Vermont's state of emergency orders have been extended through mid-May. But even as the state prepares for a surge in cases in late April or early May, how do Vermonters without primary care physicians and health insurance get tested or receive care? We talk with Department of Health officials, and a nurse practitioner running an urgent care clinic, for the latest on the virus and about getting healthcare in the COVID-19 era.
Our guests are:
- Tracy Dolan, deputy commissioner for the Vermont Department of Health
- Beth Schiller, a nurse practitioner and owner of Champlain Medical Urgent Care
Broadcast live on Monday, April 13, 2020 at noon; rebroadcast at 7 p.m.
The following has been edited and paraphrased for brevity and clarity.
Q & A With Tracy Dolan and Beth Schiller
Can you update us on the numbers?
Tracy Dolan: We currently have 748 cases in Vermont, 28 deaths and 10,365 people have been tested so far.
For the latest data regarding COVID-19 in Vermont and guidance about how to interpret it, head here.
Is it still true that we are seeing the time it takes for the number of new cases appearing to double getting longer and at the same time that we are seeing fewer positive tests?
Tracy Dolan: Both are happening. Those curves are flattening in both cases. We had been up around 10% in terms of positive cases compared with total tests. Now we are well below 10%. In the last few days, the number of new cases appearing per day appears to have flattened. We like to see several days of that sort of trend to make sure it is a trend, but we are hopeful.
Are we still doing better than the “best-case” scenario put forward in the state’s initial modeling?
Tracy Dolan: We are. It looks like, according to the initial modeling that if we were to continue in this way, that our hospitals would be able to manage peak. Again, we’re not exactly sure if we are in peak now or if that’s still coming in the next couple of weeks.
Ideally, our deaths would stay under what was originally predicted.
Let’s talk about false negatives. For people who have symptoms of COVID-19 but who test negative for COVID-19, are you confident that they don’t have COVID-19?
At its peak, Vermont saw a positive test rate of 12%. That rate has since dropped to 7%, says Deputy Health Commissioner Tracy Dolan
Tracy Dolan: What we are confident of is that the test is fairly accurate (I would have to check the percentages on that) but what we don’t know, is whether they might be very early in their illness and have a low viral load.
That would be true for any infectious illness, but particularly a viral illness.
So if your viral load is very low, you could just be in the very early stages of your illness such that your test comes back with the result “undetected” which is what we interpret as negative. Or, you may be at the tail end of the illness, in which case your viral load is very low. If that is what you mean by false negative, that is very different.
Only 7% of the people we are testing right now are coming back with a positive test. You will see that that rate was much higher at the beginning because we were primarily testing people who were very sick, with moderate to severe symptoms.
Now that we have expanded our testing, we are testing people with very moderate symptoms or who may have something else entirely.
How, at the state, do you communicate the dual message that we are doing better than expected, but that people still need to be keeping themselves at home?
Tracy Dolan: This is a really tenuous time right now. I would say the situation is fragile. The reason we are seeing those numbers stay relatively low is because the state has become fairly aggressive in its stance on asking people to stay home, in asking people to wear masks and in encouraging social distancing, along with all of the major things we did around schools early on.
This is really the time to double down. A few weeks more of doing this as much as we can will give us better results down the road. As much as it feels like it’s not really that bad right now, this could really bump up if we pull our foot off the gas.
For more about Vermont’s COVID-19 modeling and what it means for the weeks ahead, head here.
I am really impressed that Vermont keeps getting called out nationally, as a state that’s doing well. That is partly because of our population density but in part because people are taking it really seriously.
Prevention is sometimes a lag game. We will see the results in two to three weeks.
Questions About Safety in Public Spaces
Do you see a direct relationship between people staying home, wearing masks and the slow growth rate?
Beth Schiller: What I can see is that people are doing what’s being asked of them. People are dedicated to staying home and continuing to self-isolate and I think it’s working.
I certainly think Vermont is unique in that population density is low, but I also think Vermonters are dedicated and will do what needs to be done so they can move on.
Can you walk us through the reasoning for why it’s important to cover your face and nose in public?
Beth Schiller: The idea of wearing a facial covering is to make sure you’re not breathing or coughing into the air where someone else can get that particle in them.
By covering our mouths with a mask and nose, we are just trying to limit that potential spread.
