RESPONDING TO COVID

COVID

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Responding to COVID in Fresno County

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FRESNO COUNTY IS IN THE COVID-19 “GOLDILOCKS ZONE” – JUST THE RIGHT SIZE TO MOUNT AN EFFECTIVE RESPONSE AGAINST THE CORONAVIRUS THAT HAS SWEPT ACROSS THE GLOBE IN SIX SHORT MONTHS, SAID RAIS VOHRA, M.D., WHO HAS BEEN LEADING THE FIGHT AGAINST THE DEADLY VIRUS FOR THE COUNTY’S 1 MILLION RESIDENTS. >>

Dr. Robin Linscheid Janzen, US Reprehensive James Costa and Public Health Officer Dr. Rais Vohra volunteering their time at a local Surveillance Testing for COVID

Clovis Community Medical Center Emergency Department The county is big enough to have the necessary skills, knowledge and resources, but not too big for those in the battle to be able to pick up the phone and connect quickly on problems, explains Fresno County’s interim Public Health Officer. “What has allowed us to be efficient and get stuff done is the kind of intimacy you get in a town that’s not any bigger or any smaller than Fresno,” said Dr. Vohra, who is the current medical director for the Fresno/ Madera Poison Control Division, an emergency physician at Community Regional Medical Center and a UCSF Fresno faculty member.

While cases locally continue to steadily climb, the hospitalization rate among those testing positive for the novel SARS-CoV-2 has remained under 10% and the mortality rate is 2%, with 57 deaths in Fresno County as of mid-June. So far, Fresno County has avoided the public health issues of bigger locales like Los Angeles, Santa Clara and San Francisco counties, with area hospitals continuing to have the capacity for COVID-19 patients.

Dr. Vohra ticks off a few more things that have made the difference: county supervisors who listened, provided resources, and supported an early declaration of a healthcare emergency; the City of Fresno’s early shelter in place order; an agile, seasoned public health team; and a mumps outbreak in the jail that gave the county a road map to follow for congregate settings.

David Pomaville, director of Fresno County’s Public Health Department, agreed that previous experience with smaller disease outbreaks were helpful. But he also credits Dr. Kenneth Bird, the previous county health officer, for laying the groundwork with his “Eight Pillars of Public Health”.

Dismal healthcare ratings for Fresno County had spurred Dr. Bird to pick up his pen and urge others to do something about it. Dr. Bird explained that while good health depends on access to social/economic opportunities, quality schooling, safe neighborhoods and workplaces, a clean environment, and quality social interactions/relationships, those things need support from every part of the community to ensure they happen.

“It didn’t take long for me to go to that ‘Pillars of Health’ and get all these sectors actively engaged and involved in this pandemic,” said Pomaville. “We went to our schools. We started to work closely with the local business community. We went to all our local government partners to establish lines of communications. We went to the medical community to have discussions about what they needed to be prepared. We went to media and set up a

Dr. Jeffrey Thomas discussing national COVID cases at the CMC COVID command center in Downtown Fresno.

structured communications system. You can’t just look to one sector to solve the crisis.”

Pomaville added, “I certainly have learned in all my years of handling crises, I don't try – at all, ever – to do everything.”

Cooperation and relationships key to slowing COVID-19 spread Dr. Vohra had just stepped into his role as interim health officers a few months before COVID-19 hit, while Pomaville had been through three different boards of county supervisors in his years as the public health department’s top administrator. Their combined experiences worked to bring people together quickly and early to respond to COVID-19.

“While he may have leaned on me for some of the inner workings of government, I have definitely leaned on him for his expertise about local healthcare systems and his credibility in the medical community,” Pomaville said of Dr. Vohra.

In January, Pomaville’s team was warily watching the news of a novel coronavirus killing people in China, knowing it could jump across oceans with ease and land in Fresno. By February SARS-CoV-2 showed up in a Seattle nursing home. Soon after it arrived in San Jose and San Francisco. “We had really prepared our board (of supervisors) and talked to them about what our triggers would be to declare a public health emergency,” Pomaville said, listing the triggers as community transmission, multiple cases and COVID-19 deaths.

Pomaville helped walk Dr. Vohra through the steps, helping prepare proclamations way ahead of when they would need to ask the county board to vote on it. By March 15 Fresno County had two positive COVID-19 cases, both men who had contracted it while travelling outside the country. Some in the community thought it was too early to react, but larger studies showed regions that responded early with shelter in place orders had fewer deaths and less impact on their hospitals.

