Q&A w/ Dr. Alan Melnick: Using Nursing Home Capacity As New COVID-19 Metric

This is the first part of a two-part Question and Answer session with Dr. Alan Melnick, MD, MPH, CPH, Director of Clark County Public Health, as he and his team manage the complexities and pressures of the COVID-19 pandemic.

Question 1: How is COVID-19 test data gathered daily?

We get data and test results in a variety of ways: From local providers within 24 hours (clinics, hospitals, labs, all of them) rolling in throughout the day and most send data electronically, some send via FAX, and those are rolling in throughout the day. We have a big team of nurses who do the investigating. The data comes in and we go through all of that daily. We are staffed seven days per week. We have about 24 nurses and five office assistants working each day. The nurses are calling cases to interview them and identify close contacts, and working on facility investigations (if we have multiple cases in a workplace, health care setting, long-term care facility, school, etc.). The office assistants are supporting the nurses.

In addition to those folks, we have teams that do contact notification. These are the people who call everyone who is identified as a close contact of a confirmed case, notify them of their exposure and give them instructions on quarantine. They also monitor those individuals who test positive during their isolation and close contacts during quarantine, by calling and/or texting every day. We contract with an organization, Public Health Institute, to provide these services. They are working seven days a week and have five teams with eight contact notifiers on each team.

We also have staff coordinating wraparound services (such as seeing if cases need rental assistance, groceries, etc.), epidemiologists and data analysts compiling our data, among others.

Question 2: Does Clark County track cases by ethnicity?

Yes, we do. There are disparities by ethnicity. Some are impacted more than others. 

Question 3: With the current cases per 100,000 that are in place do you foresee the possibility that we should look more at hospitalizations per 100,000? As the numbers currently stand getting kids back in the classroom appears nearly impossible.

We do look at hospitalizations and capacity. When COVID-19 activity increases in the community there is a lag time and there is a long incubation period. It can be as long as 14 days. So one of the things I’ve shown to our Board of Health is that kids are less likely to get sick than adults, so why are we concerned about schools? Not all kids do so well. Certainly kids can get sick, but number two the schools are not an island and kids have a congregate setting in a school. They take the infection home to their parents and grandparents. Schools are part of the community, and that will bleed out into transmissions. We see more of the disease in young adults. There are reports in Florida that the older population is in jeopardy. We had some cases involving young adults who are partying with each other and not practicing physical distancing or masking. The incubation lag time is 14 days. Then there could be more lag time before that and when they visit grandpa and grandma, after several weeks you can start seeing cases in older people. Once you get to that point, it’s the point of no return.

We look at hospital utilization, but the number is creeping up slowly a bit. You also have to look at capacity in the nursing homes, and we are approaching capacity there. The hospitals have no place to discharge those patients if that happens. I’m concerned about that. We are entering the Fall where more people will be exposed indoors. I’ve got data on where people are exposed. I’m really concerned about nursing home facilities. I will want to take a look at nursing home capacity. This will be a new metric. We haven’t published it. These are the things that keep me awake at night. This is horrible. It’s all horrible. I’m speaking as a public official and physician, and there’s an incredible amount of logic applied to it, and it’s become political. It’s a recipe for disaster. When you go into a business and the masks use has become a statement of political stance. It’s similar to what we went through with the measles outbreak. Dealing with anti-science makes this political. The virus doesn’t care about our politics. COVID-19 is a top cause of death in the United States.

Question 4: After a person tests positive and then they go back in for subsequent tests so that they can go back to work, if those tests are positive also are they considered new positive cases?

A person is counted as a case once. They can have 10 positive lab results. 

Question 5: How is Mead School District near Spokane able to open up yet they’ve had more than double the COVID cases?

I listen to all perspectives also. Everyone who lives in Clark County is our constituent. So we have to listen to their perspectives. I can’t answer why Spokane is doing what they are doing. These state guidelines are recommendations. We have looked at the data, schools are not an island. We’ve looked at the metrics of not only cases per 100,000. We have considered the impact of the holidays. We decided as a group to delay to make sure the metrics are post three weeks Labor Day. We don’t want to open up to have to close again. They are bringing back special needs kids in small groups. The other thing is that we’ve had some cases in staff at some of the schools. We are putting out a dashboard about what is going on in the schools. We want to be proactive with parents. We have a vocal group pushing for reopening. It’s a complex discussion. We are trying to be as thoughtful as possible.

Question 6: Is the 25 cases per 100,000 metric that allows schools to open as normal even attainable before Spring 2020?

It depends. If people practice physical distancing and masking we can do it. We have it in our power to do something about this, but the poltical nature of this has inhibited us. We were there. The idea is to protect everyone else around us. COVID-19 is a disaster but it’s an opportunity for us to see what we can do to look out for our neighbors and co-workers, our kids. We have it in our power to protect us, and listen to the science, and make this less political. It’s a cloth, it’s a mask. Wear it.

Question 7: What is the COVID-19 recovery rate in Clark County?

For us, we’re not really tracking or categorizing cases as recovered because we interview cases and then we monitor those cases during the isolation period. We check in with them during the 14-day quarantine period. Beyond that we don’t have the bandwidth to verify recovery. We don’t follow up at the end of that isolation period. 

Question 8: When you submitted your application for Phase 3 you were confident the County was ready for that. Then we had an outbreak at a local business that derailed that and then the Governor put a pause on any variances statewide. Do you think the Governor’s approach is too draconian? Is his approach the correct one?

It’s the right approach. We wouldn’t be in this position if people would physically distance and use masks. Other countries are opening up. We need to be concerned about doing our share. The best answer to improve mental health is to mask up and social distance. We were in the moderate range and now we’re a 95.6 cases per 100,000. We were at 19.45 cases per 100,000 when we submitted that application in June, over 14 days. Take a look at our website https://clark.wa.gov/public-health and look at epi-curve. July 4 and Labor Day did us in. 

The remaining questions and answers will appear in Part 2. We will likely have more interviews with Dr. Melnick. Do you have any questions you’d like us to ask?