In some recent national and global reports we’ve seen, there’s been some new guidance suggesting that people who are exercising may need to give each other more than six feet of distance to prevent the spread of COVID-19.
How much space should people give each other while exercising?
Tracy Dolan: We also know that when you are exercising you are breathing more vigorously. In a regular breathing pattern, most of the tests show that six feet is generally enough space. Respiratory droplets don’t travel much beyond that.
But when you are exercising, or singing or doing something that requires or causes a more vigorous exhale, you may have it traveling farther. We really encourage people to give even more distance [while doing these things].
We don’t suggest a particular distance or number of feet, but we do say to stay well away from others when you are out running, biking or walking very quickly. We encourage people to exercise but we do not encourage people to exercise in groups.
If there are trails you frequent that you notice are crowded when you arrive at the trailhead, try going to another trail. Vermont is full of trails — you could likely explore a new one every day for a full year.
We aren’t encouraging people to travel too far because we don’t want them stopping for gas on the way, but if you need to go a little farther and you’re not getting in and out of your car on the way, that’s another way to handle that.
Should people be wearing facial coverings while they are exercising?
Tracy Dolan: If they are around other people, they should. If they are on their own, they don’t need to. If you are going to be down on the bike path, and there are a lot of people there? A facial covering is a great idea.
The majority of people are wearing masks when they go out to the grocery store now, but it’s not all of them. We are going beyond recommending. We are strongly recommending that you wear a mask when you go to the store or out in public. This is a very fragile time and we want to keep the numbers where they are.
What advice would you offer to people who are still having trouble finding or making masks to wear? Are there acceptable alternatives?
Tracy Dolan: I would suggest even a handkerchief, a scarf — anything you’ve got. It may not be the best, but it will provide some protection.
I have seen a lot of people going into markets with a handkerchief or a scarf covering their mouth and nose, and that also works.
Do you need to wash your groceries when you bring them home and if so, what should we wash them with?
Tracy Dolan: We would recommend that for any fresh produce, you wash your produce in the same way you did before, whether that is with soap and water or not.
The Vermont Department of Health reports that phone registration for 802Quits was up 41% in March 2020 over March 2019, and that online registration was up 167%.
In terms of containers, we don’t have a particular recommendation about wiping down containers. Some people are taking wipes and wiping them down, but it’s not an official recommendation from the Health Department. We would leave that up to you.
Some people are leaving their perishables in paper bags for a couple of days in the hopes that if there is virus on that surface, it will die.
What about smoking and contracting the virus? Does exhaling smoke carry the potential to transmit the disease?
Tracy Dolan: I haven’t seen the research on smoking and transmission, but we do know that smoking increases the risk for contracting COVID-19. Dr. Levine at the Health Department has been talking about this being an opportune time while maybe a stressful time, for people who are at home to consider quitting smoking.
We’ve seen a real uptick in our online quitting program. We know it’s a complicating factor when it comes to risk. We encourage anyone who is considering smoking to reach out through our free resources.
What should Vermonters do if they see visitors from out-of-state violating the governor’s order to self-quarantine for 14 days upon arrival in Vermont?
Tracy Dolan: You continue to stay home, wash your hands and take care of yourself. We have not advised that Vermonters regulate each other. If you’re friendly with them, you may want to reach out and make a phone call.
Questions About Accessibility and Affordability of Treatment and Testing
For those concerned about high insurance deductibles, is it true that the test for COVID-19 is free and that getting it is also free for all Vermonters?
Tracy Dolan: That is correct on both fronts.
What trends are you seeing among the people coming into Champlain Valley Urgent Care right now, especially among those seeking treatment for things unrelated to COVID-19? Are you seeing the same volume of patients as usual?
Beth Schiller: No, absolutely not. Our volume has dropped by 75% and that includes telemedicine visits for folks that are afraid to come in. We are seeing a few people here and there, but business is down considerably.
We’re here, we’re waiting, but there’s not a lot of business right now.
Why do you think that is?
Beth Schiller: I think people might be reassessing what’s urgent or necessary. Folks will come in when they’ve got things that bother them so much they need to come in, but I think people are staying home.
Are you concerned that people aren’t seeking the care that they need unnecessarily?
