Here’s what happens when someone tests positive for coronavirus — and who gets informed
Idaho has confirmed community spread of the coronavirus in 13 counties — including Ada, Canyon, Gem, Elmore and Payette in the Boise area.
Once that happens, health districts say, it’s time to stop worrying about who might have the virus and assume the worst.
“People want to know where it is,” said Brandon Atkins, the program manager in family and clinic services at Boise-based Central District Health. “… If you’re willing to take that risk (to go out in public), you need to understand it could be anywhere.”
Idaho’s seven health districts are charged with trying to control the spread of more than 80 reportable illnesses, and they’ve spent the past four weeks investigating more than 1,100 cases of COVID-19 — the disease caused by the coronavirus. That entails tens of thousands of phone calls to close contacts of those patients in an attempt to track and prevent spread of the disease.
At Central District Health, where Ada County had 418 cases through Monday, and South Central Public Health District, where Blaine County had 423, the caseload has reached the point where the districts must focus their efforts on the highest-risk situations and back off on some of the investigations they were doing when Idaho’s outbreak began with the first positive test on March 13.
They’re relying on the public’s willingness to follow Gov. Brad Little’s stay-home order to flatten Idaho’s curve of new cases.
“Everyone should act with extra caution and understand if they enter a public space and get within less than 6 feet of another person they have the great potential of being exposed to COVID-19 at this point,” said Brianna Bodily, the South Central Public Health public information officer.
“… One thing that can be easily taken away from this entire situation is that public health officials are doing absolutely everything that they can to slow the spread of this virus. And the fact that it is still spreading … is proof that we need the entire community to work with us. It has to be a unified effort from every single person in the entire community to make an impact on this virus and slow it down.”
Here’s how the health districts handle COVID-19 cases — from the first phone call to the patient to the contacts they will and won’t call to the impact of an ever-growing workload:
What happens when someone tests positive for COVID-19?
The lab that runs the test contacts the health care provider and the health district. The epidemiologists at the health district contact every patient — and they try to wait long enough that the provider breaks the news of the positive test.
“It is important to us that somebody is notified by their doctor,” Bodily said last week. “I believe so far every person that we’ve contacted was notified by their doctor first. … At some point, I’m sure we will contact somebody who has not been contacted yet. It’s bound to happen.”
How does the investigation work?
A health district epidemiologist calls the patient to begin an investigation into how the person acquired the coronavirus and who else might have been infected. They’ll try to determine a timeline of symptoms, any recent travel history that could have played a role and any “close contacts” who might be at risk — and, in particular, any contacts who have heightened risk, like senior citizens and those with compromised immune systems.
The epidemiologists also try to identify a likely point of transmission. That becomes less important once a county receives the community transmission designation.
Ellie Morgan, an epidemiologist at Southwest District Health, tries to get patients to provide details up to “two days before they started to feel sick,” she said. Southwest District’s territory includes Canyon County, which has the third-largest caseload in the state.
That timeline could mean reviewing two weeks or more of activity searching for places where the patient might have infected someone else.
“The last few days have been better,” Morgan said Friday. “I think that people are taking it more seriously and most people have been isolating at home. So when we do call them, their contacts just include their household. But we have had cases where there are 10, 20, 30 contacts or more.”
The increased awareness also leads to patients who are more prepared for the questions, Bodily said.
“Once they start showing symptoms and they go to the doctor,” she said, “they’re already running through their mind, asking themselves, ‘Where could I have gotten this?’ So that actually helps. They’re doing a little bit of investigative work themselves, and what we can do is help them work through the possibility of those options that they’ve come up with, and investigate anything they might not have thought of.”
With the increasing workload, health districts have prioritized which patients they contact first. Health care workers, people with risk factors and anyone who’s connected to a long-term-care or group-living facility are high on the list, Atkins said.
The district’s calls include advice for the patient on how to protect the public from their illness, including how to self-isolate and when it’s safe to interact with others again.
What’s a close contact? Who gets a phone call?
The definition of a close contact is someone who was within 6 feet of a COVID-19 patient for 10 consecutive minutes, the health districts say. So you won’t get a call if you were just in the same store, or even the same workplace, as someone who tested positive unless you meet that criteria.
“I want to reassure people that if there was a public health exposure, we would let people know,” Bodily said. “If we believe that somebody might have spread COVID-19 to a restaurant and everybody in that restaurant, we would let people know.”
For districts still running full investigations, and in counties where community spread hasn’t been detected, close contacts will get a phone call and be monitored by the district. Southwest District is still doing that in Canyon County, where community spread was detected, but Central District and South Central say they’ve had to cut back on their calls to close contacts because of the caseload.
