For the past three months nursing homes, and assisted living centers, have struggled with restrictive COVID-19 testing guidelines and unavailability of testing kits, so the recent announcement by the Maine Center for Disease Control and Prevention that testing would be expanded was universally welcomed. The question now is, what does it mean to the front-line clinicians in nursing homes, and should we stop advocating for more now that we’ve gotten the ultimate “more,” universal testing?

“Universal testing” has a nice ring to it and is easily understood by the public. Instead of more, the state can now say we are doing the most possible testing, since there is nothing more than universal. To geriatricians like myself, testing of whole sections of our buildings is very important under certain circumstances, and until recently we had to fight to get it. So yes, we like the change in state policy.

As always, however, the devil is in the details. Reading the new Maine CDC policy more carefully reveals that “universal testing” is not testing of everyone in the building; rather, it is the targeted testing of exposure cases limited to the section of a facility where the first case is diagnosed. There is, of course, nothing wrong with that, except that it is not called “universal testing.”

This targeted testing is in fact what we have been advocating for as the first step when we have one positive case in our facilities. The second step medical directors are advocating for is to do actual universal testing of everyone in the facility when we have multiple cases-This provision used to be called universal testing at the Maine CDC, and the cutoff for it was three positive cases.

When faced with COVID in congregate settings, like nursing homes, one test, universal or otherwise, is not enough. We need follow-up testing to cover potential cases still in their 14-day incubation period and haven’t turned positive yet. The Maine CDC’s new policy offers limited follow-up testing provisions, and they are mostly focused on staff and not the vulnerable nursing home residents.

The authors of the new policy are careful to mention that facilities (medical directors) can do more testing if they wish but the state lab will do only the tests that conform to their new recommendations. With swabs in short supply, and commercial labs officially not required to perform COVID testing on asymptomatic cases, this leaves us with very few options for proactive testing in nursing homes. We will again be waiting until outbreaks reach mass proportions until we are free to test freely.

That is why I, and many of my colleagues, continue to advocate for aggressive targeted smart testing that detects possible, not just probable, COVID cases early, and testing of any exposure cases before they develop symptoms. This should includes follow-up testing during the 14-day incubation period, and surveillance testing of staff with high risk of exposure, like COVID units staff, medical providers rounding on patients at multiple sites and staff working at multiple facilities or units.

This is how we ended up with predominantly asymptomatic and manageable cases in two of our facilities recently (Durgin in Kittery, and Clover in Auburn), and some other facilities are following the same path led by their medical directors. The result of smart proactive testing has been many asymptomatic cases and zero casualties so far. It is also allowing our facilities to stay operational and for our staff to feel safe and protected during the COVID surge – policymakers should consider adopting this successful strategy.

Independent medical directors know that this is going to be a marathon and not a sprint, and hope that the state continues supporting our clinical work even if it doesn’t always align with the non-geriatric world.

I recently posted this comment after having my one and only conversation with Dr. Nirav Shah of the Maine CDC: “I can’t expect everyone to know our geriatric world the way we see it, but I hope that the independent geriatric perspective will at least be considered and used when it makes sense and saves lives.”

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