Background: For the past 10 weeks, Washington State has been dealing with an unprecedented public health emergency – the SARS-CoV-2 Pandemic. Lacking either a vaccine or effective antiviral medications and facing severe limitations in personal protective equipment and adequate testing resources, Washington State implemented an increasingly restrictive set of community mitigation strategies. These mitigation strategies started with isolation and quarantine of know cases and contacts and progressed to school closures and, on March 23, 2020, a state-wide closure of all non-essential businesses, a stay at home order, and a ban on all non-essential travel. These extreme measures were successful in stopping the exponential spread of the pandemic coronavirus and preventing the demand for hospital care from exceeding the capacity to deliver that care. This “flattening of the curve” has dropped the number of new cases of COVID-19 infection from almost 600 per day in late March to around 250 per day. Demand for hospital services is also slowly declining. The success of this effort is precarious and the most recent data shows that case rates may be climbing upwards again. Washington State has not set a numerical target for suppression of new COVID-19 infections. The CDC has recommended 0.7 cases/100,000 population. This would translate into 50 cases/day in Washington State and 7-8 cases per month in Jefferson County.
The Way Forward: Indefinite closures of non-essential business and home isolation are neither desirable nor sustainable. These extreme measures were designed to prevent a medical catastrophe and save lives that would have otherwise been lost for lack of advanced medical care. This goal has been achieved. Washingtonians have had over 6 weeks to learn social distancing, hand hygiene, and other mitigations designed to limit spread of coronavirus. On May 3, 2020 Governor Inslee renewed his emergency proclamation with significant modifications. The new plan authorizes a set of Phase 1 activities to begin on May 5th and last until at least May 31st. 10 rural counties with populations less than 75,000 and with very low levels of Covid-19 activity (as evidenced by no diagnosed cases for 3 weeks or longer) were authorized to seek a variance to move from Phase 1 to Phase 2 activities before the rest of the state. This variance request could seek authorization to adopt all Phase 2 activities or could request a subset of these activities. The formal process starts with a recommendation from the county health officer to the local board of health. If a majority of board of health members supports the variance request (either as submitted by the health officer or as modified by the board), it advances to the board of county commissioners for final approval. The application must provide information on 5 essential metrics and contain a certification from the local hospital that it has adequate bed capacity and PPE to respond to an increase in COVID-19 cases.
Jefferson County Response: On Thursday, May 7, a joint videoconference meeting was held with the Jefferson County Board of Commissioners, the Jefferson County Board of Health, and the Port Townsend City Council. After a presentation by the health officer and considerable discussion, it was decided to move forward with a deliberative process to gather public comment and carefully consider each option on the list of Phase 2 activities for possible early implementation in Jefferson County. This process would involve a special meeting of the Jefferson County Board of Health on May 14 and a final vote at the Board’s regularly scheduled meeting on May 21.
New Developments and Status of Variance Requests in Washington State: At the time of the May 7th meeting, Jefferson County had not recorded a confirmed case of COVID-19 for 28 days and was clearly eligible to submit a variance application. On May 9th, a Jefferson County resident was diagnosed with COVID-19. The source of her infection is unknown as is the date the infection was acquired and is the subject of an ongoing case investigation requiring additional specialized testing at the University of Washington. Last week 5 rural counties in Eastern Washington (Columbia, Garfield, Lincoln, Ferry, and Pend Oreille) were granted variances to move to Phase 2 activities. Three additional eligible counties (Stevens, Skamania, and Wahkiakum) were approved on May 11. After submitting their application, Kittitas County experienced a large outbreak of COVID-19 at a meat packing plant and their application review has been “paused”. In addition to the 10 counties deemed eligible by virtue of their population size and >3 weeks of no new cases, 2 other counties have expressed interest in obtaining variances despite a small number of COVID-19 cases in the past 3 weeks. It is reported that Mason county has applied for a variance and asked that alternate measures of low COVID prevalence be utilized. The legislative representatives from Clallam County have made a similar request for consideration. It is unclear whether Jefferson County remains eligible for a Phase 2 variation and this eligibility will need to be determined by the Secretary of Health, Dr. Wiesman.
Special Considerations for Jefferson County: Jefferson County scores favorably on several metrics for pandemic preparedness: adequate public health and hospital capacity to provide prompt case investigation and contact tracing and to meet the medical needs of diagnosed COVID-19 patients, either through hospitalization or medical case management in an outpatient setting. PPE supplies although hardly optimal, do meet state standards for adequacy. A major concern for Jefferson County is its high percentage of residents at risk for the complications of COVID-19 infection. U.S. census projections are that 36.9% of Jefferson Counties 32,221 residents were 65 years of age or older as of April 1, 2020. This is the highest population percentage in Washington State. Mortality risk increases with age for COVID- 19 with 90% of Washington deaths due to this infection occurring in those 60 years of age or older. An additional serious consideration is Jefferson County’s proximity to Seattle and the urban centers of the I- 5 corridor where COVID-19 infection remains prevalent. The Phase 1 openings of State and National parks to day use and permitting of recreational fishing have already dramatically increased travel to the Olympic Peninsula. Any Phase 2 openings that further encourage tourism and travel will likely increase this trend. This risk is especially acute if Jefferson County is perceived as the closest “open” county to Seattle and thus an attractive day trip to escape the restrictions of the urban “lockdown”.
