Dear Governor Sununu,

We commend the Governor’s recent action for implementing a “stay at home” order to help flatten the curve in New Hampshire. We recognize that NH is taking the lead compared to other states. However, given the invisible nature of epidemic spread, our limited medical capacity, and our particularly vulnerable senior populations, this aggressive action is not enough.

NH must continue to lead, not follow. To summarize, NH needs increased testing, treatment, and tracking.

As of April 4, 2020, the NH DHHS has reported 621 COVID19 cases in NH. Most of the cases and testing are concentrated in the Nashua and Seacoast area.

For example, only 1 case is identified in Keene, and a total of 9 in Cheshire County. Less than four or fewer cases are identified in all of Coos County. The low rates or lack of adequate testing gives the public a false sense of security. The testing conducted to date is predominantly limited to hospitalized patients displaying COVID-19 symptoms and associated medical staff and first responders. But far more importantly, even 621 “official cases” reported by NH DHHS means that community transmission is happening across NH and that the number of “true” COVID cases in NH may be 10 times that (or 6,210 people) to 100 times (62,100 people).

Based on a study of Diamond Princess Cruise Line passengers, 54 percent of the passengers that showed no symptoms were found to have COVID-19 based on CT scans of their lungs.[1] The CDC has also stated that people who show no symptoms can still have COVID-19 and can infect others.[2]

We can develop a logical strategy that protects lives and our healthcare workers, allows specific populations to return to work, and ensures NH citizens have the data they need to make responsible personal choices for their safety. We need much more COVID-19 testing now. With expanded testing capability in NH, why are there only 94 tests pending in the state and 1,773 monitored? The current test rate is still under 1 percent, at only 0.5 percent. At this rate, we’ll need to be testing NH for 17,000 weeks (~330 years) to gain understanding of the full extent of the risk.

The lack of testing makes us especially vulnerable since NH is a tourist state, with seasonal visitors coming from places like New York City, to escape high rates of COVID-19 infection. These will likely create new community infection vectors.

We strongly suggest NH adopt the following strategies.

1. NH DHHS must issue clear and expanded guidance to physicians to test both hospitalized and outpatient cases based on physician assessment of COVID-19 symptoms. We understand in current emergency response scenarios physicians may be hospitalizing and treating “as if” the patient has COVID-19 and waiving formal testing in short term triage. But testing must be immediately expanded and ramped up on current and suspected cases using RT-PCR or similar technology that can identify the virus in real time. We note that while RT-PCR has a high rate of false negatives (as much 41 percent [3]), however, it is an important tool in the toolbox for this time in the crisis.

2. It is critical for the citizens of NH to understand the potential risk of not complying with recommended guidelines with clear and transparent presentations of science and evidence-based models of scenarios. The presentations should clearly present what/if scenarios that include total potential case rates, hospitalization rates, death rate projections, PPE needs, other critical healthcare equipment needs, staffing and bed projections, and NH readiness for each of the scenarios. This information should be provided to citizens by a qualified epidemiologist and qualified health care administrators.

3. We must move to expanded antibody testing to understand community/county spread of COVID-19. Many biomedical technologies are receiving emergency FDA approvals (www.fda.gov) for “rapid testing” for antibodies which would identify those exposed to COVID-19, and those who may have short term immunity. Those identified with immunity could return to work more quickly to help restart NH’s economy.

4. Set up increased access to drive-through RT PCR testing (for outpatient and real-time identification) and also antibody testing to see who has immunity. Drive-through testing facilities could be set up at NH National Guard temporary “hospitals.”

5. To control this outbreak, we must employ a consistent, coordinated, and evidence-based approach. We need expanded real-time testing data with digital contact tracing technology utilizing cellular phone applications (see graphic below). Currently, people in NH are “advised” to stay home if presenting COVID-19 symptoms, but their compliance with self-isolation is (highly suspect, frankly) not known or enforced. This increases the likelihood that social distancing requirements will extend past April to control disease outbreak, further impacting the economic effects on NH. South Korea has effectively kept the epidemic under control using digital contact tracing and GPS mapping, adapting its policy decisions in an iterative, expeditious manner. Digital technologies can be adapted and implemented to map and trace the general location of positive cases and used to inform who and where people need to initiate self- quarantine. Patient privacy protections to protect confidentiality would be implemented. We strongly emphasize NH must test, treat, and track COVID-19 cases to produce accurate, evidence-based data for decision-making and public education. We need data, so NH can move forward to save NH lives and restart NH’s economy as rapidly as possible.