BY BECCA LOUX, JULIANA DEMAREST, AND ALEX HOEFT | Moonshine Ink
As case counts continue to flatline, the Tahoe Forest Health System and the state of Nevada are joining alongside El Dorado, Nevada, and Placer counties in phasing into the gradual reopening of nonessential businesses and recreational activities.
Without adequate testing or contact tracing thus far, is the Tahoe region ready? This area, like many others globally, has faced a lack of contact tracing (investigating people who’ve been in the vicinity of or had direct contact with a COVID-19 positive patient to trace the spread of the virus) and a severe overall testing deficit.
Due to these gaps in data, local public health officials are operating essentially in the dark, and “we know that we have missed cases,” said Dr. Aimee Sisson, Placer County health officer and public health director.
Yet the reopening begins. Nevada County announced on April 27 its movement into a gradual reopening phase, citing a “successfully avoided” crisis-like situation in the region from the spread of the novel coronavirus and the disease it causes, COVID-19. The county’s “stay-at-home” order was amended to allow for outdoor recreational activities that abide by physical distancing recommendations. (Per the updated order, and among other additions, fishing and golfing are now permissible as long as physical distancing is maintained and separate equipment is used.)
Tahoe Forest Health System, too, is planning for a phased reopening of non-coronavirus hospital services, including clinic and outpatient options, over the next four to six weeks.
During Straight from the Source, an April 29 community conversation hosted over Zoom by Moonshine Ink, local health officials discussed with community members the latest pandemic trends in Tahoe, as well as what it’ll take to fully reopen shuttered doors. TFHS CEO Harry Weis, Placer County’s Sisson, and Nevada County health officer Dr. Ken Cutler participated as the expert panel.
Later that day, Placer County formally announced the expiration of its local health order on May 2, following suit with its neighboring county.
El Dorado County is allowing its local stay at home order to expire as originally planned on April 30, whereafter the county will be “guided primarily by the governor’s order,” according to a press release.
No rush
Use of the words gradual and phased are intentional and key to the carrying out of these local legislative updates; though the counties and the hospital will begin to loosen some of the region’s self-imposed shackles, it’s the state that’s the keeper of the keys.
“Regardless of what action is taken at the local level, Placer County remains under the governor’s stay-at-home order, which is in effect until further notice,” Sisson said during the Moonshine Zoom conference. “The governor has made it clear that any decisions to relax the stay-at-home order, at least initially, will be done on a statewide level. It will not be a local decision.”
Cutler’s interpretation for Nevada County of the county-state balance of power was similar: “Those [stay-at-home] orders will be modified over time, and the state health officer essentially sets that floor. We can be more strict at the local level but we can’t be really more lax than the state order.”
The counties’ stay-at-home orders were very similar to the statewide mandate, but a local order allows each county to provide clarifying information to the public.
As an example, one of Placer’s restrictions more stringent than the state’s mandate allowed essential businesses to assign employees to work outside the home only if that employee could not perform his or her duties from home. California Gov. Gavin Newsom’s order allows those working in essential businesses to attend their workplace as long as physical distancing practices are observed.
Newsom has identified six indicators to consider before the statewide order is lifted, including the monitoring of COVID-19 cases through testing, supporting physical distancing in businesses, schools, and childcare facilities, and the handling of potential case surges. On April 28, Newsom outlined a four-stage approach to reopening the entire state, with California currently trapped in phase one — residents are staying home unless they’re a member of an essential workforce.
Sisson provided specific examples of what to expect for the next stage we’re working toward: “Any initial relaxation of the stay-at-home order puts us into stage two, which is when lower-risk workplaces can reopen. That includes things like curbside retail, like manufacturing, like offices, and then some opening [of] public spaces such as parks and trails that have been closed.”
She believes that the timeline for entering that phase is likely weeks away rather than months. It will be months, plural, Sisson warns, however, before we enter stage three, which will allow for high-risk workplaces to open such as hair and nail salons, movie theaters, and gyms.
