonfinancial relationships to disclose. His artistic rendering is by Emily Stamey. Maine PD News receives no outside funding. www.mainepdnews.org

Active cases

Let’s talk about active cases of COVID-19 in Maine.  By this, I mean people here in the state who are currently sick with COVID-19.   It sounds simple enough, but it is not a number that we have, because while we are shown a count of infections among state residents, we in the public sector do not know the number of infections among visiting non-residents.  Those that have tested positive in our state are counted in their home states (and the same is true for out-of-state Mainers, another number we don’t have).  I think these numbers should be public, because if people are ill in Maine (or anywhere for that matter), they impact healthcare and could influence decisions about opening businesses, and influence Mainers as to calculating their own risk.   So what do the numbers of active cases mean, and how can we count them?

Because the state is posting totals at midnight,   we will reference data as of July 10, 2020.  To calculate how many Maine residents have an active infection we take the total number of cases since testing began (3,520), subtract recoveries (2,971) and deaths (112), to arrive at 437 active infections (Maine CDC lists these as “other” cases).  The peak of active cases so far in Maine occurred on May 24, 2020 at 714.  The number declined steadily following that peak until June 23, (two days after Father’s Day), with 393 active cases.  The average time for symptoms to show after infection is 5 days, and testing of people with COVID-19 is usually a few days after that.  Since this virus spreads when people congregate, we could expect a “bump” in active cases a week or two after Father’s Day (if people were congregating, especially indoors). By July 3 (12 days later) we reached 529 active cases (a 35% increase), which was not simply a function of increased testing.  Numbers of hospitalized patients did not fall during this time. 

I was on call July 4th weekend, and drove to the hospital a few times.  I saw a lot of people in town, a lot of shopping, crowding, gathering, and a lot of out-of-state tags.  The one hopeful issue about July 4 is that most gatherings were likely outside, where chance of infection is lower. And, in the six days of data available following July 4, active cases trended down. The current 7-day average of new cases has dropped from 33 to 19. While those declines might sound very hopeful, they might also represent the other side of the Father’s Day “bump.”  However, we might be about to see another bump. We are now 7 days out from July 4.  Let’s hope that over the next week we do not see an increase. 

We are also seeing the ongoing opening up of Maine and the tourism industry. New York, New Jersey, Connecticut, Vermont, and New Hampshire residents are not being asked to quarantine, and we are seeing a lot of visitors from those states.  According to the CDC in Atlanta,  in the last week new cases in each of those states has totaled the following:  New York (4,476), New Jersey (1,914), Connecticut (563), Vermont (45), and New Hampshire (151).   Maine has seen 131 new cases in the past week.  Since our states have different population sizes, we can look instead at the number of cases per 100,000 of population to get a sense of how widespread infection is in those states compared with our own: New York state excluding NYC (1,628), New Jersey (1,956), Connecticut (1,321), Vermont (203), and New Hampshire (440), and Maine (261).  We are not even close to the numbers being seen in New York, New Jersey, or Connecticut.  And, we are all seeing a lot of Massachusetts tags, though they are asked to quarantine or show a negative COVID-19 test if they want to visit Maine. Massachusetts has had 1,559 cases in the last week, and the case count per 100,000 is 1,606.  

While we hope that visitors are being tested before coming here, the problem is that in traveling itself we all visit the same rest stops, gas stations, and so on.  The virus spreads where people congregate.  And, asymptomatic carriers likely represent a high percentage of spread.   People may come here thinking they are well, but still spread virus.  For reasons that are still not completely clear, some people have no symptoms, or only mild symptoms, but they may give someone else a fatal infection.  

Cases in New England are improving overall, but case trends around the country are not looking good.  Texas is experiencing a huge increase in cases, currently counting over 114,000 active cases (from over 230,000 since testing began), and having suffered over 3000 deaths due to COVID-19.  In the last seven days Texas has seen 54,369 new cases.  I trained at the Texas Medical Center in Houston, which was the world’s largest, with over 50,000 employees and multiple huge hospitals, including the DeBakey VA Hospital (one of the largest federal buildings in the country), the Ben Taub County Hospital, huge Methodist and Presbyterian hospitals, and the MD Anderson Cancer Center Hospital.  Recently, Texas Children’s Hospital (also in the TMC) had to start housing adult patients with COVID-19 because space had run out elsewhere. Florida has seen over 63,000 new cases in the last week.

Here in Maine tourists and summer home owners are arriving, and the number is not trivial.   The Maine Office of Tourism reported 33 million people visited Maine in 2015.  During just the summer of 2018 11 million overnight visitors came to Maine.  

To that point, when I last posted on this topic I noted that there was some confusion (at least in my mind) regarding the numbers being stated at Maine CDC briefings when compared with the data given on the same agency’s website.   I want to take a moment here to say I truly appreciate what the Maine CDC and Dr. Shaw have been doing.  The numbers were confusing nonetheless, and I want to follow-up on that.  As discussed in that last post, the case trend numbers given during briefings did not match the data shared in the website table  “All Reported COVID-19 Tests in Maine,” which has consistently shown a higher number than the total cases in the state. I called the Maine CDC and asked for clarification. In order to get this information, I became one of the Maine CDC’s “consultations.”  What I learned was that the number given in briefings is basically a headcount of positive and probable cases among Maine residents; whereas the “All Reported” table includes only lab test results, and does indeed include non-residents who have tested positive while visiting Maine.  That table includes all positive results, even if they belong to the same person.  Put another way, if a person has had more than one positive test – for example, a hospitalized patient who needs a negative test prior to discharge, they are counted.  A breakdown of those numbers explaining how many of each category was not given.  However, we do know that the table does not include “probable tests,” which currently stand at about 400 of the 3520 cases.  Thus, 3120 Mainers have tested positive.  We can use these numbers in a simple calculation and say that 4652 total positive tests minus 3120 individual Mainers leaves 1532 additional positive tests, some out-of-staters, some duplicates. It should be obvious that we are doing better than many other states. And, it should be obvious that raising our summer population by millions is a risky proposition during a pandemic.

So, please don’t let down your guard. Remember, health resources are also limited.  This includes people.  Since testing began 831 health care workers have tested positive in Maine (24% of reported cases), and this number grew by 100 new cases in just three weeks.  Around the country about 700 health care workers have died from COVID-19.   

