It’s a unique moment in history, when communities are dependent on one another to not transmit a disease. In Washington state, officials have enacted some strict interventions to limit all gatherings of more than 250 people, close schools and in-person classes at all colleges and universities, public or private.
These measures are to curb the rise in the number of cases, or “flatten the curve,” as public health officials say, to keep our local hospitals and health care system functioning. While hospitals in the Seattle-area are struggling to find space for patients needing treatment for COVID-19, Spokane-area hospitals have capacity currently, and Spokane County’s health officer, Bob Lutz, wants to keep it that way.
“I want to be on that flat curve as much as possible right now. We have capacity, but what we’re trying to do is be proactive and prevent the (system) from being overwhelmed,” Lutz said Saturday. “At this point we are doing well, but we certainly have our partners on the west side to learn from, and they were overwhelmed because of the quick onslaught at which these cases came. So the earlier and more prepared we are, the better we will be to deal with the issues.”
Spokane County has three confirmed cases of COVID-19, but statewide the number rises to 642. Beyond statewide prohibitions on gatherings and shut-down schools, every person is going to have to change their behaviors, medical and public health officials say.
“I think it’s going to come down to each individual (who) takes this seriously and practices social distancing, sanitation, and don’t go out when they’re sick,” said Dr. Gretchen LaSalle, a family physician at MultiCare Rockwood.
People over the age of 60 and those with underlying health conditions are at higher risk to develop serious illness if they contract COVID-19, but people who are low-risk for developing severe symptoms can still transmit the infection. Health care providers and public health officials agree this is why social distancing, for everyone, is crucial.
“We don’t want to wait until people are symptomatic to start doing that because with most viruses you are contagious for at least a couple days before you have symptoms,” LaSalle said.
So what does this look like in the community?
Lutz is recommending social distancing, leaving about 6 feet of space between you and another person, as well as practicing good hand hygiene and coughing etiquette. Social distancing is not social isolation, however. The difference, while awkward for people day-to-day, is not a complete shutdown of everyday life.
Lutz recommends businesses make it easy for people to maintain social distance, by setting up spaces differently or seating people away from one another. Employers can ask employees to telecommute and work from home if possible.
For example, eating at a restaurant would be fine with guests sitting at a table at least 6 feet away from others. Rescheduling gatherings or parties in spaces where people cannot stand far enough apart is not a bad idea, Lutz said.
Why all this caution?
The novel coronavirus, is just that, novel and new. What researchers know so far is constantly changing, but we do know at least two ways it spreads, LaSalle said. The virus is transmitted person-to-person, via respiratory droplets, when a person coughs or sneezes in close contact, or within 6 feet, of another person.
A person can also get COVID-19 by touching an infected surface and then touching their hands, eyes or mouth. The virus can also be transmitted fecal-orally, increasing the importance of handwashing, LaSalle said. So far, researchers have not confirmed COVID-19 and airborne transmission.
“This is something that they are researching now and trying to figure out,” she said.
LaSalle said COVID-19 is more contagious than the flu but not as contagious as something like measles. People are thought to be most contagious when they are most symptomatic, Centers for Disease Control and Prevention guidance says, but the disease might also spread before people show symptoms, like in cases of community spread seen already in cases in Eastern Washington.
Keeping the health care system ‘strong’
Collaboration among health care providers in the Spokane area is already underway, Lutz told reporters Friday, despite being competitors in the health care industry.
“Unfortunately, the lessons learned form the West Side are dictating some of those best practices now,” Lutz said. “Many of their partner organizations on the West Side are finding themselves overwhelmed and at times looking at having to make critical decisions, such as who gets ICU beds, and that’s again what we don’t want to have happen here.”
Lutz has the authority to expand the 30-day ban he put on gatherings of 250 or more people as well as institute stronger interventions community-wide, should he need to.
“A lot of it is going to be based upon the conditions in the field,” he said. “I need to be looking at the impact on the health care system, first and foremost. It has to be strong and flexible.”
His decisions will be primarily based on what he hears from local health care providers.
“If I hear that the health care system is being overwhelmed, then the orders are going to be extended, and they may become a little bit more stringent,” Lutz said.
Hospitals in the Spokane area have been preparing for COVID-19 in the community. Providence and MultiCare hospitals in the area have implemented visitor restrictions, tightening who and how many visitors can see patients in the hospital.
Collectively, there are about 80 negative air flow rooms in the four main Spokane hospitals, which can be used to isolate and treat patients with COVID-19, although hospitals have the ability to convert beds and units to treat patients with respiratory conditions.
Providence Sacred Heart Medical Center also has a 10-bed special pathogens unit, which has been used to treat COVID-19 patients who were passengers on the Diamond Princess cruise ship in Japan. To date, there is one passenger left in the unit in satisfactory condition.
While these types of rooms are available, it is unlikely many of the beds will be open. Most hospitals in the state do not have a lot of extra capacity at any given time and are not likely holding beds open for possible COVID-19 patients, according to the Washington State Hospital Association. A 2017 point-in-time capacity report of Spokane’s four hospitals found the average hospital capacity was at 90%, or nearly full. Hospitals, however, have facility and regional plans to address surge capacity, should beds be needed to treat patients.
