Dr. Allison Kelliher, an Anchorage family-practice physician, struggled to breathe. Her chest and throat ached, her head throbbed and a fever forced her under the covers. A healthy 42-year-old, she really began to worry when her sense of smell disappeared.
“It’s terrifying. I’ve had symptoms that I’ve never experienced before in my life,” said Kelliher, who believes she contracted the coronavirus from a patient. For the past two weeks, she has placed herself, the patient and a colleague on home quarantine. But you won’t find them among the 42 “confirmed” coronavirus cases announced Tuesday by the Alaska Department of Health and Social Services.
Kelliher’s message to Alaskans? Now that the virus is here, more people have it than you might think. That’s because testing is more limited, less foolproof and slower than many Alaskans realize.
State officials on Tuesday announced the first COVID-19 death of an Alaska resident. Yet as the state hunkers down and settles in for a prolonged disruption of everyday life, only a fraction of Alaskans are eligible to receive the limited number of tests available. Even those who test negative might still be carrying the virus due to the limits of current testing methods. What’s more, people living in remote communities across Alaska will find it especially difficult to learn if they have coronavirus because swabs are not yet widely available from health aides. Even some of those living in the most populated areas, like Kelliher, are being told that they must wait a week or more to get results once tested.
One Wasilla resident said she was told it could take up to 14 days to find out if her hacking cough, low fever and fatigue meant she had COVID-19. (Tests sent to state laboratories are processed in a few days but those sent to private contractors can take much longer.)
Hospital officials in Fairbanks are urging residents to shelter in place because they’re sure the virus is already spreading through the community, but delayed tests mean they can’t confirm it. A Mat-Su doctor offering drive-up tests says he is no longer using a California-based private lab because results don’t come back for 11 days — past the recommended quarantine period.
With its vast geography and low population, there are fewer known cases here than in many states but no indication Alaska will escape the continued spread seen elsewhere across the country and the globe. In a state of 731,000 people, fewer than 2,000 have completed testing.
In Kelliher’s case, she said she called the state coronavirus hotline on March 15 seeking a test but was told not to take one because she wasn’t showing symptoms. Then, days later, she took a drive-thru swab but was told the results wouldn’t be available for a week. As of Tuesday, she was still waiting.
‘If we wait for test results we will be waiting too long’
State health department guidelines over who will be tested, and which of those tests will be prioritized for processing, has changed throughout the month. Currently, you must be showing symptoms in order to get tested for COVID-19.
The guidelines are based on national recommendations from the federal Centers for Disease Control and Prevention, according to DHSS epidemiologist Louisa Castrodale.
“It’s a way to conserve our resources and to make sure the people who really need to be tested do not get lost in the crowd,” said Dr. Bernd Jilly, director of the Alaska State Public Health Laboratories.
While the state sets the guidelines, it’s up to health care providers to determine where someone’s sample gets sent, Jilly said.
The state labs don’t know whose sample they’re testing once it arrives at the lab, because they don’t receive that information, Jilly said.
A certain group of symptomatic people, based on the state’s guidelines, are considered “high” priority, meaning that their samples should get sent to the Alaska State Public Health Labs in either Anchorage or Fairbanks for testing, according to the guidelines. This determination is made by providers, Castrodale said.
That group includes people who are hospitalized, live in a long-term care facility or work in health care or as a first responder. (Kelliher, the Anchorage doctor, said she doesn’t know why her test wasn’t flagged for a fast turnaround given she treated patients on a regular basis.) It also includes people who have traveled in the past two weeks to places with community transmission of COVID-19.
Patients who are more vulnerable to the illness — people who are over 60 or have a chronic condition like heart disease — are considered “medium” priority and are supposed to get their sample sent to a commercial laboratory.
“Any other patient as determined by clinical discretion” is listed under “low” priority by the state, and can have their samples sent to a commercial laboratory, according to the state’s guidelines for providers.
In Fairbanks, people who think they might have the virus and meet state criteria can get tested at several places including a drive-thru station and a remote station at Fairbanks Memorial Hospital. As of Tuesday, the hospital had administered more than 400 tests. They have almost 875 remaining test kits available.
Providers there say they are already seeing apparent COVID-19 cases that seem to have spread within the community, Dr. Angelique Ramirez, the hospital’s quality medical director, said Tuesday. Providers are seeing them in urgent care and emergency settings.
But they can’t prove it.
“We do not have the test results back to document it,” Ramirez said. “If we wait for the test results, we will be waiting too long.”
Saying that the likelihood of existing community spread makes it too late for social distancing to stem the virus, local leaders have asked Gov. Mike Dunleavy for a statewide shelter in place order that includes the entire Interior region. Dunleavy has resisted that request.
The medical director at Capstone clinic, a Wasilla drive-thru respiratory disease testing facility, says he is relying as much as possible on the state’s testing lab rather than sending tests to the private Quest lab in California.
It’s taking 11 days to get results back from there, Erickson said.
“It’s just too long,” he said. “You’re out of quarantine by then. Three days after symptoms have resolved or seven days from the onset of symptoms. With that, why wait 10 days for your results to come back?”
Capstone is the only testing site in the borough of more than 104,000 residents besides Mat-Su Regional Medical Center. Between the two of them, there are about 600 test kits in the borough, Erickson says.
Nationwide and in Alaska, supplies are low for a key testing ingredient
Dr. Bernd Jilly, who directs the state’s public health labs, said the two labs are processing tests within one to three days and have been able to handle the flow of the samples they receive.
But there is a limited capacity for testing between the two labs, he said.