Fresno County’s state of emergency declaration, unanimously approved on March 17, allowed the public health department to bypass procurement rules and the required government bidding process to quickly get supplies and equipment. It freed Vohra and Pomaville to pursue state and local emergency funding. It also allowed county workers to be deployed from their usual jobs into roles responding to the health crisis. So librarians became call center staff and environmental health inspectors became contact tracers.

“The culture change that happened was amazing,” Dr. Vohra

said. “It was like someone flipped a switch.”

Pomaville praised county supervisors’ support: “They don’t just give us a free pass. But they welcome us to challenge them to think things through differently and not just tell them what they might want to hear. I know that there have been struggles in other counties.”

Vohra agreed, “The supervisors are not biologists. They’re not trying to know anything about medicine. And they gave us the complete benefit of the doubt” when asked for an emergency declaration. That respect and trust is mutual. Board of Supervisors Chairman Buddy Mendes told the Fresno Bee he appreciated that Dr. Vohra was still working shifts in a hospital: “He works in the real world. He seems very practical … you get the real story from him.”

By March 18, Fresno Mayor Lee Brand had issued a shelter in place order for the city and a day later the whole State of California followed, shutting down most businesses and prohibiting any gathering larger than 10 people. Key to cooperation were the conversations public health was having with different sectors of the community to educate, explain – and then ask for cooperation. The approach depended on relationships and compromises rather than heavy-handed regulation.

Being able to call on community partners helped Fresno County overcome the fact that it has been without its own public health lab since it was destroyed following an October 2018 water main break. Public health had been relying on outside labs in neighboring counties and large commercial laboratories. Those resources were strained with coronavirus and results were slow in getting back to Fresno.

“We had the equipment salvaged… so I approached Dr. Castro at Fresno State and asked if they had a physical space that we could set up and do testing in,” described Pomaville. “He got right on it. I can remember working over a weekend with him and his team and we identified a great spot. We set up a laboratory that’s been running ever since.”

“THE SUPERVISORS ARE NOT BIOLOGISTS. THEY’RE NOT TRYING TO KNOW ANYTHING ABOUT MEDICINE. AND THEY GAVE US THE COMPLETE BENEFIT OF THE DOUBT”

Rapport with courts and jail staff was solidified during a January mumps outbreak in the Fresno County Jail. The viral infection flare-up set the county up for continued successful disease containment and prevention inside the downtown Fresno facility. When 11 inmates in the jail’s North Annex tested positive for mumps, public health worked quickly to implement contact tracing and testing to quarantine 300 inmates, limit interaction with the courts and then offer immunizations to staff and inmates.

“Mumps was our dry run for the current virus in the jail,” Dr. Vohra said. “That was a really good rehearsal for us because we were able to use almost all of our processes and structures we had put in place for the coronavirus. That’s why you don’t hear about outbreaks there like other jails. The sheriff is very supportive. It’s always helpful when you can just pick up the phone and have a conversation.”

Shifting knowledge, resources challenged public health response Public health officials have drawn heavily on past experiences, not just locally with mumps, but also their preparations during a 2014-15 California measles outbreak and a 2013-14 Ebola flare-up that ravaged parts of West Africa. But they have been frustrated with the unique challenges presented by COVID-19: constantly shifting health recommendations, politicization of the public health response and the rampant spread of misinformation.

COVID-19 was first reported to the World Health Organization (WHO) on Dec. 31, 2019. Chinese officials say they discovered the respiratory virus in November 2019. And while medical researchers and physicians treating patients are collaborating worldwide, much is still being discovered about this novel coronavirus.

“I remember being here late at night typing up guidance for my nurses and then an email pops

Courtney (left) and Jasmine (right) are registered nurses in the emergency department at Community Regional Medical Center. This was their new reality as RN’s and the frontline faces of COVID. Testing patients and working with physicians and other healthcare staff ensuring patients are cared for and safe. up with new changes,” said Mary Morrisson, a supervising public health nurse who has headed communicable disease investigations for years. “I had just written up four pages of guidelines. I just threw up my arms. It was either laugh or cry.”

Recommendations and regulations from state, federal and global health organizations not only were rapidly changing in the first weeks of the pandemic, said Morrisson, but they often contradicted each other. “It’s been mixed messages,” agreed David Luchini, assistant director of Fresno County Public Health. “WHO says something that causes confusion with the public and then the CDC says something different. And we’ve got the state with different recommendations. It’s been really hard to align our practices with these.”

But even worse has been the polarized public response, he asserted. “In 27 years in public health I will say this has been the most politicized infectious disease crisis I have ever been in. When wearing masks to protect people from a disease is a political thing, that’s a problem. And when people say that we’re faking the numbers, that’s a problem. We’ve had comments coming in to our social media posts saying that public health was making it up and that the local hospitals and doctors were complicit.”

