State and county health officials have struggled in the first weeks of the Oregon coronavirus outbreak to identify, contact, and monitor everyone near known COVID-19 patients, acknowledged this week of public health officials in interviews with The Oregonian / OregonLive.
The weeks before Governor Kate Brown issued a stay-at-home order on March 23 marked a crucial opportunity to slow the spread by identifying people potentially at risk for confirmed infection and telling them to stay home.
But health officials in charge have not contacted all of the Oregonians who tested positive, let alone all of their loved ones, the press room revealed.
And after publicly touting the surveillance system as a way to keep an eye on the spread of the coronavirus and help protect people, state officials suddenly stopped communicating a key set of tracking numbers without explanation. .
State health officials are now refusing to say how many were ultimately found and placed under surveillance or how many of these first weeks were asked to isolate themselves in their homes.
Shannon Liedtke, for example, has yet to hear from public health officials.
Liedtke said she tested positive for COVID-19 last month, but never received a phone call from state or county officials asking for a list of people she could have unknowingly infected , who in turn could have spread the virus to others.
Liedtke is a registered nurse. It provides palliative care to dying Oregonians.
“Maybe I fell through the cracks,” she said. ” I do not know. I was surprised that no one followed through. “
The fact that Oregon’s tracking system was overwhelmed so quickly foreshadows the need for an even more robust effort when coronavirus cases finally start to fall, giving the state and the nation a second chance to control the highly transmissible virus before it can rebound.
Dr. Paul Cieslak, Oregon medical director for communicable diseases, admitted that many counties lacked the resources to continue monitoring as cases escalated. State officials privately recalled the county’s health service expectations in March and this week said surveillance was generally no longer necessary.
“It’s sort of a consensus that builds up, as we hear more and more county health services saying that they are overwhelmed, they can’t keep up with the cases,” said Cieslak. “Washington County, for example, has been hit very hard.”
In many ways, Oregon is no different from other states overwhelmed by the increase in infections and the harsh reality that the coronavirus was too widespread to be brought under control through traditional public health defenses.
At some point, Cieslak said, the aggressive identification of people to watch is no longer valid given the number of people infected with unknown sources.
“If there are a lot more undiagnosed patients, what do we really do by following the handful we tend to hear about? Said Cieslak.
It is unclear what impact the Oregon tracing efforts and associated challenges have ultimately had on efforts to remove the coronavirus.
Oregon health chief and epidemiologist Dr. Dean Sidelinger said it was entirely possible that state and county health officials may have missed some tracing cases, leaving people to spread the virus. and infect others.
No public health survey of this magnitude identifies everyone, he said.
But Sidelinger said Oregon’s monitoring efforts were solid, and, coupled with more aggressive social distancing and home-keeping guidelines since, have hopefully dampened the growth rate of new infections. , as recent statistical models seem to show.
“I don’t think it’s contradictory to say that I’m proud and confident that our public health response was at the start,” said Sidelinger. “And that, yes, there was a time when the cases sort of overwhelmed us and some sort of prioritization had to take place.
“This is part of the assessment of our response to the epidemic. “
Surveillance numbers disappear
The Oregon Health Authority initially expressed confidence in its ability to keep the virus under control after identifying the state’s first case on February 28.
A primary school janitor who worked in Lake Oswego but lived in Hillsboro had been hospitalized with COVID-19 despite the fact that he had no connection with anyone infected or returned from China, where the epidemic had started. the origin.
This meant that the coronavirus was already circulating in Oregon without being detected.
Rather than respond immediately with long-term school or business closures, state officials have ordered county health departments to identify all close contacts of patients with COVID-19 through a proven but time-consuming epidemiological process called contact tracing.
After identifying an infection, health workers are expected to find this person’s close contacts. Officials must then contact them within 72 hours for information on their potential exposure, advice on the need for isolation and keep an eye on these people in case they develop symptoms.