The way to avoid COVID-19 is to practice physical distancing. If the virus can’t get to another host, it can’t spread. Stay at least 6 feet away from others not in your household.  Stay as far as possible from people who do not wear masks in public and avoid sharing indoor spaces with these people.  It would seem very likely that people who don’t wear masks are more likely to carry the virus that causes COVID-19 than those who do.  Of course, stay away from people with COVID-19, and if you are ill, stay home.  

If you are healthy and are around others in public, wear a cloth face cover or a mask.  Remember that the mask does not mean you are free to stand closer. It is a simple barrier which helps, but does not guarantee safety.   Also, wear a mask the right way.  Studies by the Center for Infectious Disease Research and Policy (CIDRAP) have reported that in review of news footage an average of 25% of Americans are not wearing their mask correctly.  Many do not cover the nose, for example.  A mask should cover both the mouth and the nose at all times.  There is also a great deal of inappropriate handling of masks.  You should only touch the mask with clean hands, handle the mask by the drawstrings, and do not touch the part through which you breath.  If you touch your mask, remember that it is a filter for the virus that causes COVID-19. You could be contaminating your fingers. Wash your hands.   A mask should not be moved under the chin, put in a pocket, or otherwise handled carelessly.   A wet or damaged mask is not helpful.

Finally, the U.S. has seen over 3 million cases of COVID-19 and over 132,000 people have died from this preventable viral infection.  Please do your part.  It is not a political issue, wear a mask and do all that you can to avoid contributing to this pandemic.  

COVID-19 update June 27, and some confusion…

Yesterday, Friday, June 26, 2020, at the Maine CDC briefing Dr. Nirav Shaw reported that as of that morning the new cumulative number of cases of COVID-19 among Maine residents had reached 3,102, with 32 new cases.  This number was made up of 2758 confirmed (with either PCR or antibody testing), and 344 probable (symptomatic people with close contact to a confirmed case).  Dr. Shaw noted that in that 24 hour period alone the state conducted 2,225 PCR tests, among them 39 positive.  As there were 32 new cases among Mainers for that time period, one could reasonably conclude this meant 7 cases were among non-Mainers – more on that below.

However, and here is where a little confusion begins, I would note the numbers given in the Friday press briefing matched the data listed on the Maine CDC website for Thursday. Perhaps that morning’s data was not updated yet? Or, perhaps the data was not concluded. In the past, the data given during the briefing exactly matched the data on the website. Perhaps that has changed?  I would also note though that the numbers given at the press briefings Monday, June 22, and the Wednesday, June 24 also did not match what was posted on the Maine CDC website for those dates (and he numbers did not represent the prior day values).  I am using the website data for calculations in this article because it is integrated into CDC tabulations.

To that end, the data posted indicates Friday there were 3154 total cases (52 new cases), 2564 recoveries, 104 deaths among Maine residents.  And, as of the time of writing this post on Saturday, June 27 the data indicates no new cases overnight.  I would question that number as the prior week’s daily average number of new cases was 33 per day.   Because of that question I have not included today’s numbers in the graphic at the top of this article.  As always, if you cannot see the graphic in email form, please view this post on the website.

The number of active cases among Maine residents as of Friday was 486. This number reached a peak of 712 on May 26, and had dropped to 393 on June 23. Active cases are represented by the green line in the graphic above. Note that line is starting to trend up.

The state has started giving information about total testing on the CDC website, noting that among the 96,295 tests run to date, 3,787 were positive.  If we subtract the total number of reported and probable cases as above (3,154) from this number we are left with 633 cases.  This again could reasonably suggest 633 non-residents have tested positive in our state.   This is especially relevant as we see more visitors and part-time residents returning with the good weather.  I would think knowing how many out-of-staters have tested, and are currently testing positive in the state would be good information to help business owners, and all Mainers for that matter, calculate their own risk.  Considered another way, if the actual number of positive tests to date is 3,787, then 633 unaccounted for people, presumably non-residents, is about 17% of the total.  That is 1 in 6 positive tests, a lot of visitors.    

Among the total number of cases reported at yesterday’s briefing 787 were among health care workers-25% of total cases reported. For the first time since reporting began Dr. Shaw gave information about recoveries among that group: 680.  This leaves a total of 107 active (or possibly deceased-data not disclosed) cases among health care workers.  There were 28 people hospitalized with COVID-19 in our state, 9 in ICUs, and 6 on ventilators-presumably on Thursday. 

Finally, though there are executive orders, and compliance with physical distancing and facial covering is high, there are still some businesses around the state that do not require their employees to wear a mask. I encountered this twice yesterday when shopping for groceries and other necessities. I would suggest that if you encounter this situation you do as I did in both cases: leave. Do not shop with those businesses. This will protect your own health, and will send a message that you expect everyone to do their best to stop this pandemic. As I have discussed several times here, wearing a mask protects you and others from spread of COVID-19. Choosing not to wear a mask places others at risk.

COVID-19 update by the numbers, June 21, 2020

As of today, June 21, 2020, there have been 2957 cases of COVID-19 among Maine residents reported by the Maine CDC.  There have been 328 cases in the “probable” category (known close contacts of confirmed cases with symptomatic disease as previously discussed).  Reportedly, 2391 people have recovered from COVID-19 in Maine.   In the last two weeks we have accumulated four new deaths due to COVID-19, bringing that unfortunate total to 102 Maine residents.  The only good news about that accounting is that the rate of deaths has been falling.   In the just over two weeks since I last reported on the numbers, the number of new cases per day has averaged 28, dropping from a prior two week average of 36 cases per day.  The number of current active cases has fallen to 464, a number which has been declining since a peak of 712 on May 26, 2020. In the attached graphic active cases are represented by a green line, which also shows a downward trend.  Note, if you cannot see the graphic, please view this article on the website.   The current seven day average number of active cases has been 478, down from 628 two weeks back. 

The number of health care workers that had been infected since testing began was 743 as of Friday, June 19 (the last day for which the data is available).  This represented 26% of cases reported in the state on that date.  Testing for health care workers has been symptom-based for the most part, in some cases related to direct exposure, and included in universal testing at congregate care facilities.  In short, the vast majority of health care workers in the state have not been tested. 

