Containing the Coronavirus

Last February, public health departments in Washington state mobilized to contain a measles outbreak. In July, they turned their attention to multiple cases of hepatitis A. So when a case of coronavirus was confirmed in Snohomish County last month, public health officials were well equipped to respond.

“We were already activated to try to prevent a large outbreak of hepatitis A, so we already had the structure in place,” said Meredith Li-Vollmer, a risk communications specialist with the public health department in King County, Washington, which is coordinating the local coronavirus response in the Seattle region. “Before it was even known that this outbreak was coronavirus, before it was confirmed here, it was on our minds. We were already looking at our plans, thinking, ‘If this happens here, what are we going to do?’”

The outbreak of coronavirus, a new strain of an existing respiratory ailment, has killed hundreds of people in China and sickened tens of thousands of others. As of Friday, there were 12 confirmed cases in the United States, with patients in Massachusetts, Wisconsin, Illinois, California, Arizona and Washington. The virus is transmitted via close person-to-person contact, but is not spreading throughout communities in the United States, according to the Centers for Disease Control and Prevention. The overall risk to the general public remains low.

But local health departments across the country still need to respond. In places with confirmed cases of the virus, their work includes isolating the sick and retracing their path during the time they may have been contagious—key investigative steps that can help public health officials limit the spread of a disease. In cities and states without patients, response is largely focused on education and outreach: debunking rumors, distributing facts and calming scared residents, all while preparing for the possibility of new cases.

Much of that work is expected during an outbreak of any contagious virus, but the coronavirus presents certain challenges. There’s still a lot that health officials don’t know about this new strain, including how long patients should be considered contagious and the details of how it spreads.

“A lot of times when it’s a disease threat that we have more information about—measles, for example—we know certain things,” said Susan Ringler Cerniglia, a spokeswoman for the Washtenaw County Health Department in southeastern Michigan. “We know that measles is highly contagious and you have to worry about the airspace in a room within two hours of when a confirmed case is in there. That’s the type of thing we just don’t know about this novel coronavirus, so it makes it very difficult to provide some of that initial information.”

Washtenaw County had three suspected cases of coronavirus. All three tested negative, so the public health response there has mostly focused on outreach—providing continuous updates through a mix of social media posts, direct communication to health providers, and face-to-face contact with vulnerable and hard-to-reach populations. 

The department has also made a concerted effort to calm fears and discourage discrimination against Asian-American populations. In a Facebook post from Jan. 30, the county urged residents to “fight this new public health concern with compassion and science, not fear or discrimination….you CANNOT tell if someone has a risk of spreading novel coronavirus by what they look like.”

That post was prompted by questions from the public about whether coronavirus was more likely to occur among Asian populations, Ringler Cerniglia said.

“Some of the initial questions we were getting was because of the fact that it unfolded in China,” she said. “But it’s not a Chinese disease. Asian people are not especially at risk, so we’re trying to talk about that and head off some of that stereotyping and discrimination. We try to focus on the science—anybody could have traveled to an impacted area, and if they did, they should have information about watching themselves and getting tested if appropriate.”

Across the country in King County, health officials have heard reports of Asian-American residents being yelled at in the streets for not wearing surgical masks and patients of Asian descent having their medical care delayed because doctors automatically assumed their symptoms pointed to coronavirus. One family was shooed away from a sample stand at a Costco in Issaquah, Wash., because their child was wearing a surgical mask and the employee thought he might infect her. Attempting to prevent those behaviors through outreach is important, but challenging, Li-Vollmer said.

“It’s a tricky balance because we don’t want to increase attention on these groups,” she said. “But at the same time, we want to prevent the stigmatization against them.”

King County held a media event on Friday to bring together business and community leaders to debunk stereotypes, discourage discrimination and discuss ways to respond appropriately to the health threat. The health department has also distributed information through its community communications network, a group of more than 600 organizations and community leaders, including homelessness service providers. Officials have also stayed in contact with the area’s foreign-language media organizations, with special focus on Chinese news outlets.

“We have a very large population of Asian Americans, and we know that one of the health impacts of an outbreak situation like this is the stress and fear it causes,” Li-Vollmer said. “It can lead people to have some negative behaviors. We are trying to do what we can to address and prevent that as part of the work that we do.”

The Washington resident with coronavirus, who had recently traveled to Wuhan in China, does not reside in King County, but does work there, so the health department’s response has also included disease investigation. Officials are working to isolate the confirmed case, as well as stay in touch with three other patients who are being tested and and disseminate updates about the 20 cases with negative test results. That process falls to the health department’s investigative team, which spends its time interviewing patients about their movements in the days before they became sick, reconstructing a detailed play-by-play that helps uncover who may have been exposed.

“Part of our routine investigation work is to ask the patient everywhere that they’ve been while they were sick, who they had contact with, where they work, what type of work environment it is, if they took any kind of public transportation or went to any places where there would be people in big numbers in close proximity to each other,” said Dr. Meagan Kay, a medical epidemiologist with the Seattle-King County health department. 

The goal of those interviews is to identify what Kay referred to as “close contacts”—people who may have been exposed to the virus by their proximity to the patient. Investigators interview those contacts as well, asking questions about their movements and also their symptoms. 

Health officials are trained to perform those tasks, but the scope of the work is much larger than normal, and departments are overextended as a result. Managing an outbreak diverts full-time staff from their regular work, which in Michigan has meant a process of prioritizing daily work that must be completed against tasks that can be pushed to the side. In King County, health officials have been able to manage the workload thanks only to the help of temporary staffers who were brought on board to help with the measles and hepatitis outbreaks. Those workers happened to still be on the payroll when the coronavirus hit.

“There’s no way we would be able to work at the speed and with the degree of intensity and the volume of people that we’re working with if we didn’t have those temporary staff here,” Kay said. “The staff capacity that we have now needs to be our baseline, and then we need to have ability to surge up beyond that. Right now we don’t even have a case in King County. We have a small number of people, relatively, that we’re monitoring, and even that is taxing our program.”

Insufficient staff in state and local health agencies is a national—and known—problem. Local health departments eliminated more than 55,000 positions due to budget cuts from 2008 to 2017, and public health efforts are currently underfunded by about $4.5 billion, according to research from the Trust for America’s Health. Those deficiencies are particularly noticeable when health officials are tasked with confronting the outbreak of a lesser-known disease, said Lilly Kan, the senior director of infectious disease and informatics at the National Association of County and City Health Officials.

“It requires a tremendous amount of time and resources that local health departments just don’t quite have,” she said. “They already expend a fair amount of resources responding to other infectious disease outbreaks, like measles, or communicating ongoing information on the flu season, so to add this new level of work and coordination with a virus that is new to everyone and that people are still learning about is where that shortfall really occurs.”