State health officials had announced plans to keep Oregonians informed of the coronavirus just four days before discovering the first infection. They launched a website and promised figures to help inspire public confidence.
The Oregon Health Authority is committed to reporting numbers in two categories: people under surveillance (PUM) and people under investigation (PUI).
Those under surveillance were symptomless Oregonians who had gone to mainland China or had been in close contact with someone known to have a coronavirus. Close contact has been considered within 6 feet of a person for an extended period of time or while coughing or sneezing.
Those surveyed met the same criteria – only they showed symptoms of fever, cough or shortness of breath – and would be tested for the virus.
“People need to understand their real risks and trust that the state and their local health services are working hard to protect their health,” said Lillian Shirley, director of public health for Oregon, in a February 24 statement. . “We hope to share these PUMs and the PUI data will contribute to them. “
Oregon stopped sharing surveillance data three weeks later.
The latest publicly available count, dated March 16, showed that Oregon had identified 51 coronavirus infections requiring tracing and 733 Oregonians who were under surveillance. Of these, more than half had cleared their two-week monitoring periods without developing symptoms, while 352 were still actively monitored.
State health officials explained the withdrawal in a brief statement posted online, noting that the Oregonians were infected from unknown sources and that the governor had closed restaurants and prohibited gatherings of more than 25 people.
When The Oregonian / OregonLive pushed for a more detailed explanation, Jonathan Modie, a spokesperson for the health authority, acknowledged in an email that “state and county public health epidemiologists do not have the resources to track each person as a PUM who may have been exposed to a case. ”
The cases were rising too high, too fast, said Cieslak, the state director of communicable diseases.
Each infection generates an undisclosed number of new people to watch, requiring more work and identification. Cieslak said public health officials have finally started making phone calls on behalf of some desperate counties.
“When a county calls us and says it’s overwhelmed, and we can’t close the gap for them, I basically told them over the phone, do what you can and focus on the risks high. people, “he said.
In 2019, the most common disease requiring intensive tracing was salmonella, with 549 cases, he said. COVID-19 overshadowed this in a month.
“It’s enough manpower,” he said, “and so it’s hard to do. “
The Oregon Health Authority officially revised its written guidelines on March 23, telling counties to focus on family contact for people with known infections or other high priority populations. The state has further lowered its surveillance expectations this week.
It is difficult to determine the precise impact and early challenges of Oregon’s tracing efforts.
Inadequate national testing makes comparisons problematic, but Oregon now appears to be doing quite well. Oregon has documented fewer COVID-19 and deaths per capita than many states, although it identified its first case earlier than most.
The actual number of coronavirus infections across the state remains unknown, however.
New modeling suggests that the total number of infections – identified and unidentified – increased five-fold, from approximately 250 to 1,250, in the approximately three weeks between the first known Oregon case and the residence order at domicile of the governor.
The count could reach 4,000 Oregonians infected by early May, projections by the Washington Institute for Disease Modeling show. As it stands, Oregon as of Friday has identified 899 infections and 22 people have died.
Washington County, the current epicenter of Oregon, has reported more than a quarter of all known infections.
No phone call
COVID-19 quickly struck Shannon Liedtke.
The RN was out for lunch on March 11 when she noticed a tickle in the back of her throat and started to feel stuffy. The next morning, Liedtke said she was short of breath. She was tested for coronavirus a day later.
Liedtke said a medical assistant at a Providence facility tested positive on March 20. Liedtke said he was told to expect a call from public health officials in Washington County, where she lives, to find out who she had been in contact with.
It never came.
Liedtke said she decided to call the county health department the next day but couldn’t speak to anyone because it was a Saturday. She said she followed this Monday and Tuesday, leaving her number twice.
Someone from Washington County finally answered the call on Tuesday, she said, but only to see what questions Liedtke had.
Liedtke said she had been informed that Washington County had not received a positive test result and that someone would follow up to ask her about her close contacts after her arrival.
“But no one has ever done it,” she said.
Liedtke, 44, does not know how she got infected.