“So far, we're lucky,” Jilly said. “We are keeping up with our workflow.”
Jilly said that things would become “a little bit difficult” if testing at the state’s two public health laboratories exceeded 300 patients per lab in a day. Jilly said he was working to avoid reaching that limit.
There are eight people statewide who can run the test from start to finish and others who can help at certain steps, Jilly said.
In order to increase capacity without burning through staff, Jilly said the laboratories can harness the help of partners and volunteers. Staff from the Arctic Investigations Program have volunteered to come over and run tests, a former public health lab employee came out of retirement to help in Anchorage, while researchers from the University of Alaska Fairbanks are helping at the lab there, Jilly said.
Another problem facing public health labs nationwide is the shortage of ingredients needed to perform the test. Reagents, the substances that help extract and reveal a positive or negative COVID-19 test, are in short supply, Jilly said.
In order to conserve some of those reagents, the state is running tests in batches, which can test as many as 92 samples at once, Jilly said.
The federal Centers for Disease Control and Prevention also changed guidelines so that tests only need a single nasal swab, instead of one from both the throat and nose.
“So that’s cut our reagent use by 50%, which is quite significant,” Jilly said.
The state labs are waiting in line in a “queue,” Jilly said, and the CDC will fulfill orders as the reagents become available, even if they have to send incomplete orders.
“They're sort of feathering it out so that everybody will have at least something to test their most vulnerable population on,” Jilly said.
Despite all of that, Jilly said there’s still a risk that the state could run out of reagents. He said he had just received an email from a colleague in Alabama who said that state would most likely run out of some of its reagents next week.
“We are not at that point yet,” Jilly said of Alaska’s situation. “I'm keeping my fingers crossed that the number of patients that we have to sample per day will be low enough that the supply chain can fulfill that.”
In Anchorage, the public laboratory works on STAT testing, meaning a test that needs an answer immediately and cannot wait as long to be batched with a group, Jilly said. As of Tuesday, batch tests were being completed in Fairbanks.
Jilly said he was working to get the Anchorage lab running both STAT and batch tests. The lab is repurposing an instrument they had in order to perform the batch testing and they’ve gone through many of the initial steps needed to get there, Jilly said.
“We want to make darn sure that our answers are right,” Jilly said.
Testing has yet to begin in many villages but health aides are training online
Meantime, many people living in villages that cannot by reached by road are still waiting for testing to begin in their communities. Some 218 people have completed an online training course designed to teach health aides -- the frontline health care workers in village clinics -- to administer the tests, according to the Alaska Native Tribal Health Consortium.
It will be up to each tribal health care organization to determine what role health aides play in virus testing within their region, according to a health consortium spokeswoman.
One of the largest regional health care providers is the Yukon-Kuskokwim Health Corp. The Bethel nonprofit services some 48 villages in the Yukon-Kuskokwim Delta but as of Tuesday only about five regional clinics in larger villages were offering local coronavirus testing.
YKHC hopes to begin collecting samples in most member villages by April 1, said chief of staff Dr. Ellen Hodges.
Village clinics in Western Alaska have not seen a spike in respiratory complaints, she said, but the health corporation is preparing for outbreaks that might be hard to reach due to bad weather and reduced passenger flights. Some 20 villages in Western Alaska have introduced travel restrictions in hopes of keeping the virus out.
“I can’t tell you how badly I want to dodge this bullet,” Hodges said. “We are expanding capabilities to all of our villages but we are not quite there yet. … We are working with state and private companies to try and get as many testing (supplies) as we possibly can.”
Zink: It would take 2.5 million tests to cover all Alaskans
Ginger McKnight Price traveled through Seattle in very early March for the funeral of a childhood friend. The 41-year-old Wasilla woman initially blamed grief for the deep fatigue that hit when she returned home.
By March 12, the cough and headache appeared, then fever. By mid-March, Price met COVID-19 testing criteria and got swabbed. Several days later, her breathing worsened to the point she ended up in the ER at Mat-Su Regional. They tested her again because her original results weren’t back yet.
She learned it could be 10 to 14 days before the first test came back from the California Quest lab. She was told not to talk about getting tested until the results came back.
Price finally got her results Tuesday morning — nine days after her first test and six days after the second. She tested negative for COVID-19, which is a huge relief.
But she’s worried that people who aren’t sure they’re positive and aren’t talking about getting tested might be unintentionally spreading the virus.
“If it’s taking potentially 14 days to get results back, and you’re not supposed to tell people, no wonder nobody’s really taking it serious,” she said. “Because nobody really knows what the hell is going on.”
Someone doesn’t have to be showing symptoms to be a carrier and pass the virus on to others, Kelliher said.
“We very likely have people who are in our community who don’t know that they are spreading the disease,” said Kelliher, who has been seeing patients through online chats this week in order to avoid exposing others to the virus if she has indeed contracted it. “Also we may have people who do have symptoms and tested negative for the disease because of a false negative.”
Asked about the lack of tests for people who are not showing symptoms but could be spreading the disease as super carriers, Alaska’s chief medical officer Dr. Anne Zink said the state is deploying its limited resources as best as possible.
“If I could have 2.5 million tests right now, so I could have enough to test everyone in Alaska a few times, because they are likely going to need more than one test, I would take it,” Zink said. “And we are doing absolutely everything we can to increase that capacity.”
On Tuesday evening, with the announcement of the first Alaskan to die of the virus, Zink pleaded with Alaskans to heed doctors’ recommendations to stay home and stay away from others.
“You may be carrying that disease right now,” she said. “I cannot emphasize enough how important it is to stay apart from each other.”