“And then finally, moving to stage four will not happen until effective therapeutics [the direct treatment of a disease] are available and it won’t be until that stage — which is essentially when the stay-at-home order will end completely — that’s when large gatherings like concerts, like live audience sporting events, and large conventions will be allowed to resume. Again, that is months not weeks away,” Sisson said.
Newsom announced on April 30 a hard closure of beaches in Southern California’s Orange County after thousands of people visited them over the previous weekend. A full list of currently closed California beaches and state parks can be found on the California Department of Parks and Recreation website.
Nevada Gov. Steve Sisolak announced on April 29 the extension of his own stay-at-home order through May 15, with some softening on restrictions beginning May 1 — specifically outdoor and recreational activities, as well as small business relief. Examples include allowance of curbside pickup for retail cannabis dispensaries, drive-in services at places of worship, and golf, pickleball, and tennis activities.
El Dorado County health officer Dr. Nancy Williams chose to default to the statewide order due to a relatively few number of cases (the current active COVID-19 positive count as of press time was four) and there have been no instances of individuals dying from complications of the disease there.
The county has reported a total of 45 lab-confirmed positive tests to date, but the majority have now recovered, according to El Dorado’s coronavirus case data page.
However, the county’s order to ban nonessential travel to unincorporated El Dorado County and its emergency ordinance restricting short-term rentals and adding a fine for visitors violating it will both remain in effect.
Tahoe Forest Hospital’s reopening will allow healthcare to become more available, in slow steps.
“We want our community to know [the hospital] is a safe place to come to and that they shouldn’t procrastinate in an undue manner for their healthcare needs,” Weis said. He clarified that TFHS has no plans to reopen non-COVID related services dangerously or all at once: “We’re also on a very careful four-to-six-week expansion of services, just to make sure we don’t have lingering issues that are being delayed too long.”
The test of time
Sisson outlined four criteria to measure regional success against the virus: the ability to test everyone with symptoms; adequate personal protective equipment numbers for healthcare workers and first responders; rapid and robust contact tracing; and a decline in new case numbers.
Despite past testing kit limitations, Cutler with Nevada County said the rough edges seem to be rounding out.
“The United States, California, locally — we’ve all seen fits and starts with testing,” he said. “Or there’ve been really blockades/barriers to getting wide-scale testing, whether it’s the supplies of swabs, viral transport media, the testing equipment itself, the agents for that (lab personnel), the amount of protective equipment people have … It’s always seemed like as one supply gets better, the other narrows. But those things are really coming into alignment.”
This comes hand-in-hand with Newsom’s April 22 announcement to add an additional 80 community testing sites across the state, particularly in underserved areas. Kings Beach is set to receive one for North Tahoe and Truckee residents, opening next week. Both Nevada and Placer counties collaborated on local testing site locations (another one is being launched in Grass Valley), which will be powered through a partnership with OptumServe, the federal health services side of Optum — a health services innovation company.
Sisson said the site “will have the ability to test 132 people every day. That’s a significant expansion in the testing capability.”
There, those with mild symptoms — who are currently asked to remain isolated at home but not officially screened due to risk of exposure and a limited number of test kits — now will be encouraged to be tested. Asymptomatic people at high risk, like healthcare workers, could be screened at the new facility, too. Testing will be by appointment only.
The Truckee/North Tahoe area peaked in cases between March 31 and April 3, according to TFHS’s Weis during Straight from the Source — the case graph has been basically a plateau ever since. Testing began at the hospital the first week of March; altogether, TFHS has tested approximately 590 patients, 56 of which were positive COVID-19 lab tests across multiple counties. There hasn’t been a positive-tested inpatient since April 18 — indicating a decline in new case numbers.
But there are questions of how accurate positive numbers are. Many patients treated at the hospital who expressed COVID-19 symptoms are not included in those totals, because there was not an official lab identification. They are considered “rule-out” cases, yet are believed to be carriers. Rule-out cases also include those waiting for test results. Two new rule-out inpatients were identified by TFHS the same day as the conference call.
Moonshine spoke with a Truckee family who experienced firsthand the anxiety and worry of being told they have the coronavirus, but were not quite sick enough to get tested. (For the sake of privacy, their names are being withheld.)
