The Maine Center for Disease Control and Prevention clarified its testing protocols for group homes Tuesday after an assisted living facility in Portland where an outbreak occurred waited days for the agency to agree to conduct widespread testing.

Death tolls at nursing homes have mounted across the United States amid outbreaks of COVID-19, the disease caused by the coronavirus, which is particularly dangerous for older people and those with underlying health conditions. Congregate care facilities come with elevated risk of outbreaks because residents live in close quarters and are served by the same health care workers.

Maine CDC Director Nirav Shah said for the first time Tuesday that his agency considers an outbreak to be at least three people who are “epidemiologically connected” testing positive.

However, an official at The Cedars in Portland said the facility has had three positive COVID-19 cases – two residents and one employee in the same unit – since Saturday, but the state did not agree to conduct facility-wide testing of the staff and residents until a fourth case was reported, on Tuesday. Such testing can help health care workers prevent the virus from spreading.

That delay – if only for a few days – concerns Dona Levi, whose 91-year-old mother lives at the Osher Inn, a 30-unit assisted living facility at The Cedars. Levi worries that waiting for at least three people to have confirmed cases of COVID-19 endangers residents and staff alike because the coronavirus spreads so quickly, including among people who do not show symptoms.

“The staff are at risk, and so are all of the residents,” the 64-year-old Cumberland Foreside resident said.

The Maine CDC did not directly answer questions about why widespread testing wasn’t triggered at The Cedars by positive cases among two residents and an employee.

Shah touted Maine’s testing policy as one of the most inclusive in the nation. His counterparts in the other 49 states were surprised to hear that Maine was testing everyone at three congregate care facilities, he said, and some are considering following Maine’s lead.  

But it’s unclear whether the policy articulated Tuesday by Shah is being followed closely. Nor is it clear what role outbreaks over the weekend at the Augusta Center for Health and Rehabilitation and the Maine Veterans’ Home in Scarborough, which as of Tuesday had 63 and 36 cases, respectively, played in the response at the Cedars.

Katharine O’Neill, the housing and communications director of The Cedars, said the first resident tested positive Friday and required hospitalization. Then a staff member developed symptoms and tested positive, followed by a second resident Saturday.

The Maine CDC said it would not conduct facility-wide testing until a third resident tested positive, O’Neill said. She said that happened Tuesday, bringing the total number of cases there to four.

She said all of the cases are in the Osher Inn. The Cedars also has independent living and long-term care facilities onsite.

The advice received by O’Neill is not consisted with Shah’s public statements.

“The approach we have taken, as a starting point, is when there’s an outbreak,” Shah said. “An outbreak is defined by any three individuals, be they staff or residents, who are epidemiologically connected in some way. In this case because they are either staff or residents of a facility.”

Shah also noted the importance of acting quickly when a case is detected in such settings because the residents are usually older, have underlying health conditions, and live and eat in close proximity to each other. He said prompt action has allowed other congregate care sites to prevent outbreaks.

“It’s a testament to the fact that that rapid intensive infection control practices can prevent one case into turning into more cases,” Shah said.

O’Neill said Tuesday afternoon that she had spoken with the CDC and expected to the agency to send two test kits – one Tuesday and another Wednesday – so all staff and residents could be tested.

Shah said during his media briefing that congregate care sites that report a single COVID-19 positive individual “immediately rocket to the top” of the CDC’s priority for scarce personal protective equipment, which is crucial to protect health workers from getting sick and spreading the disease.

And the agency connects the facility to technical assistance for infection control, epidemiological assistance and, if needed, public health nursing support for proper use of personal protective equipment, separating sick patients from healthy ones, and tracking new illnesses.

O’Neill said The Cedars received equipment and expected to receive additional technical assistance once the test results begin coming back.

“We fully expect that, once the results of the testing are in, the CDC will provide the epidemiological and public health assistance in regards to cohorting and tracking as it will pertain to our community,” she said.

Shah, meanwhile, said he and his top two epidemiological medical doctors have been debating whether they should begin testing everyone in congregate care facilities as soon as one person tests positive.

But, he said, the CDC has a limited number of tests and chemicals used in the testing process remain scarce. Also, the long incubation period of the disease – up to 14 days or more – raises questions about how often people who test negative should be retested.

“We have to balance all of those things all at once,” Shah said.