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COVID-19 and public health; one year later

Mountaineer - 4/13/2021

Apr. 11—In early March 2020, discussions were just beginning in Haywood on COVID-19 and hadn't been on the state's radar long before that.

The first virus case didn't appear until April 2, and two weeks later, the number of positive cases was still below 5.

The lead time Haywood had to develop a coordinated response made all the difference in how the global pandemic unfolded locally, said those who have been at the forefront of the effort since day one.

Patrick Johnson, the now retired Haywood County Public Health director, was recently looking over the minutes from the first department meeting on the subject on March 9.

By then, the department was already fielding calls from individuals with respiratory symptoms, including one who attended a mega-church gathering in Florida and developed symptoms exactly 14 days later.

"Patrick has been seeing mounting evidence that this outbreak is likely to be bad," the minutes state. "This will put serious strains on the existing healthcare system. There will be continued shortages in masks, prescriptions, medical staff, etc. Every other country will be going through the same scenario."

The early messaging was to 1) take this seriously by not mocking decisions to cancel events or close workplaces; 2) keep pressing the common-sense measures (later known as the three "Ws) of wearing a mask, waiting from a distance and washing hands) 3) ensure the public knows of the guidance available via the Center for Disease Control.

Early on, discussions were focused on available testing and the associated costs, contact tracing to try and limit community spread and procuring personal protection equipment.

Challenges came from both sides. On one side were those who downplayed the seriousness of the pandemic and resisted the public safety guidelines, and on the other side, Johnson said, were individuals who wanted rapid testing or to be tested too early. Results from rapid testing weren't reliable, and neither was testing someone immediately after exposure before the virus had a chance to incubate.

There were seemingly dozens of details to attend to — meeting with Folkmoot about the upcoming summer festival that would have brought in visitors from across the globe, possibly closing schools, (something N.C. Gov. Roy Cooper ordered schools across the state to close on March 14) the need for county health workers to have laptops and the ability to work from home, where the homeless population could quarantine and how to handle the expected onslaught of calls from the public, to name a few.

Johnson said Haywood was fortunate in several respects — fortunate to avoid heavy caseloads and community spread until much later than other parts of the nation, fortunate to have individuals within public health who were prepared and able to respond and fortunate to have a great working relationships across the county to develop a coordinated response.

After that first March meeting, Johnson said his public health team met at 8:30 a.m. three times weekly to review data, discuss cases, track trends such as where Haywood residents were picking up cases, and determine how to solve the pressing issues that were bound to come up as the pandemic made its way through the county.

"Without that, I don't think we would have understood the disease process so well or been able to develop a message to put out in the community," he said.

Dr. Mark Jaben, the county medical director, was brought in to help with the response, something that turned his job from a half day a week into almost full-time — for no extra pay.

Jaben said the county was lucky to have more time to prepare than other areas of the county.

"We got the message in early March," he said. "That gave us a good six weeks to get all the agencies together and make a plan. That served us well as we smoldered along with a few cases here and there for another month at least. We got a chance to experiment with the plan to make sure it would work."

A time to worry

Positive COVID cases in Haywood remained below 100 until the end of June, but just a month later, case numbers soared to 348.

The summer surge caused real concern, Jaben said, but numbers plateaued, and case numbers were manageable until early November.

"Unfortunately, numbers started rising before Thanksgiving, and by the time gatherings came around, that many more people in the community were already infected. The big concern at that point was overwhelming the health system. But if you look at numbers of HRMC and Mission, it was really quite contained until January. That was when everybody really felt stretched."

That Thanksgiving-Christmas-New Year holiday period turned out to be the virus peak in Haywood, one that would help drive case numbers past 4,000 by early in 2021. Numbers have since plummeted, and with vaccine availability and decreasing case numbers across the nation, the end of a trying period is in sight.

Looking back, Jaben and Johnson said a time of particular concern during Haywood's COVID experience was in early summer when case numbers — and deaths — soared at Silver Bluff.

As painful a time as that was for the facility, both said the safety measures that had been consistently applied and the steps taken once the first positive case was found became an important learning experience — and one that helped control outbreaks at other congregate living facilities in the county, both agree.

Though Johnson retired in October, the team in place was more than able to carry on, he said. Garron Bradish, who worked in environmental health and had been part of the COVID response from day one, was named interim director, and other key players continued performing at peak levels.

While some in public health circles hadn't taken pandemic preparedness very seriously, Johnson said, Jeanine Harris, who was charged with the task had conducted N-95 masking trainings annually and stockpiled the needed equipment.

"Jeanine was ready for all this," he said. "Our lab person, Heidi Lowe, was a key person who helped us through this business. From a practical standpoint, our nursing director, Tammy Quinn, right away began thinking how we could blend all the testing and disease communication aspects into our daily workload. Those three things made a real difference."

What next?

Experts had been predicting a pandemic would strike for years before COVID-19 was an issue, and are unified in saying this won't be the last public health crisis to hit.

Johnson said the pandemic has illustrated that the public health director needs to be at the same level as other department heads who report directly to the county manager.

"Midway through this, department heads were calling me and I had no idea who they were," Johnson said. "It would have been helpful to know who they were."

Seven years ago, the county commissioners determined consolidating the health and the human services departments would provide greater efficiencies, cost savings and better serve the public.

That action added a second layer of bureaucracy for public health on issues such as hiring additional personnel, setting up an official COVID testing site or getting funds to cover necessary costs.

"I'm not saying they have to separate the two, but the public health director should be a department head, just like the person who oversees the library and parks and recreation department," Johnson said. "The public health director should have more independence, should have a different level of direct report to the county manager."

Jaben said there are things that can be learned from this experience, particularly that the best way to an improved post-pandemic economy is through public health.

"Few people had any experience with this, though there were certainly warning signs with ebola and SARS," Jaben said. "The first chapter in communication with the public is to be consistent and straight up. WWI Winston Churchill followed that playbook exactly in talking about what could be done and painting some hope for the future. Every speech was like that. The pandemic playbook is just like that."

During the initial waves of death, health experts simply didn't know enough about the situation, Jaben said, but as information unfolded, the path forward became clear.

"Knowing what we know now, if the message had been consistent, we could have done a lot to limit spread," Jaben said. "We know the way to preserve the economy is to preserve health first. There needed to be leadership in terms of setting the measures of success. Then people would have seen it was in their best interest to play ball with that."

As of mid-April 2021, North Carolina's new case numbers were at the level of those recorded for residents sickened by the flu, Jaben said. This is a number and risk many are willing to live with and a good sign better days are ahead.

Even though more contagious — and deadly — strains of the virus have been found in the U.S., Jaben said the number of people who have already been vaccinated should depress any surges. Another positive is that the vaccine has been shown to stave off the deadly effects of the variant, as well.

"Many folks who wanted to be vaccinated have been," Jaben said, "so that should blunt the deaths we've seen since most of those vaccinated are in the older age groups. What we are seeing now is far more cases in people in the 40-60 age group. There are a lot of people with long-term symptoms, and I predict we'll see more of that."


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