Beth Schiller: The emergency department is very quiet. It is difficult to explain to people that we can safely take care of you if you come in. We have masks for both you and ourselves if you come in. Do not hesitate to come in if there is a need.
Tracy Dolan: Of course, the public health approach is always to make sure you get the preventive care you need. It’s a tricky time right now. People are being very cautious and weighing whether their emergency or preventive needs are equivalent or greater than, less than their risk for contracting COVID-19.
I hope that when we are past this period, we see an uptick in the use of emergency departments and in primary care because that’s where we see people getting most of their preventive care.
A lot of our kids aren’t getting their regular dental appointments right now. People are likely skipping some of their regular screenings right now. We’d like people to catch up after this lifts, and of course the downside is we may be missing things.
In some cases, we’ve heard from Vermonters who said their surgeries were canceled because they were deemed non-emergent, or in some cases even that their cancer treatment was delayed. There, it’s medical professionals who are saying: “We can’t offer you this treatment at this time.”
Tracy Dolan: I think that’s right. A lot of these decisions are coming from the medical community and some of it may also be coming from the public, depending on their issue. It’s a tricky one. That might be part of our easing back into a more normal state as the weeks go by.
Hopefully those procedures can be prioritized.
Should parents take their children to get tested for COVID-19 if they are concerned that they have symptoms, even mild ones? At least a week ago, the guidance from the state was that they shouldn’t.
Tracy Dolan: We have opened that up somewhat. Concerned parents should reach out to their pediatrician regarding next steps. We are in touch weekly with most physicians across the state, including pediatricians, about evolving guidance on this.
Mostly, the trigger for testing tends to be a fever plus at least one other symptom. So if a child has a fever plus one other symptom, pediatricians are welcome to refer them for testing. We have really opened up who we are testing.
At Champlain Valley Urgent Care, are you able to test patients who come in with COVID-19 symptoms?
Beth Schiller: We currently are utilizing another independent physician’s group to do our testing for us. We will have either a telemedicine visit or, depending on the situation, have them come in, but most likely a telemedicine visit.
Then we refer to Evergreen Family Health, another practice that is working with us. They are doing testing. We worked with Engineers Construction, who provided us with special respirators so that you don’t have to be donning your N-95 or face shields all of the time, and reusing or disposing of them.
The folks at Evergreen have this special respirator so that people can go out and do the testing in the parking lot and it’s working really well.
If the first step for people who suspect they have COVID-19 is to reach out to their primary care doctor, how should people who don’t have a primary care physician or who can’t access one seek testing and treatment for the new coronavirus?
Beth Schiller: This is a place where Urgent Care can be really helpful. We see a lot of people who are between the ages of 20 and 55 who maybe recently moved to the area or don’t have a primary care doctor and are happy to work with them in any capacity we can.
Tracy Dolan: Luckily in Vermont, most people do have access to primary care. If they don’t, they are reaching out through other venues, including Urgent Cares. I need to do a little more research regarding what we are advising there but can get back to you on that next week.
A lot of Vermonters have some health insurance, but many will pay a lot if they go into an urgent care clinic to seek treatment. With the rate of unemployment approaching 20% statewide, do you think people are putting off urgent care because they can’t afford it?
Beth Schiller: I think that’s within the realm of possibility. At our particular facility, we bill as primary care, not as urgent care. We have the benefit of having that lower copay that some of the other urgent cares do not have.
I can certainly understand that when people are scared and concerned about how they are going to pay for food and for their insurance premium, that they may put off coming in for urgent care.
Tracy Dolan: I think holding off is a challenge and there are costs and benefits to what people are doing right now. I’m hoping we think hard about what this means, even after this, about the inequities in our medical system. I hope we focus on how we make healthcare accessible to all. This pandemic is highlighting some of the inequities we have in our current system.
How can you tell the difference between seasonal allergies and COVID-19? Should you get tested if you have COVID-19 symptoms but know you also have seasonal allergies?
Beth Schiller: That’s a good phone call for your primary care doctor or us. We can help suss out whether it’s likely that you’re experiencing seasonal allergies and help you get treatment for that, or if it might be COVID. Allergy season is definitely here. Sometimes it can be difficult to figure out what’s what but a trained clinician can do so.
Is that sort of consultation something that would incur a charge for the patient?