These numbers are a snapshot, a look at the available data, not a picture of every COVID-19 infection, and no clear measure of asymptomatic carriers in the state.  Still, numbers are trending down.  On the other hand, we are “opening up” and our summer population is growing.   It is possible that we could see another wave of infections soon, even more likely in the fall if there is not a vaccine or some other intervention.  Physical distancing, wearing a mask, and hand washing are still excellent tools to limit the spread of COVID-19.  Please help to keep the numbers down. 

More on asymptomatic carriers and bad modeling by the POTUS

In a recent MPDN post about asymptomatic carriers  of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which causes COVID-19 I noted that these people can be infected and infect others without ever knowing they are ill.  This is particularly concerning because we have not had enough testing in the state (or the country for that matter) to know the incidence of these cases.   It is also concerning because we are opening up businesses and many people do not take the most basic precautions to protect themselves and others, such as wearing a mask in public or practicing physical distancing.  We are also seeing an influx of tourists in our state and have no way of knowing who has actually been tested or quarantined.  Finally, there have been a variety of gatherings around the state and the country, such as the heavily televised campaign rally for the POTUS yesterday, in which masks were worn by very few, voices were loud, and people were crowded at an indoor location; conditions near ideal for spread from asymptomatic carriers. 

This past week a scientific letter published in Nature Medicine about asymptomatic carriers raised more concerns about COVID-19 that have a lot of bearing on all of this.  The cases were detected by the Chinese Wanzhou District Centers for Disease Control and Prevention (CDC), which conducted RT–PCR tests on 2,088 “close contacts under quarantine.” None of these people had symptoms in the two weeks prior to testing.  This is especially relevant because in the U.S. the standard is to have people who have had a close contact with a sick person go into isolation for two weeks.  If they develop no symptoms, they come out of isolation.  In this study, a positive test was detected in 178 patients.  All 178 were hospitalized and a variety of tests were conducted.  All patients were followed for several weeks.  Among these 178 cases, 37 (20.8%) remained asymptomatic.  Within the 37 asymptomatic cases, the average age was 41 years, and 22 were female. 

A younger average age is an interesting feature that might speak to the fact that younger people seem to do better with the virus if exposed.  However, that might also lead people to a false sense of security.  First, not all young people do so well.  Many younger people (including children) with COVID-19 in our country have died or suffered a variety of serious illnesses. Second, these people might spread disease, even if they are not so sick.  If one person infects two other people, and those two people infect two other people, it doesn’t take long for infection to grow to huge numbers.  For another example of exponential growth, see this post.

It is important to understand a little about how the testing was done to understand a couple other concerns.  Recall that polymerase chain reaction (PCR) is a test for genetic material.  PCR looks for the genetic material of the organism when the COVID-19 test is done, and in that case the only way for one to have a positive test is if the organism is present (an infection).  In this study, the amount of genetic material found in the 37 asymptomatic cases was compared against symptomatic cases and found to be the same. Similar to the prior post on asymptomatic cases, this tells us that viral shedding, or the amount of virus being emitted is probably about the same between symptomatic an asymptomatic people.  (footnote)

The authors also reported that asymptomatic carriers were found to shed virus for a period of time longer than people with symptomatic disease.  The average duration of viral shedding among these “silent spreaders” was 19 days, with a range of 15-26 days (versus an average of 14 days among symptomatic patients).  This longer duration may be related to another finding in the study, that asymptomatic carriers in this report had a less robust immune response than people with symptomatic disease.  This concept fits with the idea that much of the damage done to the body with severe cases is thought to be caused by an infected person’s own immune response. In other words, a person with a strong immune response to the virus might wind up severely ill, and if they survive, stop shedding virus faster than a person with a weaker immune response and fewer neutralizing antibodies.  Also, asymptomatic people in the report had  lower levels of pro- and anti-inflammatory cytokines.  The so-called “cytokine storm” is implicated in progression to severe disease in symptomatic cases. 

However, the longer duration of positive testing could have another meaning.  Again, a positive PCR test means genetic material is present, but does not necessarily imply viral infectivity is still possible.  It could be that after one has stopped being infectious a test could remain positive for a few days due to viral debris.  It is known in many other viral infections that the immune system can neutralize viruses by damaging the outer envelope or aggregating virus particles.  These acts prevent infection but do not destroy the nucleic acid, which degrades slowly over time.  One example is measles virus RNA, which can be detected for up to 8 weeks after the clearance of infectious virus.  As an analogy, if you thought there was a nest of hornets in your attic, and you had a test that picked up hornets, it might not distinguish between live hornets and the ones left behind after fogging the attic with hornet spray.  It would take a while for the hornets to disintegrate. 

Whatever the case, asymptomatic carriers reproduce and spread virus.  Being in the presence of someone who is slowly emitting virus by talking or breathing is much less risky if that person is wearing a mask.  It is also less risky if the encounter is kept brief, if you are wearing a mask also, and if are physically distanced at least 6 feet.  Indoor environments are less dangerous if air is being circulated away from you to the outside (windows open, air exchangers, or negative pressure rooms). 

So let’s close with a few words from the president yesterday.  To paraphrase, he stated he had asked for COVID-19 is a “flu,” that testing to be slowed down in this country, because if you test, you find cases.  He made a point that some cases are mild and should not have been counted.  He stated that he had probably saved hundreds of thousands of lives by acting as quickly as he did.   He was wrong on all counts, and several more I haven’t mentioned. What he said about COVID-19 so clearly illuminated his indifference to science and experts, failure to read daily briefings, inability to grasp or accept simple medical facts, and failure to lead in a health crisis.  What he had to say, and the very fact that he brought so many people from all over the country together for an indoor rally where masks were not required, and where people who had to sign a waver stating they would not hold him liable if they caught COVID-19, was dangerous, and sent a very bad message about public health and his lack of concern for the wellbeing of even his own supporters.  This came even after the deaths over 120,000 Americans during this pandemic, a number which is still growing.   

We need a lot more testing to understand the incidence of asymptomatic cases, for contact tracing, isolation, and public health.  We need leaders who, if they don’t understand what is going on, at least listen to experts, take their recommendations, and model the behavior in those recommendations. This comment is not about politics. It is about common sense and public health. 

Until we have a vaccine or some reasonable intervention comes along we need to wear masks, practice physical distancing, wash our hands, stop touching our faces (unless the hands and the face are clean).  Stay well, and follow the advice of the Maine CDC.