“It’s been an unnerving seven weeks for us because we’ve been told to assume our family has COVID-19, but there is no way of knowing for sure,” said the husband, who we’ll call Steve.
Just before the schools were closed, one of their children developed a cough that lasted four to five weeks. The child didn’t have a fever or breathing issues, but the parents began to suspect it might be COVID-19 when the child lost their sense of taste for several days. Two weeks later, the other child started with the same cough, but was exhibiting even more in the way of COVID symptoms: fever, head and body aches, stomach issues, and loss of taste for a week.
“When we went in for evaluation, the staff explained that our child likely has COVID-19 based on the symptoms. Unfortunately, they couldn’t offer a test because he didn’t meet the criteria due to limited supplies,” Steve explained. “The doctors and nurses have been amazing throughout the process and that shouldn’t be understated. Their hands are tied with not enough tests. It’s just tough when your kid is up all night coughing and you don’t know what the next day will bring.”
The family was instructed to self-isolate at home until no one was showing any symptoms of the disease.
“If our kids have in fact had COVID, we’ve been very lucky and count our blessings that it hasn’t been worse,” he noted. “The unknowns have been rough.”
Moonshine Ink also previously interviewed a Truckee resident who formerly tested positive for COVID-19. She shared the struggles both she and friends had getting tested for the disease in Testing Triage for COVID-19 in Tahoe.
“It’s just really unfortunate that they can rule us out after telling us it’s probably COVID-19,” said Truckee father Steve, explaining that they left wondering how many others were told they likely had COVID-19 but were never able to confirm so due to lack of testing, and exactly how many rule-out cases there have been.
There was also concern that the numbers being released publicly are not necessarily reflective of the reality. “We do, however, feel that all those people like us should be tracked or part of the equation in some way — even if it is an asterisk,” he said. “Otherwise, the low number of new cases isn’t a true number and it’s only giving our community a false sense of security and people will let their guard down.”
(See the Ink’s past reporting for more on rule-out COVID-19 patients versus tested positive cases. TFHS previously told Moonshine that testing numbers were not considered useful public information. Weis provided these numbers publicly for the first time during the conference.)
Sisson acknowledged that without proper testing, there is no way to be certain we’re on the downhill slope of dealing with this virus. Yet like Weis, at one point during the conference she clarified that it’s certain we’ve reached a peak in cases, but she maintained there’s no guarantee it will be the only or last spike we see.
On PPE numbers, Tahoe Forest’s Paige Thomason, marketing and communications director, said the hospital system has an adequate supply. Sisson, too, said Placer’s hospitals have about 30-day PPE supplies.
With a somewhat sunny outlook on many of Sisson’s indicators, the last major hurdle to clear locally is contact tracing.
Concentric circles
Both Cutler and Sisson pointed to a need for adequate staffing numbers to be able to handle the need for intensive contact investigation. A fleet of contact tracers would allow people to quickly organize when a new COVID-19 case is diagnosed and rapidly uncover everyone that person has been in contact with recently.
Sisson said: “[We want to] pull those people out of circulation per se so if they have already been infected but they aren’t necessarily showing symptoms, we can separate them from others so that the disease does not spread to — if you think about it as concentric circles — another circle of people that could become infected.”
Ideally, Placer needs 100 contact tracers trained with the appropriate tools to keep track of infected cases and those they’ve come in contact with, Sisson said. Currently, the county has six staffers able to perform contact tracing. Cutler said Nevada County, too, is shifting staff around, training people who might not normally participate in communicable disease control, but have public health experience, to increase its contact tracing capacity.
Adequate contact tracing is Sisson’s white whale; it’s the final countdown to reopening, the last piece of the puzzle that will give her and her colleagues enough data to ensure the peak we’ve experienced is the last while still beginning to get back to business.
Nevada County’s Cutler said that it’s vital the county ramp up “varying aggressive, intensive contact investigations” as part of what he calls “that roadmap of recovery in a thoughtful, phased approach.”
For Sisson, it’s unequivocal: “Until we have that contact tracing ability it’s not safe to relax the stay-at-home orders in Placer County.”