Beth Schiller: The way I’ve been told this works in regards to billing is that if someone is suspicious they might have COVID, that visit will be paid for by insurance. If insurance is involved, the symptoms are there and a possible diagnosis of COVID-19 is something that was the purpose of the visit, that would get paid for.
Questions About the Availability of PPE
Do we have enough PPE and how are we making decisions about for how long and how many patients health professionals are expected to use things like N-95 masks?
Tracy Dolan: The PPE we do have is mostly coming from the national stockpile. The national stockpile is not entirely stable. We find out from FEMA sometimes a day in advance what trucks are coming and what will be on them. What we receive we hand out.
We are fairly confident that hospitals, primary care facilities and E.M.S. are getting fairly regular supplies and that we are able to meet most of their needs. There are others that have needs, that we have not been able to meet in full. We are trying to at least meet their needs partially.
Realistically, we weren’t sure what the burn rate would be — how quickly you go through this material — so we were urging caution and asking hospitals to also look at their own supplies and to determine how much PPE to use. Now that we are getting to the middle of it, I think hospitals have a pretty good sense of how much PPE they need per day.
There was some conservative use of PPE, including N-95s as we figured out this balance.
I think we are in a pretty good place, but I wouldn’t say we are experiencing an abundance. I wouldn’t say the national stockpile is abundant.
Most hospitals are using some kind of conservation strategy while making sure that with their highest risk patients and the highest-risk interactions, they have some kind of PPE and appropriate PPE use every time.
Need is a somewhat subjective definition right now when we are dealing with some limited resources.
Vermont is doing pretty well. Some have called for us to hand off supplies to other states, I’m not sure we’re that abundant.
You mentioned that while the need for PPE is being met at hospitals, it is not being met in full elsewhere. What are those other places?
Tracy Dolan: Those are places where they are not providing as direct care. They may not have what they like, or they may not have the extended supply.
That might be a mental or behavioral health agency, food and lodging inspectors.
Should people be donating PPE at this point? Didn’t Gov. Phil Scott say Friday that he is handing over some of the N-95 masks Burton offered to New Hampshire?
Tracy Dolan: They did reach an agreement, but we are also thinking hard about what we need.
For the most part, we are not looking for individual donations of PPE, but if there is a way for you to donate within your community, that would be much appreciated.
Questions About Contact Tracing
Are there any known cases of grocery store clerks who have tested positive for COVID-19? If so, where?
Tracy Dolan: We don’t report out by occupation. I can’t be sure that any of our positive cases weren’t grocery store workers.
Who provides guidance to employers of essential workers about when they need to shut down, if they need to tell other staffers in terms of when they need to quarantine? Is the state telling employers: this is what you need to report out, or is it up to employers?
Tracy Dolan: It’s employer by employer. I haven’t had a grocery store reach out to us and say, ‘A staff member was positive. What do we do?’ but we have had other facilities do so.
"We are at a point now where it is likely that you have walked into places where someone has COVID-19. The masks, hand washing, the social distancing are really our key defenses." — Deputy Health Commissioner Tracy Dolan
They reach out, they let us know, we let them know we are doing contact tracing and that we’ll reach out to the closest contacts. Then we give them other advice about disinfecting and use of masks on a day-to-day basis in that environment. We handle it on a case-to-case basis
What kind of responsibility to communicate does the employer have? Does the Health Department reach out to the individual who has tested positive, or are you relying on employers to tell you who they came in contact with?
Tracy Dolan: We do not share the name of a COVID-positive person with their employer in most cases — that is private information. We reach out through the patient themselves and we work contact tracing through the patient.
Would the Health Department reach out to you if it was discovered you were working alongside someone who tested positive for COVID-19? What if you were at the store at the same time?
Tracy Dolan: If you happened to be in the store at the same time as someone who tested positive for COVID-19, we wouldn’t be contacting you. It is close contact and our epidemiological team determines what constitutes close contact.
This is one of those times where we say: we have community-wide transmission. That’s why you wear your face masks, you wash your hands frequently because whether or not we tell you that the day you walked into a grocery store, you were there with someone who has COVID-19, we are at a point where it is now likely that you have walked into places where someone has COVID-19. The masks, the hand washing, the social distancing are really your key defenses.
If you were working alongside somebody, we would likely have our contact tracing team reach out to you and go from there.