FOOTNOTE:  We should note of course that coughing and sneezing emit huge numbers compared with talking or simple breathing.  Still, the point is important, asymptomatic people can shed a lot of viral particles, and infect others.

Should you wear a mask or face cover in public?

As we have previously discussed here, the CDC in Atlanta has recommended that people wear a cloth face cover when out in public (see footnote). A face cover is not meant to substitute for social distancing, and the recommendation that people remain at least 6 feet apart remains.  Because so many people still don’t seem to understand the reason for wearing a face covering, I will go over that here. Specifically, I am trying to address people who believe they are not infected, don’t think there are sick people around them, and therefore think they don’t need to wear a mask in public.  

The point of wearing a face cover or mask in public or around others who are not close contacts in the home is to limit the spread of SARS-CoV-2, the virus that causes COVID-19.  To date this disease has claimed over 115,000 lives in the U.S., where there have been over 2 million cases (over a quarter of cases worldwide).   

How a face covering prevents the spread of COVID-19 is simple.  It is a barrier.  We need that because  even healthy people release moisture in the form of respiratory droplets when they breathe or talk. Some people release more droplets than others – loud talkers for example.  We usually can’t see these droplets because they are so small, from 0.1 to 1000 μm (a micrometer is a millionth of a meter).  These tiny droplets tend to fly a certain distance before falling to the ground or some other target – hence the 6 foot rule.   Droplets <5 μm can form aerosols and hang in the air. The droplets and aerosol may contain viral particles if a person is infected.

To be clear, although a mask or face covering is a barrier, it still does not stop all droplets. This should not lead one to think masks are useless (as I have also heard several times).   We are not likely to get an infection unless we inhale or otherwise become infected with a certain number of virus particles, (likely a number in the 1000s).  The point of the mask is to limit the number of particles released.  It also probably helps limit the number you might breathe in, or at least block a few droplets flying at you. 

Now, back to those who think they are healthy, and don’t see sick people around them.  I hope they are all healthy, but the truth is there are asymptomatic carriers of this infection who can spread disease and not know they are infected. As I previously discussed here, if someone is infected with the virus that causes COVID-19, it can be up to 14 days before they show symptoms (the average time to symptoms is 5 days).  However, they often start shedding virus in as little as 2 days.  Thus, they are “presymptomatic,” spreading disease, and don’t know they are ill anywhere from 3-12 days.  And, there are those who become infected, shed virus, and never develop symptoms. Wearing a mask would at least limit their ability to unknowingly make someone else sick.

Unless you have just been tested, you don’t know whether you are infected.  You can’t tell just by looking at someone if they are infected either. Thus, the only thing we can recommend for now is that you wear a mask or face covering to prevent the spread of disease.  It tells others that you care about their well-being. 

FOOTNOTE:  The CDC recommendation regarding wearing a cloth face covering in public was for everyone except children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

To put on a face covering, grip the cover by the draw strings or elastic material used over the ears. It is okay to adjust to tightness around the nose, but try not to touch the material through which you will breathe. In general, try to limit touching the mask while wearing, and if you do so, use clean hands. If you accidentally touch your mask while wearing, clean your hands. Keep in mind that any cloth face cover should be washed regularly, depending on use. It follows then that any material you select should be capable of being laundered and machine dried without damage or change to shape.

There are different types of masks and facial coverings. The CDC recommends a cloth face covering for non-medical people. This should be made of cloth such as old T-shirt or a bandana. Paper surgical masks are worn by health care workers. Typically, the colored side goes out (somewhat waterproof to stop droplets from the outside), and the light side to your face (absorbent to to trap your own droplets), and the piece over the nose bends to conform to the bridge of the nose. Doctors wear these to prevent getting respiratory droplets on patients, but also to protect against droplets or other fluids. N95 masks are specialized respirators that filter particulates (95% of small particles). Wearers must be fitted, and the respirator does not work well (if at all) over a beard. Masks with one-way valves that make it easier for the wearer to exhale do not filter and do not prevent the wearer from spreading the virus-defeating the purpose of the CDC recommendation.

Wash your hands!

Vitamin D and COVID-19

Vitamin D deficiency is common in Parkinson disease (PD).  In fact, as previously discussed in MPDN, this vitamin is involved in dopamine production.  Generally speaking, we also need adequate stores for the health of our bones, heart, and metabolism. Vitamin D is also involved in innate immunity, a part of our immune system that includes physical barriers (for example, skin), compounds found in the blood, and certain white blood cells that directly attack foreign cells and substances in the body, so-called antigens.  Vitamin D can lower inflammation and help fight certain viruses.  It is also known that vitamin D deficiency is associated with respiratory infections. Normalizing vitamin D levels seems to help prevent these infections.  A meta-analysis (a comparison of multiple studies)  of 25 randomized clinical trials of vitamin D supplementation found that among the nearly 11,000 patients supplementation correlated with 12% reduced risk of respiratory tract infections. In people with severe vitamin D deficiency at baseline adding vitamin D supplementation was associated with a 70% lower risk of respiratory infection. 

Now, there is data that vitamin D deficiency is associated with COVID-19.  And, severe outcome was eight times more likely among COVID-19 patients with vitamin D deficiency compared to those with normal levels in a report from three Asian hospitals. It should be noted that generally, people with severe vitamin D deficiency tend to have underlying have underlying health issues also.  Nonetheless, vitamin D levels may play a role with severe outcomes of COVID-19, such as the “cytokine storm” that usually precipitates critical illness in this disease.

The problem is that many people with PD are not getting out to exercise or get a little sunshine.  This is a bad combination.  Low exercise is associated with poor outcomes in PD.   Not getting appropriate sunshine (and therefore the UV light needed to convert vitamin D to its active form), is associated with vitamin D deficiency.  So please, get a few minutes of sunshine daily, eat foods that contain vitamin D, and if your vitamin D is low, please replace it with the direction of your doctor.  Some authors have suggested vitamin D supplementation should be universal with PD patients, at least during the time of COVID-19.  I would caution however, that you avoid vitamin D toxicity.  

COVID-19 and the week ending June 6, 2020

It is the 6th of June, the 76th anniversary the D-Day landings in Normandy.  This should be a time for reflection, and a time to place our country and our society in perspective.  I find myself thinking about all the World War II vets I met during training-many of whom led me to study Parkinson disease.  I wonder about those that I never had the chance to meet, and what they would say about what America did with the opportunity paid in blood by the soldiers of our greatest generation.  

