Gov. Janet Mills said Thursday that she agrees with the conclusions of many public health experts that widespread coronavirus testing, tracing, reduced cases over a sustained period and adequate protective gear are crucial conditions to be met before society can safely reopen.

But when questioned about reopening Maine at a media briefing, Mills stopped short of committing to definite conditions that would have to be met before she would move forward with relaxing restrictions on business or social activity.

So it’s unclear, for instance, whether she would start reopening the state if coronavirus cases declined for two weeks, or if Maine obtained a specific number of tests, assembled a robust contact-tracing operation or acquired a given amount of protective gear. And how long it would take to move from the present restrictions to a full reopening of the state’s economy is an open question.

The decisions on reopening are fraught with risks.

Wait too long and the economy could collapse further. Open too quickly and the virus could come roaring back.

Without a vaccine or an effective treatment, a second surge of cases could cause many to die and force a painful re-shuttering of society. Many public health experts believe that a vaccine is more than a year away and COVID-19 treatments will be available no sooner than the fall.

The questions are not just how quickly to reopen, but what to reopen.

Mills said she’s primarily focused on doing that in a safe way, guided by public health experts, but without a tried-and-true formula on how and what to reopen first.

“There’s no data point that says, ‘OK now we can open beauty salons, now we can open beaches,'” Mills said.

She pointed out that if Maine opened its beaches when New Hampshire and Massachusetts had not, that would encourage even more crowding on Maine’s beaches from out-of-staters.

Even if Maine does reopen parts of society, it will have to consider, for example, how to manage its summer tourist season, which traditionally kicks off on Memorial Day weekend, with thousands of tourists crowding Old Orchard Beach, Bar Harbor and the Old Port in Portland, or standing in line at places like Red’s Eats in Wiscasset.

“I wish I had a crystal ball,” said Dr. Dora Anne Mills, the governor’s sister, who is an infectious-disease specialist and vice president of community health at MaineHealth. “The only thing that’s predictable about a pandemic is that they are completely unpredictable.”

Several public health research groups – including at Harvard University, the American Enterprise Institute, the Center for American Progress and others – have come up with similar plans for gradual reopenings. The broad outlines are similar, and among experts there is a consensus that two weeks of declining cases is essential. But the details of the groups’ reopening plans, such as how long the process will take, vary greatly.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said this week that he could see a “rolling” reopening of parts of society by the end of May. President Trump has indicated he wants a faster timeline, possibly by May 1.

Maine has not joined a group of northeastern states that is starting to conduct regional planning for reopening, but Mills said this week that she is talking to governors of New Hampshire and Vermont about working jointly on easing restrictions imposed in response to coronavirus.

Whether Maine, New Hampshire and Vermont would create a reopening task force similar to the northeastern states’ remains to be seen, but Mills said that discussions have already begun. Connecticut, Delaware, Massachusetts, New York, New Jersey, Pennsylvania and Rhode Island are cooperating as a group.

“We are talking about when and how to lift restrictions,” Mills said earlier this week, referencing talks she’s had with New Hampshire Gov. Chris Sununu and Vermont Gov. Phil Scott. A Mills spokeswoman later clarified that the talks are in the informal stages.

In the absence of federal planning, states have formed regional collaborations to work on reopening, including Washington, Oregon and California as one group, in addition to the northeastern states. The Trump administration on Thursday announced a reopening task force that includes Maine Sens. Susan Collins, a Republican, and independent Angus King.

Trump has openly feuded with governors on how and when to reopen the economy.

King, an independent, said in a statement and subsequent interview that any decisions on lifting restrictions must be based on medical science, case numbers and access to a robust testing program capable of testing millions of people daily.

“Until we have that in place, a premature opening of the economy is a crap shoot. It just is,” King said.

Collins, a Republican, said having a plan to reopen the economy is imperative once medical experts determine it’s safe to do so.

“We must also ramp up testing to better track COVID-19, along with seeking treatments and vaccine development, and ultimately give Americans the confidence to leave their homes,” Collins said.

Gov. Mills noted that Maine has a lot more in common with New Hampshire and Vermont than higher-density states like New York and Rhode Island.

“We have a more shared environment and shared economy,” Mills said. “We share a lot more things culturally and economically with those two states.”

In Ohio, Gov. Mike DeWine, a Republican, imposed shutdowns in March before most other states, but on Thursday announced a “gradual” reopening of some businesses by May 1. No details were immediately provided on which businesses, according to media reports. COVID-19 cases have plateaued in Ohio over the past few weeks but not declined, and the state has more than 8,000 cases.

Case declines

Public health experts have concluded that the first signpost to reopening society is a prolonged decline in the incidence of COVID-19, including at least a two-week reduction in the number of cases, deaths and hospitalizations.

Maine had 796 cases through Thursday, 130 hospitalizations and 27 deaths.

Despite a spike on Monday of 65 new cases caused by an outbreak at an Augusta assisted living center, the overall trend over the past two weeks or so in Maine has been a slowdown in the rate of increase. While that is encouraging, Dr. Dora Anne Mills said it’s not enough to begin considering opening society.

“You want to see a reduction in deaths, hospitalizations and cases for two incubation periods,” she said. “What we are seeing now is a decrease in the rate of growth, but you want to see an actual decrease.”

