Hawaii doctors and public health officials are debating who should be tested for COVID-19, with some doctors advocating for more widespread testing than what the Hawaii Department of Health calls for.

The issue is how to use a finite supply of testing kits and other supplies to determine who is carrying the virus. The decision, medical and public health experts say, could determine how well Hawaii can contain the virus as well as the ability of medical professionals to respond to a spike in cases.

At the heart of the issue is a limited supply of materials needed to conduct tests, including test tubes, specimen swabs and chemical compounds.

Until production can ramp up and new testing methods be developed, the debate centers on how to use the resources — whether to take an aggressive approach that would require heavy use of limited gear to try to stop the virus from spreading, or a defensive one that will keep resources available for doctors and first responders to react to a wave of patients.

The doctors who want more screening say an expansive testing program can show who has the disease and how it spreads and thus stop it. They are calling for widespread screening of people showing symptoms and even, in some cases, people not showing any. The most recent research on the virus shows that about 80% of cases are mild or asymptomatic.

The health department is calling for a far more conservative approach based on guidance from the U.S. Centers for Disease Control and Prevention. Its policy is to not test some people who have mild symptoms and can recover at home in isolation – to save test kits and other supplies that might be needed should the outbreak worsen.

Lt. Gov. Josh Green, who is also a medical doctor and in the camp calling for more testing, said the health department’s approach is misguided.

“You cannot allow a wave of COVID-19 cases to sweep over the state all at once because we’ll have massive fatalities if we do,” Green said.

After speaking out on the testing issue, Green has been banned from the state’s COVID-19 response task force. Several sources with direct knowledge of the state’s response to COVID-19 say Gov. David Ige has ordered his Cabinet officials and others to not consult Green. Ige says Green is still involved in the administration’s efforts.

The health department maintains its testing criteria are based on the CDC recommendation to not test mildly symptomatic or asymptomatic people, based on the belief that the symptomatic are far more likely to actively transmit the virus. In the meantime, health department officials say they are aggressively investigating anyone who may have come into contact with an infected individual to ensure they are isolating themselves.

Some See A Model In South Korea

“In a small way, we are fortunate in the United States in that we have other countries to look at to see how to respond,” said Dr. James Ireland, an internal medicine physician on Oahu who recently conducted a large batch of screenings. “We really need to look at what’s working and what’s not working in other places.”

What’s working, Ireland said, is South Korea’s model. It included widespread testing and tracking people who might have come into contact with those infected.

Another doctor calling for wider testing is Dr. Kai Matthes, a former professor at Harvard Medical School, now a doctor on Maui. Matthes is one of more than a dozen doctors who recently wrote an open letter to the state health department asking it to support more testing.

In an interview, Matthes said the health department criteria change frequently but generally still call for testing people who are at risk because they are older or have pre-existing conditions. He said he did not understand the state’s position of not screening some people with symptoms.

“We really need to look at what’s working and what’s not working in other places.” — Dr. James Ireland  

Green, Matthes and Ireland all said the ideal system would include testing all patients with symptoms. If patients tested positive, professionals would also test their close contacts, including even younger people not at high risk of getting seriously ill.

“Unless we run out of swabs, we should still swab asymptomatic young people,” Ireland said. “COVID-19 testing supplies could be conserved by first testing patients to see if they have bacterial pneumonia before conducting a COVID-19 test. But I’ve not heard that we’ve run out of swabs.”

Green and Ireland also said it would be helpful to also screen people who are not showing symptoms to determine the extent to which they carry the virus and potentially spread it.

“The paradox is we need to screen asymptomatic people to determine whether we need to screen asymptomatic people,” Ireland said.

Hawaii Testing Criteria

The health department’s criteria for testing has been evolving, and so have CDC guidelines. The latest health department guidance calls for prioritizing testing for health care workers and first responders with COVID-19 symptoms, older people who have symptoms of COVID-19, especially those living in “congregate settings,” and people with other illnesses who would be treated differently if they’re infected with COVID-19.