This is also the end of a week of unrest and protest in our country, triggered by the May 25, 2020 Minneapolis Police killing of George Floyd. Thousands have gathered in U.S. cities (including those in Maine) on multiple occasions since his death to say it is time for a change.  The timing is terrible of course, for gathering in large groups, for chanting, for shouting.  That kind of activity places everyone present at risk, and in turn, their later contacts.  There is after all, a pandemic.  There is still a deadly virus in our country, a country which is still reporting more cases than any other in the world by far.

I hope only good comes of these protests.  And, if you find yourself joining a gathering, please wear a mask, maintain at least a 6-foot distance from others (ideally much farther if voices are raised), and be aware of your surroundings.  As I have discussed here, louder voices, singing, etc. project more respiratory droplets, and the distance increases with effort.  If someone is not wearing a mask, move away from them.  Avoid shaking hands, linking arms, hugging, and other physical displays so common to these groups.  If you protest, do so with you head and your heart.    

The same should be kept in mind for political rallies.  Yesterday Donald Trump visited Maine and was met with what appeared on White House social media coverage to be an indoor crowd of cheering supporters.  Of note, he toured Puritan Medical Products, which produces nasal swabs for testing.  Per USA Today, Trump was not wearing a mask while visiting the production floor (also seen on WH social media), and the swabs being made that day were to be discarded.

The current numbers in our state per the Maine CDC include 2,524 cases since testing began, with 1,845 recoveries, and 98 deaths.  The number of current active cases is 581, a number which has been declining since a peak of 712 on May 26, 2020.   The 7-day average number of active cases stands at 628.  This is a trend in the right direction.  I hope it continues this way in spite of reopenings and gatherings.

This week the Maine CDC also began listing cases by zip code in order to give a more clear picture of where cases are, or have been, concentrated.  Zip codes in which the number of cases were very small were excluded in order to protect the identity of the afflicted.  There has been a great deal of discussion about this in news media, regarding where the cases “are,” and how some towns have “no cases.”  However, a point that seems missed by most commentators is that these numbers only represent positive results among those who were tested, or those who are presumed on narrow criteria to have had COVID-19 due to close contact with a known case and symptoms consistent with disease (271 of the total).   

It should be remembered that there was a long delay in getting test kits to states. While the first case in the U.S. was confirmed January 20, Maine has only been testing since March 12.   There was thus a gap of 67 days after that first case in which we could not test anyone in this state.   Recall also, that after testing began, it was very limited.  In the first several weeks of testing in Maine only those who met strict criteria (usually the very sick) were offered a test.  Many others who were presumed infected were told to shelter at home.  We don’t have an accounting of those numbers (though it was not a small number). 

I know also of presumed cases among people who lived in towns now reported as “no cases.”  The point is, don’t be over-confident in seeing those numbers.  Continue to act as though you might be capable of either contracting, or asymptomatically spreading COVID-19 until we have a better handle on this situation.  We need a vaccine and better treatments, or at least much more widespread testing. Please continue to follow guidance by the Maine CDC and Governor Mills.

Please wear a mask when visiting your doctor. We need to do all we can to limit spread and protect each other. As of the last reporting by the Maine CDC, about 25% of cases in Maine were among health care workers. We are doing the best we can for you. Please help us by wearing a mask, not just around your health care providers, but please also wear a mask or facial covering around others too. It is what smart people do.

If you cannot view the graphic at the top of this post (a chart of cases in Maine), please read the article on the website.

COVID-19 update June 1, 2020

Today many businesses around the state are reopening as part of a staged process under Executive Orders from Governor Mills.  Social distancing and mask or facial covering requirements are still in place to prevent spread of the virus.  Just to recap the last few days, on May 28 Dr. Nirav Shaw, Director of the Maine CDC, started giving daily briefing updates remotely due to a cluster of complaints at the Maine Emergency Management Agency (EMA): “a number of individuals…have developed signs and symptoms consistent with symptoms consistent with COVID-19.” He and EMA Director Peter Cook noted the 7 individuals reported fever, chills, aches.  They team deployed to alternate work sites away from the Emergency Operations Center, and the individuals were tested.   On May 29 Dr. Shaw noted all the tests had come back negative for the 7 individuals.  They planned to run other tests for other potential viruses and bacteria.  It is possible that some other organism infected the workers.  It is not clear which modality of testing was used for these workers. 

The U.S. passed the horrible marker of 100,000 fatalities due to COVID-19 last week.  We still stand apart as a country in terms of cases and deaths.  In fact, by comparison with one of our neighbors, on May 31, Canada reported 92,479 cases, which from a population 37 million represented 0.25% of Canadians. The same day, the U.S. counted 1,806,813 cases from a population of 328,239,523, representing a case rate of 0.55% of the general population, a rate over double that of Canada.  The U.S. has four times the number of cases of any other country in the world, and over 104,000 Americans have died with COVID-19 in the last four months.

Today in Maine the total count of cases since testing began stands at 2349, including a little over 200 “probable” cases” (discussed in MPDN on May 20, 2020), 1586 recoveries, 89 (3.8%) deaths.  The number of health care workers infected since testing began is 563 (24%). 

In the 12 days since I last reported on trends in case rates here in Maine, the number of new cases per day has averaged 45 (on May 20, 2020 the prior three week average number was 40 cases per day).  Overall, since testing began 83 days back, we have averaged 28 new cases per day. Sixteen Mainers have died from COVID-19 over the last 12 days.   

To date there have been 284 hospitalizations in Maine due to COVID-19 (12% of all positive cases).  The current number of active cases is 674 (29% of cases since testing began).  Of the active cases, 52 (8%) are hospitalized. Among the 52 hospitalized, 17 (33%) are in intensive care unit (ICU) beds (a higher percentage), and 10 (19 %) on ventilators, also a higher percentage.  The highest number of active cases occurred on 5/24/20: 720 cases.

To be clear, Maine has had an increase in the case rate since I last reported on this topic.  This is in part due to outbreaks and testing at congregate care facilities. Per Dr. Shah on Maine Calling last week, congregate care facilities represented about 40% of total cases.  Today Dr. Shaw gave an update on the Cape Memory Care Center, which has had a total of 84 cases (23 of whom were staff, the remainder residents).  Also listed were outbreaks at four new facilities.  Birchwoods at Canco Assisted Living has 5 staff members who have tested positive for COVID-19.   One of the John P. Murphy Homes in Auburn has 5 cases.  The Family Shelter in Portland has 15 cases.  The Barron Center in Portland has 4 cases. 

