Healthcare has been hanging by a thread for some time—in our community and across the nation. The COVID-19 pandemic exposed weaknesses inherent in an underfunded public health system, a monopolized hospital, and a fractured medical supply chain. At the beginning of this pandemic I wrote, “Our lives will not be saved by the government. And lives will not be saved by elected officials or large institutions… Lives will be saved by everyday decisions made by responsible citizens in Washington State and the rest of the nation.”
As Kitsap County faces an outbreak of COVID-19 at St. Michaels Hospital, my opinion hasn’t changed all that much. On August 13, hospital leadership as well as state and county health officials knew two patients and three employees had COVID-19. The public was not notified until one week later, on the evening of August 21—the same day I tested an ill hospital employee who was unaware of an outbreak as well. This week, the St. Michaels case count was 65.
A recently released state investigative report identified the most likely source of the outbreak as aerosol generating procedures, such as intubation, performed on patients who displayed no symptoms of illness. An additional contributing factor was noted to be a lack of personal protective equipment for employees, a struggle faced by healthcare personnel universally.
While local news organizations are covering this story from a variety of unflattering angles, this column will not be about the missteps made by the sole hospital entity responsible for serving 300,000 residents on the Kitsap Peninsula during a viral pandemic. In reality, an outbreak there was not only foreseeable, but practically inevitable.
If a large proportion of residents become infected with COVID-19, how should our community respond?
It is time to look at novel approaches to contain a novel disease.
Without access to treatments or a vaccine, control of infection requires interruption of person-to-person transmission. Successful public health strategies include contact tracing, rapid testing, and isolation of known contacts. Contact tracing is most fruitful when the disease causes a specific set of symptoms, such as fever with a recognizable rash, as with smallpox, measles or chicken pox. Contact tracing of COVID-19 is complicated by the fact that asymptomatic individuals can transmit disease unknowingly. In fact, research reveals as few as 10% of those who are infected (the “superspreaders”) are responsible for community transmission up to 80% of the time.
All hope is never lost. Home visits are one innovative method to contact trace more effectively.
Two physicians working for the Indian Health Service in Whiteriver, Arizona, Drs. Close and Stone, reduced the case-fatality rate by developing an “integrated early-response plan that relied heavily on contact tracing.” The Whiteriver Indian Hospital is located on the Fort Apache Indian Reservation and serves about 17,000 members of the White Mountain Apache Tribe and other nearby Native American communities. Knowing that COVID-19 transmission occurs through singing, shouting and coughing more often than contact with contaminated surfaces, the physicians prioritized rapid testing of newly identified contacts. The Whiteriver team focused heavily on those “high-risk” patients who could benefit most from early intervention. Public health nurses visited homes of those who tested positive each day and phoned “high-risk” contacts who were exposed but tested negative for COVID-19 to make sure they were quickly identified if they became ill.
On the reservation, as many as eight or more people can reside in a two-bedroom home, often including a “high-risk” grandparent or great-grandparent. The likelihood of contracting COVID-19 in crowded home environments is approximately 80% through sharing bathrooms, meals, and other communal spaces. The tracing team targeted those relatives of an index case at higher risk of developing medical complications.
It is during these home visits where public health nurses made a remarkable discovery. They identified cases of “happy hypoxemia,” where patients were experiencing little to no shortness of breath, yet had oxygen levels registering below 80%. (For reference, 95% or higher is normal for those living at sea level.) These happy hypoxic patients tended to be young, healthy individuals who were less likely to quarantine and would not have normally presented for medical care.
Unfortunately, because home visits are a relic of the past, clinicians usually see patients after they become sick in the later stages of disease. In reality, no infection, including COVID-19, is completely silent. There are subtle findings that often go unnoticed at first. When ‘happy’-sick patients can be identified earlier, contact isolation and tracing efforts can be more strategic. Supportive measures, such as supplemental oxygen, can be initiated at home and may lead to better outcomes.
Through simple, cost-effective measures, 1600 cases were diagnosed in the Whiteriver community and the case fatality rate was 1.1%, less than half that of the state of Arizona. While about 400 (25%) of these patients required hospitalization, only one required emergent intubation prior to being transferred to a higher-level facility for care.
The work of these two innovative doctors and their team provides valuable insight into a community-based strategy to contain COVID-19. Their experience lends support to the notion that a well-funded and effective public health system working in tandem with individual community clinicians can save lives. To quote Drs. Stone and Close, “In our current healthcare system, knocking on doors and talking to patients may be the most novel approach of all.”
That sentiment is music to my ears.