According to the criteria, those with mild symptoms are expected to stay home in isolation to recover without burdening health care resources or adding to the possibility of transmission at health care facilities. The purpose is to “help protect our most vulnerable and conserve our precious supplies,” the health department website states.

Health department officials say they are monitoring people suspected to have been exposed — as well as their contacts — as they home-quarantine. If they fall ill, they’re encouraged to seek medical care and get tested through their doctors.

“If we identify someone with long prolonged contact with a confirmed case and that person developed symptoms consistent with COVID-19, then we do test that person to confirm,” said Dr. Sarah Park, the state epidemiologist. “Somewhere down the line when we have a lot more cases, we may stop doing that and just assume that the person has COVID-19 and change the terminology from being they’re in ‘quarantine’ to ‘isolation.’”

Test kit supplies are in shortage across the nation and the globe, Park said. And testing supplies are still needed to diagnose other diseases.

“There are states that have stopped testing, such as New York, where the government announced the other day that no one should be tested unless they’re severely ill or hospitalized because they don’t have the capacity,” she said.

Limited Testing, Slow Action

Tests now can be conducted by state and private labs; however it wasn’t until Feb. 29 that the FDA approved private laboratory testing.

The state of Hawaii conducted its first COVID-19 diagnostic tests in Pearl City the last weekend of February, once it finally verified its process with the CDC.

Local private laboratories, Clinical Labs of Hawaii and Diagnostic Laboratory Services, followed shortly after, and have conducted the bulk of the tests reported by DOH to date.

Neither lab has responded to Civil Beat questions about testing rates and capabilities, following a state Senate committee report that the private labs were running low on supplies. 

Still, some might say Hawaii is testing proactively. In some jurisdictions where the outbreak is most severe, testing has become obsolete as it has not changed treatment protocols: there is no vaccine or accepted treatment for people with COVID-19.

With a total of at least 3,666 tests administered in Hawaii to date, the Aloha State has deployed a relatively higher number of tests per million residents than most other states, according to a Washington Post report.

The Pandemic Is Stretching Testing Supplies

The root cause of the issue is a shortage of supplies amidst a global pandemic that has created overwhelming demand for everything from specimen swabs to medical equipment and protective gear. The federal government exacerbated the problem, U.S. Sen. Brian Schatz told Civil Beat.

“The foundational error that the CDC and White House made was they decided to ignore what every other country was doing and build their own tests,” Schatz said. “I can’t even explain why they did it. But that caused an at least month-long delay in deploying those tests. Now there are no extra tests in other countries because everyone is ramped up to the maximum.”

Hawaii’s limited testing has revealed 90 cases of COVID-19 as of Tuesday, but testing has been relatively slow here as it has across the U.S. That leaves Hawaii and other states without a complete picture of the virus’ prevalence.

Countries such as China and South Korea, where case numbers have dropped, have deployed rapid testing to identify and isolate cases as quickly as possible. The U.S., now with 52,000 cases and 675 deaths, has essentially missed the window of opportunity. The first U.S. COVID-19 case was confirmed on Jan. 20 in Washington state. The FDA approved private laboratories to conduct mass testing on Feb. 29.

It’s been a scramble ever since the virus took hold. Efforts were delayed by errors in U.S. testing kit development and slow disbursement.

Random surveillance sampling in the islands suggests there is not yet widespread community transmission: all 263 of the random community surveillance samples conducted by the Hawaii Department of Health have resulted in negatives.

Ireland said that both governments and private parties are stepping in, moving quickly to fill demand and develop new testing devices, which could come onto the market soon.

“Literally, we’re talking about weeks, not months or years,” he said.

In the meantime, doctors like Green say aggressive testing is necessary to get in front of the disease.

“Anything short of locking it down now and knowing where our cases are is negligent,” he said.