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Triggers and Clusters

Humboldt is slowly reopening and cases are rising. How will officials know when to pump the brakes?

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When Humboldt County took its first baby step toward easing shelter-in-place restrictions on May 8, allowing retail businesses to reopen for curbside pickup and delivery service, there was an air of hope and optimism to the moment. Officials talked wistfully about how walk-in retail could soon follow, with the prospect of sitting down for a meal in a restaurant possibly on the near horizon.

At that point the county had seen just three confirmed COVID-19 cases in the previous 23 days, making the six-day period when the county confirmed 28 new cases in a six-day period in early April seem a distant memory.

Then came the positives: two on May 9, followed by four, three, three, one, four, five, four and five — 31 new cases in a 11-day period. Underscoring the gravity of the situation, the county saw its first COVID-19 death on May 17 — a 97-year-old woman who'd been residing at Alder Bay Assisted Living — followed by its second on May 19, another resident of the facility, which has become the epicenter of an outbreak cluster, with seven residents and five staff members having tested positive for the virus in recent days.

During a report to the Humboldt County Board of Supervisors before the Journal went to press May 19, Health Officer Teresa Frankovich conceded this is a "strange" time in the county as it works to loosen restrictions and allow some businesses to re-open even as case count climbs.

"Our numbers are of concern to me," Frankovich said.

But because COVID-19's incubation period is believed to stretch up to 14 days, Frankovich also noted in a media availability May 18 that recent spike in local cases likely doesn't have anything to do with businesses reopening in limited capacities. Instead, she said, she believes it's the result of people "moving about a bit more in the community" and disregarding the shelter-in-place order, which still very much remains in effect. Through contact investigations, Frankovich said public health has determined more people are gathering and making unessential trips out of the area, furthering the spread of the virus.

"It's very important that people not gather," she said. "People want to get together. We've all been doing this a long time. But when we bring groups of people together who have not been together, it does increase spread."

Similarly, she stressed the importance of the county's facial covering ordinance, which is designed to keep asymptomatic carriers of the virus — who make up as much as 40 percent of people infected with COVID-19, according to some studies — from unwittingly spreading germs.

"This is not a temporary measure," she said of the order. "This is a measure we're going to be doing for a while because it will help us move forward through stage two and three [of re-opening]. I have no intention of maintaining this longer than necessary but, right now, it is necessary."

But unrest with shelter in place is real, as evidenced by bare-faced protesters who showed up on the Humboldt County Courthouse lawn last week and restaurants mistakenly opening for patio seating in Ferndale to a Fortuna church holding Sunday services and Bear River Casino announcing plans to re-open next week with some safety protocols in place. During the supervisors' meeting, First District Supervisor Rex Bohn even mentioned he'd talked to people who'd driven over to Redding to eat at restaurants that had opened there, which, combining gathering and traveling, would clearly violate the spirit and letter of Frankovich's shelter-in-place order.

Currently, the county — which received a variance from the state giving it some local control over the pace of re-opening — is allowing retail stores, childcare facilities and some office spaces to submit health and safety plans for county approval detailing how they intend to re-open and operate safely (read more about the process on page 8). Later in stage two, the county could opt to begin allowing restaurants to re-open for modified dine-in service. (Gyms, salons, barber shops, movie theaters and bars would follow in stage three.) As of May 18, the county had approved more than 180 business to re-open, according to Sheriff William Honsal, with a few dozen others in the planning process. Frankovich also indicated at the meeting that she plans to modify her shelter-in-place order to allow residents to travel to not just businesses that are deemed "essential," but also those whose safety plans have been certified and have been allowed to re-open.

Frankovich said the county has no intention at this point of walking back its easing of restrictions or allowances for some businesses to re-open in the face of spiking case numbers and the county's first deaths. But she did say the the numbers may cause the county to slow the pace at which it allows businesses to resume operations and she has also repeatedly cautioned that easing restrictions will necessarily mean more illness as people circulate and the virus spreads.

"We're going to have additional deaths," she said flatly. "That is the cost of COVID."

This has left many to wonder — as case numbers climb and businesses open their doors — what safety measures are in place and how health officials will know if or when it is time to pump the breaks and potentially reinstate restrictions. In the 27-page document she prepared for the state certifying Humboldt County was ready to move forward through stage two at its own pace, Frankovich laid out the criteria under which the county would have to quickly clamp down with stricter mitigation measures. She splits the criteria into three categories — epidemiology, healthcare and public health — and notes that meeting one or more criteria in at least two of the categories would prompt action.

Epidemiology

This section concerns the spread of disease in the community and lays out six potential triggers or benchmarks officials can use to determine if things are starting to get out of control. The first two are pretty straightforward: If the county sees an increase of new cases of at least 10 percent for three consecutive days or a doubling of cases in a five-day period absent substantial increases in testing, that would be cause for concern. And while case numbers have certainly been increasing over the past 11 days, they have not increased at this pace.

