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Missouri Gov. Mike Parson on Thursday began to outline the framework for reopening the state, once the COVID-19 pandemic subsides, but success of that plan depends on significant progress being made in the coming weeks in several key areas.
Parson referred to those areas as the four pillars that the gradual, phased Show Me Strong Recovery Plan rests upon:
Rapid expansion of the capacity to test people for infection of COVID-19, including those still contagious, as well as those who've developed immunity.
Expansion of the reserves of personal protective equipment, such as gloves, masks and gowns. Parson wants to "open public and private supply chains," and continue to involve Missouri businesses in the effort.
Continued monitoring of hospital and health care systems' capacity, and expansion of it as necessary, including alternate care facilities.
Improvement of the ability to predict potential COVID-19 outbreaks, "using Missouri's public health data," including localized data of hospitalization of known and presumed cases; population density and mobility; lab test results; and health care facility capacity for treatment, including the availability of hospital beds and ventilators.
All of those metrics and capabilities have been issues across the United States as the pandemic has spread.
Missouri's leaders have begun to quantify the distance between the current state of affairs and where the state would like to be.
The goal is to be able to begin gradually reopening the state's economy May 4, the day after the governor's statewide stay-at-home order is currently set to expire.
"Between now and May 4, we will continue to monitor the situation and work with Missouri hospitals, health care providers, public health experts, business leaders and state departments to develop a plan, with the safety of Missourians at its core. Our approach will be deliberate and data-driven," Parson said Thursday.
TESTING
Missouri can currently test up to approximately 7,000 people a day for COVID-19, and the goal is to be able to do 10,000 tests a day, Dr. Randall Williams, director of the Missouri Department of Health and Senior Services, said Friday.
Williams added about 15 labs in the state offer a total daily capacity for up to 7,000 tests, which is an increase of about 2,000 from six days before, "as more labs come in and more labs increase their capacity."
He said once cartridges are available for a certain way of analyzing tests, that will increase the state's total capacity by another 1,000-1,500 tests, for a total capacity of approximately 8,500 tests per day.
Williams also could think of three or four labs "who tell us they're doing a certain amount of tests - they will say, 'If we had more swabs, we could increase that more.' Truman Medical (Centers) comes to mind, and Barnes-Jewish (Hospital) has told me that."
He said a shortage of swabs for testing was "a critical logjam for the whole process" about three weeks ago, and while that problem hasn't completely gone away, "with every day, that gets better."
As of Friday, 100 hospitals in the state were offering testing, including Jefferson City's Capital Region Medical Center and SSM Health St. Mary's Hospital, according to DHSS.
Among 125 hospitals reporting data to DHSS and the Missouri Hospital Association, as of Friday, 21 hospitals were experiencing a shortage of testing swabs, with seven hospitals experiencing a critical shortage - meaning having less than two days' supply available, "despite contingency strategies."
Parson said Friday there were about 90 mobile test sites in Missouri, and the goal is to get to having 100 mobile test sites.
Furthermore, "we're going to open the criteria up some next week," he said.
Williams elaborated that testing would begin to move beyond people with symptoms - cough, fever, respiratory issues - to looking at specific populations, "looking at getting people back to work, seeing if they have immunity. We haven't even started antibody testing, so that's another component of it."
As of Friday, whether someone was to be tested for COVID-19 was up to clinicians' best judgment, if a patient showed signs and symptoms consistent with the disease, according to DHSS.
Priorities for testing included symptomatic patients who are hospitalized; residents of senior living facilities; individuals with chronic medical conditions or an immunocompromised status that puts them at higher risk for more serious complications; and anyone who had been in close contact with a suspected COVID-19 patient within 14 days of symptom onset.
Williams said antibody tests will not be administered to everyone, once they are available.
The presence of antibodies to COVID-19 in someone's blood indicates the person has been exposed, their immune system has reacted and they are likely protected against the disease, according to the University of Minnesota's Center for Infectious Disease Research and Policy.
"The FDA test we're looking at is just coming on board today, so it'll take us a while to do that," Williams said Friday.
He added, "we're going to use that very strategically," to identify people who think they were exposed to COVID-19 but don't know for sure and to give first responders the knowledge of whether they have immunity.
Antibody testing will also be used in specific geographic areas or among certain populations of people, such as nursing home residents, to determine the prevalence of COVID-19, Williams said.
He said 175 antibody tests will be able to be conducted per hour.
PERSONAL PROTECTIVE EQUIPMENT
The opening of public and private supply chains to get more PPE flowing to the state will involve getting Missouri manufacturers to retool to produce PPE.
Rob Dixon, director of the Missouri Department of Economic Development, said every day information is received from hospitals and other state departments about the availability of PPE.
"We are looking at that and sharing that with our private sector partners, as well as with the end-users of PPE," Dixon said.
