How coronavirus has tested Seattle’s infectious disease response
Health care workers train extensively for outbreaks. After responding to the first American case of the novel virus, they say they are even more prepared.
“I haven’t eaten since yesterday, so I think I’m getting a little goofy,” says Dr. John Lynch, director of Harborview Medical Center’s infection control team, as we ride an elevator from the bowels of the hospital up to his office on a Friday afternoon. For the past two weeks he’s been executing Harborview’s response to the novel coronavirus, a potentially fatal respiratory disease originating in Wuhan, China, that has evolved into a global health emergency. “This has sort of taken over everything,” he says.
A tall, tired-looking man walks into the elevator as we exit it. Lynch whips him an enthusiastic high-five.
“You’re awesome. Good job, get some sleep, have a good weekend. Good job. Have a great time, Nathan, thank your family,” Lynch says, his blue scrubs swishing as he walks. Nathan, working as part of the infectious disease response team, hadn’t seen his family since Wednesday.
Lynch and his team aren’t alone in working more hours than area health care providers usually do. On Jan. 19, Puget Sound became Ground Zero for the American arm of the pandemic when a Snohomish man traveling from Wuhan was admitted to Providence Regional Medical Center in Everett, becoming the first of 12 U.S. cases and testing the resilience of the region’s extensive public health network and hospital systems.
It took only weeks for the coronavirus to spread from animal markets in Wuhan to more than 29,000 people in China and at least 160 people in 26 other countries. On top of common symptoms of fever, cough and breathing difficulty, this coronavirus induces pneumonia. At least 638 people have died so far.
The experience of health care providers like Lynch sheds light on how the Puget Sound health system might handle coronavirus if it were to spread —and how the whole area might fare against future pandemics.
An outbreak begins
“It couldn't have happened at a worse time,” says Dr. Scott Lindquist, Washington State Department of Health’s epidemiologist for communicable diseases. “We're in the midst of respiratory viral season.”
Epidemiologists don’t know for sure how fatal this coronavirus is, or how quickly it spreads. People can pass other coronaviruses such as SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) through sneezing and coughing, and there has been one confirmed transmission in the United States — between a husband and wife in Chicago.
Information gaps complicate initial responses to outbreaks, so health care workers often err on the side of caution.
“The issue is that a lot of people right now in China are being hospitalized,” Lynch says. “And I don't know whether it's for public health reasons or for medical reasons. And so until I know more about that, it's hard to know really what this looks like [for Washington].”
The federal Centers for Disease Control and Prevention and other agencies stress that only people who’ve recently traveled to the Wuhan region or come into close contact with diagnosed patients need to be concerned about coronavirus, which so far has a fatality rate of 2% (SARS’ rate was 10%). “For perspective, it’s useful to remember that in a bad flu season in King County alone, we can expect to see several hundred thousand flu cases and hospitalizations and hundreds of flu deaths,” Dr. Jeff Duchin, public health officer with Public Health — Seattle & King County, said at a recent King County Council briefing.
Still, public health officials geared up for an active response when the Providence patient was detected.
“Emotionally as a doctor I worry about the [Everett] patient,” Lindquist says. “But we tend not to have emotional responses — not because we're robots or anything, but we train continuously on outbreaks like this.”
The CDC diagnoses disease samples, provides advanced screening and sets national guidance during outbreaks, but that guidance relies on a perfect synchrony of state, regional and local agencies and health centers.
Hospitals and clinics look to public health agencies like Public Health and the Department of Health for locally targeted advisories, best practices, assistance in evaluating and managing cases, tracking the spread of disease and other support. The Department of Health has responded to 26 events in the past six years, from communicable disease outbreaks like measles to natural disasters. It uses an emergency preparedness program with an incident command structure, and plans and procedures that get updated “every couple of years at least,” says Department of Health State Health Officer Dr. Kathy Lofy. “And then there's very-just-in-time protocols that come from CDC like this one [for coronavirus].”
Health groups also coordinate during crises through regional emergency alliances like the Northwest Healthcare Response Network, which helps nearly 3,000 health care organizations collaboratively handle emergencies and disasters. To prepare for multiple outbreak possibilities, local and state agencies, health care groups and even the Port of Seattle regularly get together to perform drills of different scenarios.
“We're seeing a lot of these [outbreaks]. This has become our norm,” Lindquist says, pointing to the anthrax scare of 2001 as a tipping point for public health emergency preparedness.
When Dr. George Diaz, an infectious disease specialist at Providence, found out that the country’s first coronavirus case would be under his care, he was “mostly nervous,” he said Monday. When he spoke with Crosscut, Diaz was hours from announcing he had discharged that first patient, who survived the infection well enough to convalesce at home. “I wanted to make sure that we did things absolutely perfectly,” he says.
“We had been drilling for [outbreak management] for quite some time, but you never know when it's actually going to happen,” says Diaz, whose hospital had participated in an Ebola response scenario weeks earlier. A team of 10 to 12 nurses had also volunteered to train over the past five years to treat biocontainment cases like this.
