State approval now required before doctors can flag possible COVID-19

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The state is changing its coronavirus protocol, making doctors first consult with a state investigator and getting approval before filling out a “Patient Under Investigation” form and collecting specimens. Always Investigating explains what’s changing.

KHON2 was first to reveal yesterday that Hawaii doctors alerted the state to 8 cases they thought could be coronavirus. But the state did not send the specimens to the CDC for testing and discarded them, saying the patients did not meet the definition requiring testing.

When the COVID-19 outbreak started in Asia in January, Hawaii doctors were instructed to fill out a “Patient Under Investigation” form if a patient showed symptoms and had recently been in an outbreak area. The instructions specified how doctors should “as soon as possible send completed form to the Hawaii Department of Health,” then call to confirm they got the fax. Doctors were also instructed to “collect two (2) nasopharyngeal (NP) specimens as soon as possible.” Always Investigating found out 8 doctors have done just that so far, but the DOH discarded the specimens.

KHON2 asked Lt. Gov. Josh Green, a physician, what he thought about those 8 cases not getting tested by the CDC, and the samples being thrown out and declared not to qualify.

“I think that we should send some of these tests over, and I think we should always trust the clinical physician in the community,” Green said, “unless there is someone who is very, very far outlying, no need at all.”

The Department of Health told KHON2: “A disease investigator contacted all of the physicians and, based on their discussions, the specimens did not meet the criteria for testing.”

We asked if the 8 were among those self-monitoring, and the state responded: “We have confirmed the eight persons under investigation that were submitted to the Department of Health are not part of the 61 patients who are self-monitoring.”

DOH tells us that as of today, the protocol for flagging a patient is changing: First, the doctor will evaluate for flu-like symptoms and travel to outbreak areas but must call Department of Health investigators before any paperwork or samples are taken.

“According to the new COVID-19 Hawaii Department of Health (HDOH) Risk Assessment and Management Guide,” DOH told us regarding the steps updated Wednesday, “after the physician evaluates the patient using the Person Under Investigation definition and in consultation with HDOH investigators, if the patient meets criteria to test, DOH will authorize testing at that time. Only then will the PUI Form be filled out to accompany the specimen(s) to the State Laboratories Division.”

As of the late afternoon Wednesday, the healthcare providers guidance on the DOH website still had the prior procedures – last updated 2/18/20 – and not the new COVID-19 protocol described to us Wednesday.

The state’s provider website still had these instructions as of 2/26/2020: to collect the specimens and fill out the PUI form on the PDF link provided; see below for further instruction on the form.

The provider instructions still linked to the PUI form that has been in place since the 1/22/20 date noted on the PDF.

The state’s provider instructions still linked to the January form as of 2/26/20
The January version of the Patient Under Investigation form (where the link on the provider webpage still leads as of 2/26/20) instructs doctors to fill out the form first, then call DOH to make sure the fax was received.

There’s still no way to test any specimens for COVID-19 except at the CDC on the mainland.

“We do expect to get the tests here, but not until mid-March, too late from my perspective,” Green told KHON2. “So we’re going to have to start sending some FedEx boxes over to the CDC. It’s just what the people want, and I think we’re going to have to reassure people this way.”

Lawmakers agree.

“Time is of the essence and we cannot wait,” said Rep. John Mizuno, chairman of the House Health Committee. “This is going to affect all of our people. This is the safety of our people.”

“The word that comes to mind in unconscionable,” Mizuno said of how the PUIs submitted so far were handled, “because this is evidence that we need to determine if certain people have the COVID 19 illness or not. They should not throw away that documentation or information.”

As of this week, 43 other states and territories have sent hundreds of samples to the CDC for testing – presently the only way to test for COVID-19. Hawaii still has not tested anyone for COVID-19.

KHON2 asked Green: “Hawaii is among the very few who are not sending it off. Why?”

“The reason that I’ve been given is because the CDC gave us very narrow parameters — which I think are far too narrow,” Green said. “I think we should test, and I may be a slightly outlying voice in this regard. I want to have some capacity right now.”

“I’ve asked repeatedly that the CDC allow us to use the Japanese tests,” Green said. “They’re very uptight about that so they don’t do it, and that’s unfortunate. I hope that will happen.”

“People are saying tourism is our top economic driver in the state,” Mizuno said. “What are we doing to ensure tourism continues but at the same time we need to take into consideration the public safety issue, a pandemic that is upon us affecting the whole world.”

KHON2 asked Green: “Has there been pressure from the powers-that-be to delay testing as long as possible in order to protect our tourism reputation?”

“No, I don’t think so,” Green said. “I’m ironically maybe one of the powers-that-be now, and there’s not been a single peep about not testing people because we’re worried about that, that I’ve ever heard. I think actually we don’t want to alarm people or scare people because we haven’t had that profile of (1) in from China and (2) sick and (3) having a pneumonia-like symptom. We haven’t had that.”

“I’ll push the DOH along a little bit more because I’d like to see where we are. They’re testing a lot in Italy, they’re finding a lot of cases. We’re learning as we go,” Green said. “This is the time. You’ll probably see a lot of tests going out from Hawaii in the next 10 days if I had to make a guess.”

Green explained officials are anxiously awaiting CDC distribution of test kits to states including Hawaii.

“We’re pressing CDC very hard to get those darn tests,” he said. “My physician friends want the tests if nothing else then to reassure people that they are not positive. We probably will have a bunch of negative tests which is good news, that’s good news, but then people won’t be sitting around home, in home observation worrying do I have this disease.”

Green said that once Hawaii does start testing locally, final results will still be checked and confirmed on the mainland.

“Before long a lot of people will get tests and it will be at our own urban lab,” Green explained. “That will be looked at as a kind of a temporary result and then it will be finalized over at CDC. But at least then we’ll have that presumptive positive if we need to know, or negative for that matter.”

A follow-up coronavirus briefing at the Capitol was expected this week but will be sometime in March instead.

“Because the COVID-19 illness is such a fluid situation, it is prudent to re-calibrate and focus on Hawaii’s strategy to combat the virus and safeguard Hawaii against the illness,” Mizuno said.

“While no cases of COVID-19 have been identified in Hawaii at this time, we do expect to eventually identify cases here because it is a global threat to our entire nation,” said Department of Health Deputy Director Danette Tomiyasu. “While an imminent threat to Hawaii is low, our state, local and county agencies are intensifying our preparations, and we are asking the community to take steps now should the risk of community spread increase. We really are shifting from a containment posture to mitigation because we will likely see it in our community.”

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