Presumably, the new cases at congregate living facilities are being brought in by staff or some other visitor (a vendor, for example).  Since patient visitors are not allowed, the numbers must be small.   However, I know from facilities with which I have had contact, that there is screening, that staff with signs or symptoms disease, or travel out of state, are not being allowed in facilities unless first quarantined or tested negative. 

This means many (or probably most) cases at these facilities are caused by asymptomatic carriers who do not know they are ill and are bringing the virus into the facility.  As discussed in my last post, asymptomatic carriers are those people who are infected but not showing symptoms.  Asymptomatic carriers represent a significant number of people, people who can spread disease without knowing it.  So, why not institute a policy of regular testing of all employees at congregate living facilities? The limitation has been the number of tests available.  In May the state testing lab increased capacity to 1000 tests per day.    This is a lot, but perhaps not enough.   We need more tests, but we need to use them wisely also. That would mean regularly testing of all health care workers, workers at meat packing plants, any place where people congregate.

And, we still do not know the number of asymptomatic carriers in the general population-a great reason to keep wearing that face covering, and keep on social distancing.  To figure out the rate of asymptomatic carriers, the state could conduct tests on samples of the population, for example, 100 people each in several communities. These would have to be volunteers, of course. This sentinel testing could make a big difference and guide the reopening of businesses, schools, and so on.  Such tests would also allow notification, isolation, contact tracing to try and curb other outbreaks.  To date, the state of Maine has run over 54,000 tests in a population of 1.3 million.  As mentioned previously in MPDN, many of the tests were repeats of patients who for example, had a syndrome very suspicious for COVID-19, but initially tested negative.  Or, these may have been patients with confirmed COVID-19 who recovered and needed a negative test for discharge from a hospital. The Maine CDC is in the planning stages of sentinel testing.

Note, to view the graphic associated with this article, please view it on the website.       

Risk and the asymptomatic carrier of COVID-19

Asymptomatic spread of the SARS-CoV-2 virus that causes COVID-19 is a big problem.  And, this problem  does not behave the same as with many other viruses, even the close relative SARS-CoV-1, the virus that caused SARS in 2002-2003.  When SARS struck, health authorities controlled and eventually stopped the epidemic by using symptoms to detect cases.  Typical symptoms of fever, cough, and shortness of breath about 5 days after exposure led to testing, isolation, and quarantine.  Similar to COVID-19, transmission of SARS was primarily via respiratory droplets.  In less than a year after approximately 8100 people were infected (primarily in Asia), and about 10% of those infected died, the epidemic ended.   

So how has SARS-CoV-2 spread all over the world to over 5.8 million people (1.7 million in the U.S.)?  This grim week, how has COVID-19 killed over 100,000 U.S. citizens?  One big issue is that screening without testing is inadequate with this virus because there are too many asymptomatic and unknowing cases who are just as capable of spreading the virus as are the symptomatic cases.  COVID-19 can be spread by people who appear and feel well. Far worse, if one does not know they are infected, they might not be taking precautions to prevent spread.  A significant minority of people don’t wear masks in public and ignore, or are too lax with, social distancing.  As I have said before in MPDN, it is so important that everyone act as though they might be capable of spreading or contracting the virus, and take appropriate steps to prevent that until we have a vaccine or at least good therapies for prevention or treatment.

Why doesn’t COVID-19 behave like SARS? 

One major difference between SARS and COVID-19 is that the SARS-CoV-2 virus infects, replicates, and sheds in the upper respiratory tract of infected people with and without symptoms. (1) This means coughing, sneezing, talking, or simple breathing might shed virus.  The SARS-CoV-1 virus on the other hand, replicated primarily in the lower respiratory tract (2), and cases of SARS were infectious during their symptomatic period, not during the incubation period (the time it takes between exposure and illness). (3)  What I am again getting at here is that people with and without symptoms are spreading COVID-19, and this is an important point to understand.  For the sake of definitions, an infected person who is symptomatic has symptoms; whereas as an infected person who is asymptomatic does not.  Both might shed virus and infect others.  An asymptomatic person can remain that way until the infection stops, or the person might be presymptomatic, meaning they are on their way to having symptoms, getting sick, in the incubation period (see below).  Viral load (the amount of virus measured from some source such as blood or sputum) in SARS-CoV-1 was usually elevated at symptom onset and made symptom-based detection more likely and more effective. If you had symptoms, you could be isolated, tested, and contacts could be traced, etc. The same is not true for SARS-CoV-2, wherein viral load may be high before a person is symptomatic. (4)  This makes detecting cases much more difficult.    

Consider the COVID-19 outbreak in a skilled nursing facility in Washington State. (5)  Authorities first learned of the outbreak when a symptomatic health care worker tested positive for infection on March 1, 2020.  Universal testing of residents in the facility took place with the nasopharyngeal swab test: real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) on two dates: March 13 and March 19–20.  Note the delay in testing, which if not ideal, would have at least allowed time for many of those exposed to develop into infection, making the test more likely to detect infections. (footnote)  Note also that RT-PCR detects the RNA of virus.  You have to have the virus in the nasopharynx (that place very far back in the nasal cavity where test swabs collect a sample) at the time of the test to get a positive result. 

The residents were all asked about symptoms over the prior two weeks, including fever, cough, and shortness of breath.  From the 76 residents tested, 48 (63%) were positive, 27 (56%) asymptomatic at time of testing.  Within an average of 4 days after testing 24 of the 27 became symptomatic.  This means  24 had been presymptomatic, and 3 remained completely asymptomatic.  Therefore, it is important to note that more than half of those who tested positive overall had no symptoms at the time of the test.  Note also that 3 patients were infected but never developed symptoms, very dangerous in a congregate living situation.   