What’s added to the mistrust has been the rush from some commercial health companies to offer quick virus and anti-body tests, as well as the boasting by some countries about mass testing in short periods of time. People wonder why tests have been so restricted and slow locally, said Pomaville. “When we talk about the 20,000 tests we've done in the last 14 days, it’s the gold standard virus test … There's a lot of different testing methodologies and approaches that are out there that have had more questionable results from a public health perspective,” Pomaville explained.

Luchini may have one of the toughest jobs in this crisis as the liaison officer, dealing with public complaints and inquiries, answering

questions from businesses wanting to open up, and meeting and engage them. But I need to find partners who can reach regularly with schools, community groups, faith-based out to other groups in the rural communities and especially to organizations and local government representatives. “We’re underserved groups like farmworkers.” Those groups need to stuck in the middle. One of our biggest challenges is trying be armed with education to help protect themselves and slow to find the right balance,” he said. “We have some parts of the the coronavirus spread, he said. community say we’re being too assertive, too aggressive in locking down too many things. And some say we’re not doing Light staffing hasn’t been intentional, Vohra thinks: enough … We see studies that say we probably saved a lot of “Sometimes you succeed yourself out of a job because you lives by jumping in early and shutting things. And then another do things so well after a while people stop valuing what you study will say by shutting down too long we may be doing provide because it's just part and parcel of what they’ve come damage mentally for other people with the social isolation.” to expect. Vaccination of the public, clean water, clean air, these During three- credits public health for times-a-week Zoom doing it. Then when conferences with there’s a crisis, people media, Dr. Vohra “I KNOW HOW TO TALK TO DOCTORS ask ‘Where's public has tried to help the public make sense of LOCALLY AND ENGAGE THEM. BUT health?’ and say ‘They're not doing their job.’ the shifting health I NEED TO FIND PARTNERS WHO Well it's because they recommendations and understand CAN REACH OUT TO OTHER GROUPS were underfunded and undervalued for a long how COVID-19 is IN THE RURAL COMMUNITIES AND time.” spread and attacks the body. He’s ESPECIALLY TO UNDERSERVED Nimble adaptation also tried to dispel myths about politics GROUPS LIKE FARMWORKERS.” required stay ahead of COVID-19 playing into health Staff and supplies may recommendations or have been limited, resource allocations. but Fresno County’s Tight resources and staff have also challenged public health’s expertise, adaptability and support of other county staff, response, said Rose Mary Rahn, the public health nursing acknowledges its newest member. “This team is really a smart, director and director of the county’s Maternal, Child and agile, flexible, expert team,” Dr. Vohra praised. “This team Adolescent Health. “Public Health has not always been the has been really resilient … and we were able to recruit from most well-funded entity. It isn’t like we had a whole team of departments that shut down.” investigators on standby when this hit,” she said. “In the old days we used to keep staff that would work on projects and Veteran nurse Rahn said that response has been key. “I’m could be deployed for that.” amazed at how we all came together. All of us mobilized and And in the old days, Rahn observed, everyone kept stockpiles them into complex disease investigation.” of supplies around. “But now we have these real time deliveries with food, business supplies and we have seen the real impact The challenge has been the continuing stress of doing new of that as well in public health,” Rahn said. And when the work long-term and the constant adjustments, Morrison said. whole world needed the same supplies of testing chemicals, “We’ve been working day and night and weekends to do our respiratory equipment and personal protection for clinicians best to contain this and flatten the curve. We’re asking people and no one had warehouses set aside of those supplies, it to change how they think and what they’re doing and they’ve exacerbated the health crisis. really had to adapt quickly,” she said. “Then the next week “I do wish we had a bit deeper bench,” Dr. Vohra said of the January we really didn’t know anything about it.” public health resources. “I know how to talk to doctors locally are all things that are public health victories. But no one really Department of Public Health has a huge storehouse of jumped right in … I’ve taken brand new nurses and thrown things have changed again. This is a really new virus and in