The incubation period of COVID-19 – the time when people are contagious – is not entirely known, Mills said, and could range from four to 14 days. So two incubation periods could be as short as two weeks or as long as 28 days. Mills said what state officials will have to decide is whether to wait until near-ideal conditions before relaxing some restrictions, or start doing some limited opening before then.

“That is the billion dollar question. We know there are health impacts for shutting the economy down, so there’s a balancing act,” she said.

Testing and tracing

When cases plummet, states should be ready to ramp up testing on a massive scale and do contact tracing, experts say.

With contact tracing, public health workers can locate people who came into contact with an infected person and quarantine them for 14 days. If this can be done on a large enough scale that it catches most of the cases, it can prevent much of the spread of the virus and lead to reopening of society.

Maine and much of the country have had difficulties increasing testing, but testing volume has improved compared to March. After a slow start, the United States has now conducted nearly 3 million tests, or about 9,000 tests per 1 million population.

Maine’s current testing capacity is about 3,500 tests, and while there’s no consensus on how much testing needs to expand, middle-of-the-road projections suggest a substantial increase in testing capacity is needed. A Harvard University study says the United States needs at least 5 million tests per day, while the U.S. is currently conducting 1 million tests per week.

In addition to increased testing, states need to have the capacity to trace all or most contacts, experts say.

It’s similar to the strategy employed by South Korea, which ramped up testing and tracing in the very early stages of the pandemic, and has avoided complete lockdowns, hospitals being overrun with people and extremely high fatalities.

South Korea and the United States had their first recorded case of COVID-19 on the same day, Jan. 21. Widespread testing and tracing early on mattered, with South Korea’s per capita testing capacity in late February nearly 30 times that of the United States. As a result of their aggressive early response, South Korea’s COVID-19 death rate is four deaths per 1 million population, compared to 101 deaths per 1 million population in the U.S.

If Maine’s cases decline to near zero, being able to test people with mild symptoms is key, said Joshua Michaud, associate director of global health for the Kaiser Family Foundation, a Washington-based health policy think tank.

“The earlier you can identify cases, the better that is for disease interruption,” Michaud said.

Currently, Maine prioritizes health care workers, hospitalized patients and those living in congregate care settings for testing, but Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, has talked about expanding the categories of people tested when Maine’s testing capacity increases.

Mills, at MaineHealth, said that as testing capacity increases, perhaps a scaled approach makes sense to ensure supply meets demand. First open up testing to high-risk populations with symptoms, and if there’s enough supply, then open up to everyone who has symptoms.

A Massachusetts strategy

In Massachusetts, Gov. Charlie Baker is hiring about 1,000 workers through a contract that would assist state public health workers in contact tracing. Since Maine’s population of 1.3 million is about five times less than Massachusetts, to run a similarly-scaled program in Maine would require about 200 workers.

Michaud said that states should be looking to Massachusetts as a model for contact tracing.

“The Massachusetts approach is a solution many should be considering,” he said. “It’s a really cutting edge idea to making the transition from social distancing to opening up.”

Shah said at a news briefing last week that the idea in Massachusetts was “intriguing” and that he had consulted with Massachusetts officials about it, but no decisions have been made in Maine.

Other solutions involve using technology such as phone apps to track people who have been exposed.

“You could have a process where everyone who gets a text who had been exposed to COVID-19 is required to self-quarantine,” Michaud said.

App tracing also has been discussed in research and policy reports, but no state has yet embraced the idea, at least partly because of privacy concerns. It’s unknown how long it would take for a phone app to be adopted broadly enough to be an effective tool.

Another idea that is being floated by national experts is to conduct widescale antibody testing to see who had the disease but was asymptomatic or had only mild symptoms. People who have already had COVID-19 would presumably be immune – although there are concerns about how long the immunity lasts. Still, if an antibody test were developed, those who had COVID-19 immunity would be permitted to go back to work and mingle in crowds.

Shah said if antibody tests become more widely available than many “can re-enter society, enter the workforce (and) not worry about being infected or infecting others.”

Dr. Dora Anne Mills said other important factors before opening up society are having enough protective gear for health care workers and having a large-enough health care workforce to meet the demands.

An effective treatment also could be a game-changer if it allows people to recover more quickly, and reduce hospital stays and mortality. One potential treatment is an anti-viral drug by Gilead Sciences Inc. that is being tested at Maine Medical Center as part of a worldwide human clinical trial. If testing shows it’s effective, the drug could be available for hospitalized patients as soon as this summer.

The bottom line, however, is that without a vaccine or treatment, some level of physical distancing will need to be kept in place to avoid a resurgence of the disease.

“I think the last things to come back will be where there’s large crowds of people, such as concerts and large sporting events,” Michaud said.

Shah said there must be a “prolonged” period without cases, but he didn’t define how long that might be.

He said the pandemic may shape how we live for many years. Just knowing that it could happen again could act as a check on how people view infectious diseases.

“There will be ways in which we go about living our lives that will never be the same as it was before,” Shah said. He said seeing a worldwide pandemic begin with a few cases in China will always give people pause. “In that respect, we will never return to normal. We will always have that awareness how interconnected our world really is.”

Correction: This story was updated at 6:33 a.m. on April 17, 2020 to correct the number of deaths in Maine from COVID-19.

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