This is not like SARS. Asymptomatic spread is a worse situation.  And, health authorities wanted to know about levels of virus at the time of these tests.  The thought was, and is, that a higher viral load in the nasopharynx is more likely to spread disease.  They checked this by measuring quantitative SARS-CoV-2 viral loads, which showed high levels of virus whether the residents were symptomatic, presymptomatic, or completely asymptomatic.  And, among the presymptomatic patients 17 (71%) had viable virus 1 to 6 days before the start of symptoms. In other words, live coronavirus was shedding in high concentrations from the nasal cavity before symptoms developed for up to 6 days.  Asking people about symptoms did not detect over half of infectious cases.  This is why universal testing in congregate living facilities is so important, and why mass testing generally would be much more effective than what we are doing now.  This is why health authorities keep saying we need more tests, a lot more.

This congregate living facility is not the only example by far.  Another study looked at 94 patients with laboratory-confirmed COVID-19 and found the highest viral load in throat swabs at the time of symptom onset, which the authors interpreted as consistent with a peak of infectiousness at or even before symptom onset. (6) They estimated that 44% of cases had been infected by people who were in a presymptomatic stage: they contracted the virus from another person who they thought was well.  In this study, the incubation period averaged about 5 days, while infectiousness started about day 2 or 3 after exposure (rapid in the infectious disease world).  In other words, people were spreading the virus for 2-3 days and did not yet know they were sick.  

There have been several other reports of asymptomatic carriers infecting others. In one report an asymptomatic 20-year-old woman who tested positive by RT-PCR (but had negative chest imaging) infected friends and relatives. (6) She was kept in isolation for a month and never developed symptoms.  In another case an asymptomatic 10-year-old boy with COVID-19 and abnormalities on chest CT spread infection to members of his family. (7)

A paper published this week reported a cruise ship which left Argentina in mid March. (8)  On board there were 128 passengers and 95 crew.  Before boarding everyone (passengers and crew) had been screened for COVID-19 symptoms and body temperatures were taken.  No one on board had passed through China, Macau, Hong Kong, Taiwan, Japan, South Korea, or Iran in the 3 weeks prior.  Multiple hand hygiene stations were placed in the ship, including the dining area. The two physicians on board screened all passengers and crew with “regular body temperature reviews.”  The first fever of the outbreak, a passenger, was recorded on day 8.  Immediately isolation protocols began: all passengers confined to cabins, surgical masks issued to all, full personal protective equipment (PPE) used for any contact with febrile patients, N95 masks worn for any contact by crew with passengers in their cabins.  But the outbreak was spreading, or at least incubating.  Additional fevers were detected in 3 crew members on day 10, 1 crew member on day 11, and 3 passengers on day 12.  The ship had been on its way back to Argentina, but the country had closed its borders due to increasing regulations with the COVID-19 outbreak, and was refused permission to disembark at Stanley, Falkland Islands.  The ship sailed to Montevideo, Uruguay, arriving day 13.  Passengers were kept on board.  Among them 8 (6.2%) required medical evacuation due to impending respiratory failure.  For the remaining 217, on day 20 universal testing for COVID-19 with RT-PCR took place (supplied by Uruguay), revealing 128 (59%) positive. Remaining passengers and crew did not disembark until day 28, and the stats on that day are as follows: among the positive 104 (81%) asymptomatic, 24 (19%) symptomatic.   That is a staggering figure, and very troubling given the amount of time passengers had to become symptomatic, and the steps taken to prevent spread as soon as the first fever was detected.  

This is a complex problem. 

Not all asymptomatic carriers seem to pose the same risk.  Some seem to pose very low risk.  (10)   The reasons for this are likely multi-faceted.  One interesting reason might be immunity. As previously discussed in MPDN, the coronaviruses are a family of viruses that have been known to science since the 1960s (though likely much, much older than that), and until 2002 were known to cause epidemics of mild upper respiratory tract infections (URI), or sometimes diarrhea.  There are two subsets that infect humans: alpha coronaviruses (HCoV-229E and HCoV-NL63) and beta coronaviruses (HCoV-HKU1, HCoV-OC43).  Infections with these “benign” viruses would usually cause a cold.  But, if a person had been infected with one of these strains, they would usually make antibodies and be immune to re-infection for 2-3 years.  The viruses that cause SARS and COVID-19 are newer beta coronaviruses. 

The two “benign” beta coronaviruses are recognized by the human immune system, which induces antibodies that can protect us against either virus.  In other words, infection with one of those viruses results in antibodies against either. That is known as “cross-reactivity.”  And, it is known that SARS-CoV-1 infection can also result in neutralizing antibodies against at least the HCoV-OC43 virus, and that HCoV-OC43 infection results in cross-reactive antibodies against SARS-CoV-1.  (11)  We don’t know yet if this cross-reactivity protects some people from developing COVID-19, but it is a hopeful thought, that could lead to protective treatments. It might also explain why so many cases of COVID-19 are mild. If you have had a cold due to HCoV-OC43 in the last year or two, you might be protected. We still don’t know, and the issue with antibody testing is too complicated to get into here.

Opposite to these issues are the super spreading events (SSE), when case numbers explode after some episode of people congregating, such as at a church  (12) or a nightclub.  There are several factors that can lead to super spreading.  One factor could be changes with the virus itself.  There is at least one preliminary report suggesting SARS-CoV-2 could have 2 distinct genetic subtypes, one more aggressive than the other.  (13) There are also super spreaders. An infected person might have a long duration of infection (more time to spread disease than normal), a higher amount of virus in the upper respiratory passage, a high degree of coughing, lots of sneezing. Even loud talking or singing can shed more virus.  There are also environmental factors such as the density of the population present (for eg, a crowded market, a party, or a funeral), and whether infection prevention and control measures are being used such as social distancing and wearing a mask.  Closed environments such as gyms, restaurants, offices, may drastically increase the risk of infection by trapping air (or recirculating it through ventilation).  SARS-CoV-2 has been found in stool (14), meaning toilets need to be kept clean, and hands washed after using the bathroom.   And, there are so-called high emitters, who shed many times the amount of virus that is seen in average cases. (15)  This obviously increases risk of spread. 

So what should we take from this knowledge?  One big point is that unless they have been tested, we don’t know who the asymptomatic carriers are.  We should continue social distancing and wearing a mask where appropriate.  This is especially due to the increasing growth of active cases in our state (currently over 700).  This is not simply the effect of increased testing, though that is part of it.  We are seeing more cases in our hospitals in Maine, currently 58 people hospitalized, 22 in critical care, and 14 on a ventilator per the Maine CDC.   So, take it seriously, follow guidance from the Maine CDC, be careful where you get your information, and be COVID-aware. 