Diaz had a checklist: talk to infection prevention, talk to the people bringing the patient in the ambulance, make sure the nursing staff is activated and coordinated to come to the special pathogens unit, make sure facilities is familiar with setting up the biocontainment unit, check the software for their robot doctor and more.
The pace of treatment has been faster than anything he’s experienced, Diaz says, with doctors learning new things daily. They work on most disease treatments over months to years, involving a lot of treatment iterations. “The rapidity of information coming in… is much faster than anything I've seen in my field in the past,” Diaz says. For example, he infused and eventually cured his patient on Jan. 26 with an experimental treatment based on a Chinese paper released in China two days before.
“It’s only one patient, but it was a hopeful response to treatment that we might not have done had we not known what the experience was from the paper,” he says. “That’s not our usual timeline.”
Sixty-three people in Washington state are known to have come into contact with the Everett patient, who was quickly contained and treated; and no additional cases have been found.
“I think, if anything, we demonstrated our environment and our layout of the health care system was so efficient we detected the first case” on a holiday weekend, Lindquist says.
Even with only one confirmed case here, Washington hospitals and health agencies are still in high gear to track the disease, gauge its patterns and screen for symptoms. Hospitals have screened two dozen potential Washington cases.
To maximize communication, Harborview set up a community care phone line, FAQ websites, social media accounts and more. Within 24 hours of receiving its patient, Providence changed its electronic health record system to include asking all patients two questions: Have they been around someone who’s traveled to China or done so themselves within 14 days, and are they experiencing coronavirus symptoms?
“We can reliably get that history even if the patient doesn't come telling us that to begin with,” Diaz says. Harborview’s Lynch adds that the hospital has been sensitive to making sure people of Asian heritage aren’t disproportionately screened.
When patients enter hospitals coughing or sneezing, a front-desk person, a triage nurse or other personnel gives them a mask and runs through the screening questions. Patients of concern are moved from public spaces into isolated care.
Harborview and Public Health also started a three-person home assessment team that visits people when they need evaluation, but don’t have the symptoms to merit a clinic trip. This reduces exposure, removes the need for transport, frees up emergency room beds and puts less stress on patients.
So far, the assessment team has responded to four cases, involving a doctor and nurse doing assessments and obtaining specimens to test for multiple viruses. “It actually takes us more time to get our personal protective equipment off than it usually takes to see the patient,” Lynch says. “So it's been a very positive experience.”
Many Public Health and Department of Health staff have been working nights and seven days a week. “We've received a lot more calls than we usually do from providers who may be evaluating a patient,” Lofy says.
“The whole crew has us on speed dial, so to speak,” Lynch says, referring to regional health care agencies. “The last two weeks, I've felt like a teenager with the amount of phone attention I’ve been giving. It’s just been nonstop texts and emails and phone calls because of all this stuff.”
Health care workers are often the most vulnerable to infection during outbreaks. Both Lindquist and Lynch say enforcing essential hygiene — hand washing, covering coughs and staying home when someone feels ill — can be difficult.
“They're like, ‘Oh, but it's not like I'm not going to get infected,’ ” Lynch says. “I'm like, ‘But that's what everyone who got Ebola [in 2014] said, too.’ ”
Public Health's Duchin told the King County Council that federal public health emergency preparedness dollars have been decreasing for 10 years. “We’ve learned to make the most out of a bare bones capacity — no health department in the U.S. is adequately funded to meet the needs of a sustained long-term increased surge that a large-scale pandemic would require,” he says. “Emergency funding would need to become available just in time to sustain those types of responses.”
Puget Sound’s status as a travel hub leaves the region more vulnerable to pandemics. “We are a multicultural state where we have lots of flights from around the world,” Lindquist says. “I'm not sure that's a weakness; it's really just a standard of our living. We live an airplane ride away from any disease.”
The Seattle Hazard Identification and Vulnerability Analysis points to our rapidly growing population and homelessness crisis as risk factors, and points out vulnerabilities during previous outbreaks. “The 2009 H1N1 flu epidemic showed how potentially easy it is to overwhelm the health care system. A pandemic influenza that caused moderate or severe disease would have a much larger impact on the community," the analysis says.
What would set off alarm bells for all of them is evidence of multiple person-to-person transmissions in the U.S. Washington planned for high likelihood of local transmissions, “but try as we might we have not detected that here,” Lindquist says.
When we spoke on Jan. 31, Lynch said he’d feel better if there were no new local cases by Feb. 3, based on the incubation window for contacts of the original Everett patient — and there weren’t. But he said even seeing more cases in countries outside of China would still concern him.
“No one's ever going to quarantine like China did. Ever. And clearly it didn't work; it was a little too late,” Lynch says. “I think we're going to continue to see more cases not only in China, but everywhere in the world. To some extent, that's what you want to see actually because that means your surveillance are working.”
“The witching hour’s upon us,” he says when the clock hits 4:30 p.m. “It's almost inevitable. So I'm not taking the scrubs off.”
Even the energetic Lynch recognizes his personal resources would buckle under a prolonged pandemic.
“Doing everything all-in for a week, that's fine,” Lynch says. “But doing everything for a month is a big deal. Being on call 24 hours a day, for months … it has a cost.”