Then, if the county were to see more than three unlinked chains of transmission — or three unlinked virus clusters — in a 14-day period, that would be a trigger because it would mean the virus has gained footholds in different, unlinked sections of the community where it was spreading simultaneously. During a recent media availability, Frankovich said this might currently be the case, as she believes the county may have seen three or more unlinked chains circulating over the past two weeks. In addition to the cluster among Alder Bay staff and residents — believed to be the result of a staff member contracting the virus through local community transmission and bringing it into the facility — there's at least one other believed to be travel related. Public Health has not publicly discussed any others.

"I would say we have at least three right now," Frankovich said. "It's possible we have a fourth."

Another trigger would be a high likelihood of exposure at a mass gathering or the delayed detection of a case from a mass gathering. This trigger is potentially very important locally with Bear River Casino having announced its plans to re-open May 24. While the casino has implemented a variety of safety protocols, Frankovich has voiced strong objection to the re-opening, saying there's no getting around the fact it would constitute a mass gathering of people together in a confined space for a prolonged period of time.

"I'm very concerned about introducing mass gatherings," Frankovich said, explaining that while the goal of sheltering in place is to limit the ability of one person to spread the virus widely, mass gatherings make that possible on a huge scale, meaning a single person could potentially expose hundreds of others to the virus, bringing the risk of exponential spread. "It's not safe right now."

Other triggers include a "steady increase" in reports of influenza-like illness circulating in the community for 10 consecutive days or an increasing number of healthcare workers confirmed to have the virus for five consecutive days.

Healthcare

If things are starting to look a bit unsettling with the spread of COVID-19 locally, officials indicate the current state of healthcare infrastructure should provide some reassurance. In short, it is far from being overwhelmed.

Triggers in this category include an inability of local intensive care units to see a doubling of patients from current numbers, providers no longer having the capacity to screen large numbers of symptomatic patients or a lack of capacity to provide baseline healthcare services in addition to COVID-19 care. Similarly, seeing more COVID-19 hospital admissions than discharges over three consecutive days would be a potential trigger, as would healthcare facilities being too overrun to prevent spread throughout their facilities or not having sufficient personal protective equipment for staff and patients.

As the Journal went to press, the county had seen just 11 COVID-19 patients hospitalized at any point in their care. Public Health has so far declined to offer any additional information regarding the status or condition of their hospitalizations, meaning we don't know if those people were admitted and discharged in the same day or underwent long-term intensive care. But for context, having built additional surge capacity, local hospitals have the ability to treat about 65 people in intensive care, according to health officials.

Public Health

This category essentially surrounds the public health department's ability to sufficiently track and monitor spread of the virus, as well as isolate patients who can't do so on their own.

Triggers here include the inability to find contacts for 20 percent or more of confirmed cases or seeing 10 percent or more of symptomatic contacts fail to get promptly tested — either of which would hamper investigators' ability to quickly find people who may be infected and get them tested and isolated, slowing spread of the virus. Similarly, if the county ran out of hand sanitizer or didn't have someplace available for non-hospitalized COVID-19 patients who are homeless or can't safely isolate at home to stay, that would be a trigger.

The last trigger is a bit more nebulous but in some ways may be one of the most important: if officials "no longer have the ability to convey physical distancing recommendations which change behavior in residents." That essentially means if health officials feel residents aren't following recommendations and orders — for example to wear facial coverings, keep their businesses closed or avoid mass gatherings — they may feel forced to shut everything down.

While saying she doesn't yet see the need to pull back substantially, Frankovich expressed concern about the current state of COVID-19 in Humboldt County at the May 19 board meeting, particularly regarding residents' willingness to stay the course. Answering two different lines of questioning, Frankovich spoke about the need for residents to refrain from unnecessary travel and quarantine upon return if they do leave the area, to avoid mass gatherings, stick to their household units and to mask up when in public, then talked about the incredible challenge of protecting senior living facilities from the virus.

"It's the thing that keeps us all awake at night," she said, explaining that while all local skilled nursing and assisted living facilities have extensive safety protocols in place, testing technology simply hasn't progressed to the point where they can rapidly test each staff member at the beginning of each shift.

But as Alder Bay has seen, once the virus enters a congregate living facility where all the residents fit into one of two major risk categories — being 65 or older or having underlying health issues — the impacts can be devastating. Part of protecting those living in these facilities comes down to limiting the spread of virus in the community, which decreases the chances of staff members becoming infected and unwittingly bringing the virus into the facility.

As the county navigates the re-opening path ahead, Frankovich made clear that — to every extent possible — senior citizens and those in the community with underlying medical conditions should not be part of it and should instead continue sheltering in place.

"Stay home and protected," she said.

Thadeus Greenson is the Journal's news editor and prefers he/him pronouns. Reach him at 442-1400, extension 321, or thad@northcoastjournal.com. Follow him on Twitter @thadeusgreenson.

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