FOOTNOTE: In early March testing was very limited, even in Washington State, where the first case in the U.S. was identified.  View this episode of Frontline to learn more.

Please note that URLs were collected on date of publication and are subject to change, as are statistics regarding infection, as with any ongoing epidemic.

REFERENCES

  1. Wölfel, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020 April 1 (Epub ahead of print).
  2. Cheng, et al. Viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome. Lancet 2004;363:1699-1700.
  3. Guang, et al.  Infectivity of Severe Acute Respiratory Syndrome during Its Incubation Period Biomed Environ Sci. 2009 Dec; 22(6): 502–510.
  4. To, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis 2020 March 23 (Epub ahead of print).
  5. Arons, et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med 2020;382:2081-2090.
  6. Xi, et al.  Temporal dynamics in viral shedding and transmissibility of COVID-19 Nature Medicine. 2020:26;672-675
  7. Bai, et al. Presumed Asymptomatic Carrier Transmission of COVID-19  JAMA. 2020;323(14):1406-1407. doi:10.1001/jama.2020.2565
  8. Chan, et al.  A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.   Lancet. 2020;395(10223):514-523.
  9. Ing, et al.  COVID-19: in the footsteps of Ernest ShackletonThorax Published Online First: 27 May 2020. doi: 10.1136/thoraxjnl-2020-215091  https://thorax.bmj.com/content/early/2020/05/27/thoraxjnl-2020-215091
  10. Ming, et al.  A study on infectivity of asymptomatic SARS-CoV-2 carriers  Respir Med. 2020 May 13 : 106026. doi: 10.1016/j.rmed.2020.106026 [Epub ahead of print]
  11. Kissler, et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period Science  22 May 2020:Vol. 368, Issue 6493, pp. 860-868  DOI: 10.1126/science.abb5793
  12. South Korean city on high alert as coronavirus cases soar at ‘cult’ church. New York: The Guardian, February 20, 2020 [cited 2020 Mar 8]. https://www.theguardian.com/world/2020/feb/20/south-korean-city-daegu-lockdown-coronavirus-outbreak-cases-soar-at-church-cult-clusterExternal Link
  13. Tang, et al. On the origin and continuing evolution of SARS-CoV-2. Natl Sci Rev. 2020;nwaa036; [Epub ahead of print].
  14. Gu, et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020;Mar 3:pii: S0016-5085(20)30281-X. Epub ahead of print].
  15. Tsai, D., Riediker, M. (2020). Estimation of SARS-CoV-2 emissions from non-symptomatic cases. medRxiv. https://www.medrxiv.org/content/10.1101/2020.04.27.20081398v1

COVID-19 update May 20, 2020

Today the Maine CDC is reporting a total of 1816 cases of COVID-19 among state residents since testing began on March 12, 2020.  The total numbers now include not just confirmed tests, but 187 probable cases (essentially those with close contact to a confirmed case who have syndrome consistent with COVID-19).   Tests are not used on these patients unless they become ill enough for hospital admission.  Meanwhile, the overall increase in numbers is also in part due to a policy of testing all staff and residents of congregate living facilities where outbreaks occur (three or more cases).  In these cases it is likely that asymptomatic or pre-symptomatic cases will be detected, thus increasing the numbers or positive tests in a way that would not have been possible prior to the policy.  This policy of mass testing is meant to limit spread within facilities where more vulnerable people are living. We don’t have to look far in the news to understand why that is a good idea.  Congregate facilities are not the only groups that are now being mass-tested, as outbreaks have occurred at a food processing plant, a construction company, an apartment building, and a jail. 

The total number of Maine healthcare workers with COVID-19 since testing began has risen to 417, (23% of the total number of cases). 

To date, there have been 40,609 tests conducted in the state.  Note that this number is not the total number of people tested, but the total number of tests conducted.  The number is different because in some instances, such as when a person under interest (PUI) has a condition that looks convincingly like COVID-19, the initial test might come back negative.  This means a second test may be necessary, especially if that person is hospitalized or in a high-risk situation.  It is also typical that a person who is hospitalized with a positive test result will in turn require a negative test result to lessen the use of personal protective equipment (PPE) by staff taking care of them during hospitalization, or before discharge of the patient to home or rehab. 

In Maine 231 people have been hospitalized with COVID-19 since testing began, and 40 are currently hospitalized, with 12 currently intubated and on a breathing machine (a ventilator).  The total number of deaths due to COVID-19 currently stands at 73, with an average of one death per day in the last three weeks.  

The current number of active cases in the state stands at 633, up by 148 cases since I discussed these numbers on April 27.  As above however, the growth in numbers is measured differently now, and the comparison is thus unequal. The state is casting a wider net, there have been new outbreaks, and the numbers are therefore higher.  Because of all of this testing, we had 75 new cases today.  In the last three weeks the average number of new cases per day has been 40. 

Among those positive tests to date, the state has used polymerase chain reaction (PCR) on 37,725 tests.  This is a form of amplification of viral genetic material.   It is only positive if the virus is present in the sample taken from the patient (usually a nasal swab).  The state has also used antibody testing for 2,884 tests. Antibodies are evidence that our body has either and active or a past infection with the virus. 

The state has increased testing capacity due to a partnership with IDEXX in Scarborough.  The IDEXX PCR Test Kit allows Maine’s Department of Health and Human Services Health and Environmental Testing Laboratory (HETL) to process up to 1000 tests per day.  This means that HETL is now taking specimens ordered by a physician for any person who has one or more symptoms consistent with COVID-19, or any person who may be at risk for spreading COVID-19.  This could include asymptomatic close contacts of confirmed cases from an outbreak setting, asymptomatic health care workers who have had contact with or exposure to a confirmed case, or asymptomatic people tested as part of a sentinel COVID-19 disease surveillance program by the Maine CDC. 

The expanded testing means that in the last week Maine has tripled its daily testing capacity.  That is a good thing.  But take a moment to consider what this really means.  We have still tested less than 3% of the population of our state.  Maine had in 2019 1,344,212 citizens.   If we tried to test everyone at a rate of 1000 tests per day, it would still take over three and a half years.   We need a lot more testing.  Alternatively, we need a vaccine, much more effective treatments, or preventives that work.

More to come. Until then, be patient, don’t listen to pseudo-science, and stay out of trouble.