“Now, in the areas where there’s community spread, instead of reaching out to every single close contact,” Bodily said, “what we’re going to do is reach out to the most at-risk.”
Contact monitoring is one of the most labor-intensive portions of the health districts’ COVID-19 response. During full investigations, they call each of those contacts on a daily basis for about two weeks inquiring about any symptoms of the disease. Some contacts will be put on passive monitoring, where they’re encouraged to call if they experience symptoms, Morgan said.
Among contacts, family members are among the most likely to be infected, she said.
“It’s pretty common in households,” Morgan said, “… because you’re sharing all the same spaces.”
When the district calls contacts, the epidemiologists tell them they were exposed to someone who tested positive. They don’t provide the name.
But in many cases, the person already knows. Patients are encouraged to inform their close contacts themselves — and, in Ada, Twin Falls and Blaine counties, that’s now the only way most of those people are going to find out, unless they have heightened risk factors.
Do districts follow up with patients?
Patient monitoring usually is done passively, Morgan said. People are told to contact their health care provider and the district if symptoms worsen. As long as they are following the advice to self-isolate, they aren’t a public health concern.
In the case of high-risk patients, health care workers or people connected to long-term care facilities, the district makes daily contact, she said.
“Unfortunately, we don’t have the capacity to follow up with every single patient every day,” Morgan said.
The reality, Atkins said, is the vast majority of those who test positive will recover without a severe illness.
“We know that most people, over 80% of individuals, are going to have mild to moderate symptoms and they’re going to recover on their own,” he said.
How long do patients and contacts have to isolate themselves?
Patients who tested positive and had symptoms must self-isolate until they’ve gone 72 hours without a fever or use of fever-reducing medicine; seen improvement in their other symptoms; and it’s been at least seven days since the symptoms first appeared.
Patients who tested positive without symptoms must self-isolate for seven days after the date of the test. If symptoms develop, they must follow the protocol for patients with symptoms.
Close contacts, intimate partners and caregivers of patients who tested positive must self-isolate for 14 days after their last close contact with the sick person. If the patient and contact share a household, the contacts must wait 14 days after the patient has been cleared to end self-isolation.
Anyone in self-isolation should avoid all public places.
This is standard guidance created by the Centers for Disease Control and Prevention.
Will an employer know if an employee tests positive?
Yes.
Patients are encouraged to inform their employer of a positive test, but the health district can inform the employer if necessary, Atkins said.
“I can tell you, in my years working as an epidemiologist,” he said, “that I have never had someone who wouldn’t tell their employer that they had something that could have been a risk to somebody else.”
What if the health district can’t reach a COVID-19 patient?
This has happened at least five times in the Southwest District, spokeswoman Katrina Williams said — four in Canyon County and one in Gem County.
“Southwest District Health (SWDH) has the authority to issue orders of isolation and quarantine and orders to report for examination to prevent the spread of infectious disease such as COVID-19,” Williams wrote in an email.
The exam is so the district can conduct a contact investigation. In these cases, the patients were instructed to contact the district by phone by noon the business day after receiving the order, Williams said.
Patients usually are asked to voluntarily isolate themselves but in these cases an order of isolation can be issued, Williams wrote.
“Prior to issuing orders, SWDH staff make several attempts to contact the individual,” Williams wrote. “If communication efforts are unsuccessful, we coordinate with our local prosecuting attorney and law enforcement partners to have the individual served with the orders.”
Violating the orders can result in a misdemeanor charge.
“To date, all individuals issued an order have quickly complied with our requests, and we are grateful for their cooperation as we work to control the spread of COVID-19 in our communities,” Williams wrote.
How are the districts getting all this work done?
It’s a combination of long hours, reassigning staff from other areas and help from a crew of volunteers kept at the ready for emergencies like this.
Southwest District has two epidemiologists who are working 10 to 11 1/2 hours a day, Morgan said, with one day off per week. Other staffers have gotten involved with patient and contact phone calls, while the Medical Reserve Corps volunteers — often retired health care workers — help staff the call center.
South Central has three people working investigations, has reassigned staff to COVID-19 investigations and also is using the Medical Reserve Corps for the call center, Bodily said.
Central District, which is the state’s largest, has a five-member epidemiological staff and about a dozen people working on investigations, drawing from the medical and environmental health teams, Atkins said.
“Anybody who works that amount of time, it can be fatiguing, so we have to do our best to try and fill in and support one another so that we can take breaks and alleviate some of that pressure,” Atkins said, “because no one can go forever and not be susceptible to illness themselves.”
Editor’s note: This story was updated at 9:45 p.m. April 7 to include the section about patients who can’t be reached.
This story was originally published April 7, 2020 at 4:00 AM.