Hospitals can get creative to use their clinical units or separate clinics to house patients needing inpatient care and treatment or transfer patients to different hospitals that have extra beds, as needed. In Eastern Washington, the Regional Emergency and Disaster Health Care Coalition coordinates how hospitals will triage and treat patients in the event of an emergency. Health care providers, emergency responders and public health officials have been actively training and drafting these plans since 2017 and continue to do so today.
Spokane County has three confirmed cases of COVID-19, but more are expected to be confirmed in the coming days and weeks. While Lutz has no documentation of community spread yet, he expects it is here.
More testing will lead to the health district’s ability to track community spread of the disease, clusters of cases and ways to better prevent further spread. Lutz issued a more liberal testing criteria for health care providers in Spokane for patients who are showing symptoms, including high fever, coughing, nasal congestion, runny nose and body aches.
“If you are testing for flu, test for COVID-19,” he said.
As testing capabilities expanded last week to private lab companies, the Spokane Regional Health District is unable to track how many people locally have been tested, Lutz said. Local health officials are notified of test results, however. As of Saturday, 70 people in the county have tested negative, and three people have tested positive so far.
MultiCare providers in the Inland Northwest had collected tests for 32 patients as of Thursday. Providence would not release the number of patients sampled for testing in its facilities.
“We are not disclosing the number of patients we see and/or collect samples from regarding COVID-19. Our focus is on patient care and safety at this time,” a statement from a hospital spokeswoman said.
State officials have requested federal stockpile assistance to replenish personal protective equipment (PPE) for health care workers in the Seattle area, and Spokane-area hospitals are preparing and conserving their PPE resources. Providence and MultiCare systems have the PPE necessary to serve the community, hospital spokespeople confirmed.
Researchers studying how the Chinese health care system responded to the COVID-19 outbreak in Wuhan, Hubei Province, the epicenter of the pandemic, believe the United States needs to significantly ramp up its hospitalization and ICU capacity to treat patients in the near future.
“Plans are urgently needed to mitigate the effect of COVID-19 outbreaks on the local healthcare system in US cities,” Harvard researchers wrote this month.
Dr. LaSalle agrees nationwide capacity is limited, further increasing the importance of limiting community spread and widespread cases of the virus.
“We need to limit the spread of this as quickly as possible so we can delay a huge spike in illness and make that a slower rise over time, so we can accommodate those people,” LaSalle said.
Emergency departments and ICUs are needed on a daily basis for other patients needing immediate critical care from car accidents, strokes or heart attacks, among other emergent medical needs.
“It will come down to decisions – if there’s not enough beds or ventilators or ICU supports – doctors will have to make hard decisions about who to give that support to,” LaSalle said. “We don’t want to have to make those decisions.”
The health care system in Eastern Washington has had a few weeks to prepare, which health officials believe, paired with intervention strategies, should work.
“I would like to believe we will not see the numbers or intensity of the infection due to these efforts,” Lutz said, acknowledging how fluid the situation and the spread of COVID-19 can be.
Learning from other countries, data
The pandemic has highlighted differences in the public health systems of affected countries, with federal authorities in the U.S. being criticized for a lack of widespread testing. The private sector, meanwhile, has made unprecedented changes, canceling major sporting events, concerts, conferences and travel plans.
Lutz pointed to South Korea as an example of an effective government response.
“They have been able to keep themselves on that shorter bell curve by being very aggressive at social distancing, (canceling) mass events, and screening and testing,” he said.
Despite a delayed government response, strict quarantine measures and construction of temporary hospitals in China’s Hubei province have proved effective at slowing the spread of the virus.
Singapore and other countries in Asia, meanwhile, have received praise for developing and maintaining response protocols following the early 2000s outbreak of Severe Acute Respiratory Syndrome (SARS) and the 2009 outbreak of H1N1 influenza, better known as swine flu.
In Singapore, those measures have included segregating teams of hospital workers to limit any potential spread of COVID-19, and requiring people to get their temperatures taken before entering most buildings.
“They realized they wanted to invest for the future, to reduce that economic cost if the same thing were to happen again,” Martin Hibberd, an infectious disease researcher at the London School of Hygiene and Tropical Medicine, recently told Wired magazine.
A report published Friday by a team of genetic sleuths, including scientists from the Fred Hutchinson Cancer Research Center in Seattle, uses publicly available data to trace the spread of the virus overseas and through communities. The report is on the website Nextstrain, “an open-source project to harness the scientific and public health potential of pathogen genome data.”
The researchers wrote “the virus is widely circulating across the globe, with evidence of local transmission on multiple continents. At this time, we urge focus on efforts to slow the spread within communities; travel bans are less likely to be effective.”
One finding stands out: The researchers wrote that mutations in the virus show a strong connection between cases in Washington state and cases from the Grand Princess cruise ship, which recently was quarantined off the coast of San Francisco with 21 confirmed cases of COVID-19 among passengers.
“We aren’t sure yet whether the virus spread from the cruise ship to Washington or the other way around; as we get more data, we’ll update our analysis,” the researchers wrote.
Limiting local transmission of the virus requires limiting personal contact.
“Social distancing – that is, decreasing the number of people you encounter each day – can be challenging, but is hugely beneficial to the public good,” the researchers wrote. “If everyone decreased their daily contacts by 25%, we would expect to see a 50% decrease in the cumulative number of cases over the next month.”
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