Basis of Health Officer Recommendations: As the appointed Health Officer for Jefferson County since 1996, my duties are clearly defined in statute. RCW 70.O5.070 (3) assigns the health officer the duty to “Control and prevent the spread of any dangerous, contagious or infectious diseases that may occur within his or her jurisdiction”. Additional statutes and rules assign specific powers and duties to control communicable diseases, including broad isolation and quarantine powers. A health officer’s prime directive is to prevent the spread of infectious diseases. This is not to minimize the importance of other social determinates of health – jobs, civil liberties, economic and food security, education, and more.
Public health is always a balancing act between community health and individual liberty. As in many other health-related activities, the risks and benefits of specific choices must be carefully balanced.
Risk/Benefit Analysis of Phase 2 Activities: Phase 2 activities modify physical distancing measures in 4 key areas: recreation, gathering size, travel, and business/employer activity. There is still much that is
unknown about SARS-CoV-2 transmission and the proportionate risk of different behaviors and activities. Models are being developed by the Institute of Disease Modeling (https://www.idmod.org/ ) and others to better quantify these risks but are not yet available. One early finding is that manufacturing and construction activities have high economic benefit and low disease transmission risk. Conversely “leisure activities” have low economic benefit and comparatively higher transmission risk.
Given the greater likelihood that strict physical distancing, hand hygiene, Covid-specific occupational health standards, and restriction of ill workers can be best accomplished in the structured environment of a construction site or a manufacturing facility, these findings appear plausible. Leisure activities, by their nature, are less structured and more likely to violate physical distancing standards. Activities that promote tourism increase coronavirus transmission risk by encouraging travel from high prevalence areas to low prevalence areas. This effect is magnified when these activities are not available in adjacent counties.
Another important consideration is enforcement. While Governor Inslee’s proclamation is backed by the force of law and violations carry gross misdemeanor penalties, there is no active enforcement of travel or gathering sizes. To be effective, citizens must be motivated to follow physical distancing requirements by a mix of personal benefit and the desire to protect others. Some activities are readily enforceable. Isolation and Quarantine orders have specific enforcement mechanisms. Licensed food establishments (like grocery stores and restaurants) have licenses issued by the local health department which can be suspended or revoked for violation of public health codes. Individual businesses can enforce physical distancing restrictions by setting conditions for entry (e.g. number of customers or an indoor masking requirement). Salons, barbers, and pet groomers can limit appointments to local clients only.
Benefit/Risk Ranking of Phase 2 activities:
High benefit/low risk: Manufacturing (non-essential repair, maritime industry, and others), additional construction phases, in-home domestic services (nannies, housecleaning, etc.), professional services/office-based business [non-tourism oriented, telework strongly encouraged], pet grooming [local customers only]
Medium benefit/medium risk: Outdoor activity with 5 or fewer people outside your household (no overnight camping), indoor gathering with 5 people outside your household per week, hair and nail salons/barbers [local customers only]
Lower benefit/ higher risk: Outdoor activity with 5 or fewer people involving overnight camping (RV or campgrounds), Restaurants with sit down service, real estate (beyond current permitted activities), pet grooming (out-of-area clients), hair and nail salons/barbers (out-of-area clients), retail (in-store purchases)
Jefferson County Health Officer Recommendations Phase 2 Variance Activities Recommended:
Recreation: Outdoor recreation involving fewer than 5 people outside your household excluding all overnight camping.
Gatherings: Gather with no more than 5 people outside your household per week, masking encouraged if social distancing cannot be maintained. Visitors from high prevalence areas strongly discouraged.
Travel: Essential travel and limited non-essential travel for Phase 1 and 2 permissible activities. Out-of- area tourism strongly discouraged (ferry signage, advertising, local governmental directives) until statewide Phase 2 implementation.
Business/Employers: Manufacturing (non-essential repair, maritime industry, and others), additional construction phases, in-home domestic services (nannies, housecleaning, etc.), professional services/office-based business [non-tourism oriented, telework strongly encouraged], pet grooming (local customers only), hair and nail salons/barbers (local customers only)
Phase 2 Variance Activities NOT Recommended:
Recreation: Outdoor activity with 5 or fewer people involving overnight camping (RV or campgrounds)
Business/Employers: Restaurants with sit down service, real estate (beyond current permitted activities), pet grooming (out-of-area clients), hair and nail salons/barbers (out-of-area clients), retail (in- store purchases allowed with restrictions), professional services/office-based business (tourism focused)
Note: The Governor’s Safe Start Washington plan (https://www.governor.wa.gov/sites/default/files/SafeStartWA_4May20_1pm.pdf ) contains detailed physical distance and infection control requirements for individuals and businesses. These apply to all phases of the State’s reopening plan and are critical for the prevention of coronavirus transmission.
Failure to rigorously adhere to all of these community interventions will constitute grounds to revoke Phase 2 status for individuals or businesses.
Thomas Locke, MD, MPH
Jefferson County Health Officer