There was a suspicious illness in her daughter’s classroom. She returned home after a trip to Hawaii in early March. She was also in and out of Washington County and Yamhill facilities a few days after that, visiting nursing homes and patients.
“These are the possibilities,” she said.
Liedtke still hasn’t heard from Washington County and wonders if health officials still haven’t received his test results through official channels two weeks later. According to her own estimates, Liedtke said she may have been in close contact with a dozen people, including her immediate family, just before she became ill.
She is concerned that she has spread the virus to two of her now-in-law parents-in-law.
Washington County spokeswoman Wendy Gordon said health officials had interviewed or followed up on all known cases of COVID-19 until March 22.
“We have a person in this period who was not reachable and to whom we sent a certified letter,” Gordon wrote in an email. “It may or may not be the person who contacted you. However, despite everything, we would like to talk to him about contacts and also fill in any gaps in our system. “
Liedtke said she never received a letter from the county. After consulting with doctors and her employer, Liedtke said she has no symptoms and plans to return to palliative care this weekend.
“I trust that the information I receive is accurate, that I am no longer a danger,” she said. “I will wear a mask during my visits, just in case. “
Army of tracers
It is impossible to know how many times Oregon and county health officials have not fully tracked contracts while it was still planned.
The numbers are kept in a state database. The Oregon Health Authority refuses to disclose them.
“I cannot comment on specific cases or specific investigations,” said Sidelinger, the state epidemiologist.
The health authority also refused to disclose the number of people under surveillance since the start of the epidemic. A spokesperson said the count is “unreliable” due to changes in the way counties investigate cases.
The challenges persist.
Michelle Spencer said Washington County health officials called her last week after her mother, Barbara Spencer, 77, was hospitalized at the Providence St. Vincent medical center with COVID-19. The call came four days after her mother tested positive for the coronavirus, she said.
Spencer said she went into great detail about her mother’s close contacts and travels.
A Washington County official called back this week to try to pick up most of the same information, said Spencer. Frustrated with the ineffectiveness, Spencer said she hung up.
“If you’re going to contact families who are going through this situation, if you have to spend an hour or more on the phone, that’s fine,” she said. “But do it and be done with it because people have to do” I take them off with a fan? “”
Washington County spokeswoman Gordon said she could not respond immediately on Friday evening as officials addressed the new federal guidelines recommending that all Americans wear masks in public.
In the coming months, the United States will need to do robust contact tracing and general testing, as officials end up loosening social distancing efforts, public health experts say. These efforts will help determine how America is able to move forward.
Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention, called contact tracing “extremely important” when calling journalists on Thursday. Frieden cited China’s efforts to find 700,000 contacts.
“We need an army of contact tracers in every community in the United States to be ready to find every contact and warn them to take care of themselves and stop passing them on to others,” said Frieden. .
Some countries, including South Korea, Taiwan and Singapore, have relied on technology solutions, including smartphone tracking apps or websites that warn people when they come in contact with someone who tests positive. They allow rapid notification, while risking privacy.
In the United States, efforts are underway to develop similar applications, including a project in Seattle, which aim to preserve the confidentiality and security of health data.
Dr. John Townes, medical director for infectious diseases and control for OHSU Health, said it will take creative thinking to make contact tracing effective. Townes cited Taiwan as an example where tracing worked.
If someone showed up sick, the centralized government could quickly determine if they had flown and contact other travelers. The United States does not have the same system or the same capabilities and has a very different approach to civil liberties.
“We have a public health system that is not designed to handle this kind of situation,” said Townes. “It will be quite difficult to do the kind of contact tracing that would be needed to end the epidemic.”
Shane Dixon Kavanaugh contributed to this report.
– Brad Schmidt; [email protected]; 503-294-7628; @_brad_schmidt
– Noelle Crombie; [email protected]; 503-276-7184; @noellecrombie
– Rob Davis; [email protected]; 503-294-7657; @robwdavis
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