DED spokeswoman Liz Coleman said via email that the department also provides "a continually updated list of companies (suppliers and manufacturers) that currently have PPE to Missouri hospitals and the State Emergency Management Agency (SEMA), who provides PPE to first responders, veterans' homes, mental health facilities and some hospitals. So far, the department has provided information about 270 different companies that offer PPE," though not all are Missouri-based companies.
DED has reached out to approximately 90 Missouri companies about retooling their manufacturing lines to produce PPE, Coleman added.
The department also provides resources that offer "information and specifications necessary" for the products to meet U.S. Food and Drug Administration and American Society for Testing and Material guidelines.
Dixon said companies that have altered production include brewers shifting from producing alcoholic beverages to hand sanitizer, as well as clothing companies switching to making gowns and other such products.
"It is not easy to do that. It takes a degree of technical expertise for companies to change their production model on a dime. There are FDA requirements, certainly that they have to be aware of. It is not something that happens overnight," but Missouri businesses are stepping up, Dixon said.
Parson wants the state to be more independent - to have its own stockpile of PPE and be less reliant on obtaining it from entities outside the state or country.
Just last week, the state had to recall tens of thousands of KN-95 masks manufactured in China that ultimately did not meet standards for protecting first responders. The state has so far recovered some but not all of tens of millions of dollars spent on those orders alone, and some legal action to recoup approximately $8.25 million is possible.
DHSS has already been working in conjunction with the Missouri Hospital Association to provide reports each day of how much capacity Missouri's health care systems have, including on supplies.
The report is released each afternoon with the latest update on the number of COVID-19 cases and deaths in the state.
Among 125 reporting hospitals - out of a total of 154 in Missouri - a significant number were experiencing a shortage or critical shortage of certain PPE as of Friday.
A shortage is defined as: "The facility is experiencing a current or anticipated shortage of supply despite contingency strategies being utilized."
A critical shortage is defined as a facility having "less than two days of supply, despite contingency strategies."
"This is not a situation that's going to be solved in one day. It's not going to something that we get to some moment where all of the sudden we've produced all of the PPE that we need. This is an ongoing need and will be an ongoing need for the foreseeable future," Dixon said.
HOSPITAL CAPACITY
DHSS and the Missouri Hospital Association's daily hospital capacity reports also include metrics on the availability of different hospital beds and ventilators.
For example, as of Friday, 133 of 154 hospitals reported to MHA that there were a total of 757 intensive care unit beds available, out of 2,129.
Also, as of Friday, 125 of 154 hospitals reported a total of 460 adult-only ventilators being available, out of a total of 686. There were 950 adult/pediatric ventilators available out of 1,507, and 42 pediatric ventilators available out of 83.
If hospitals reach and exceed their capacities to care for patients, the state can open up alternate care sites, such as the converted Quality Inn hotel in Florissant that opened last week.
That site was prepared to accept up to 100 mild or non-symptomatic COVID-19 patients, as well as people identified as requiring treatment but not hospitalization, according to a news release from Parson's office.
"Hospitals may also transfer recovering patients no longer in need of acute care but still requiring medical assistance. Criteria could be adjusted in consultation with health care professionals as the situation continues to develop," the news release added.
The alternate care site is staffed by members of the Missouri National Guard's 139th Medical Group and the Missouri Disaster Medical Assistance Team, according to a news release from the Missouri National Guard.
The site was selected for its location within an area of potential need, its sufficient space for patients and having utilities available to quickly start construction.
Sandra Karsten, director of the Missouri Department of Public Safety, said Friday that 375 Missouri National Guard soldiers and airmen are assisting state and federal authorities.
Beyond staffing the alternate care site in Florissant, National Guard members are also continuing to assess other potential sites as well as provide "rush transportation" of PPE and assisting the St. Louis County coroner, if necessary, at a temporary facility established by the county.
LOCAL HEALTH DATA
Williams said local health departments have had a better ability than the state to hear about the recovery of COVID-19 patients as well as report patient demographics such as race.
The Cole County Health Department, for example, not only reports the total number of cases and deaths in the county, but it distinguishes between cases that are active and those who have recovered.
The state currently is publicly providing data on cases by county or jurisdiction, age range, race or ethnicity, and biological sex. Data on deaths is by county, age range, and race or ethnicity.
Data, including on race, has been inconsistently provided to the state.
The state would like to get data from all 114 health departments and aggregate it, Williams said.
The kind of localized data the state is particularly looking for includes data on known and presumed cases; population density and mobility; lab test results; and health care facility capacity for treatment, including the availability of hospital beds and ventilators, as Parson described Thursday.
Williams said having all the information will help the state direct resources - PPE, tests and health care staff - to areas that may need them, if new clusters of infection develop.