But by late February, Pomaville said, they knew enough to pandemic has been figuring out new ways to work together get ready. Their department assembled into an incident crisis “The silver lining for this crisis so far has been the cross command structure – weeks ahead of the county’s public training of staff and community partnerships,” Luchini health emergency declaration. Responsibilities were shifted, said. “We’re trying to develop even more partnerships with training started on how to track diseases and isolate those community organizations to help us with contact tracing. exposed. “Today, we’ve got about 100 people doing medical We think CBO’s can do a better job, because they have investigation and contact tracing,” he described. “They’re from strong trust with certain neighborhoods and communities a variety of different places in our public health nursing and and can play a critical role there.” we’ve been borrowing our environmental health specialists to do this since they haven’t been needed to inspect tattoo parlors Readying for the next wave or things like that.” Public health will likely lean on community partners even Environmental health inspectors are also working as liaisons in a pandemic you have a second wave,” Rahn elaborated. with Fresno County’s “Different communities 15 cities to ensure local – Hmong, migrant governments are getting farmworkers, some rural good information and “WE ARE CREATING SYSTEMS THAT pockets – haven’t really help with some large employers and reopening ARE WORKING BETTER AND NOW been as educated or felt this yet. We know some of businesses, said WE’RE STARTING TO GET IN THIS workforces are going Pomaville. He’s also been able to augment RHYTHM. I THINK WE CAN SUSTAIN to be hot spots. I’m hopeful people maintain the county workforce by THIS FOR A WHILE. THIS IS NOT A vigilance.” hiring people from related sectors. “We actually SPRINT; IT’S A MARATHON.” Dr. Vohra is starting hired 15 paramedics from to enlist community American Ambulance to leaders from underserved do contact tracing. We areas to do televised wanted to give them really good knowledge of public health and radio public service announcements on remaining issues and they saw a significant slowdown in their work so vigilant, maintaining social distancing and mask wearing. they were available,” he explained. He’s looking to hire licensed “We’re piloting this, but I’m hoping it will last beyond this vocational nurses from schools next. pandemic. That will be the real gain is if we build on these Pomaville explained: “We already trust their work …we can bring them on quickly, they can work with us for a couple of Readying for the second wave will require more months in the summer and then when they go back to their surveillance, contact tracing and testing. Currently, school job they've got that knowledge and understanding Pomaville said high volume testing sites, like the one at of disease outbreaks. We hope they’ll be our frontlines, so if Fresno City College, are run by an outside lab and they’re COVID-19 crops up in a kindergarten class then they're going doing up to 100 tests a day with about a 4% positive to be the ones that will have the expertise to initiate contact rate. Those sites are testing even asymptomatic people. tracing and educate parents.” Pomaville’s aiming to get similar testing up and running in As everyone else did, the county learned how to transition to more in the coming months, Luchini predicted. “We know relationships.” western Fresno County. work remotely via laptops and change policies to allow more Increasing testing is great, but there needs to be more employees to work from home, Rahn said “We are creating coordination to operationalize and make sure testing data systems that are working better and now we’re starting to get in is used quickly. “One of the critical failures we have had is this rhythm and I think we can sustain this for a while… This the timeliness of getting a positive report in our hands and is not a sprint; it’s a marathon.” the disjointed reporting systems that we have in the county and state,” he said. “There’s work to do to streamline those Both Morrisson and Luchini agreed one of the big gains in this functions so if somebody’s tested in a private office or a

hospital the report gets to us right away. We’re still seeing delays getting tests through the state’s reporting system and then down to us.”

Dr. Vohra is bringing on help for the continuing response. When UCSF Fresno pulled residents out of clinical rotations for their safety and to conserve PPE, Dr. Vohra brought on as many as he could to help in the public health department. One of those, Sukhjit Dhillon, M.D., just finished her residency and is joining the department as deputy health director.

Morrisson is already thinking ahead to how to mobilize vaccination clinics for nearly a million people when the COVID-19 vaccine is developed and available. “We’ve done drive through flu vaccination clinics, so I think we know how to do it,” she said. “I think this is just going to become one more of those diseases we have to manage as part of our regular routine.”

The whole team figures along with a surge in COVID-19 cases they’ll also begin to see other diseases like measles resurface and chronic health challenges such as diabetes become worse. “We understand these other diseases have not gone away. They’ve been kind of driven underground to some extent, but they’re going to come back and bite us,” Dr. Vohra said. “But at the same time we now have a stronger, more agile structure to address these other issues.”

Hope for Fresno County’s public health future COVID-19’s hardships have also spawned community connections and lessons that promise a brighter public health future for the region, said veterans in Fresno County’s department.

For Rahn the COVID-19 crisis “has reinvigorated my passion for public health … I’ve also learned how important relationships are. I knew that before, but I really saw it in this crisis.”

Morrisson agreed, “We as a community and health department banded together to fight. I feel like we bonded through this and I think we will come out stronger on the other end.” She added, “And the biggest lessons for us is that public health is a critical piece of our overall health system.”

Pomaville’s not so sure that lesson has been absorbed by the general public. “I think the light bulb has come on for some of our government partners,” he said. “And I think that’s more meaningful right now.

“I believe our school administrators have a far better understanding of what a robust public health department needs and how we can work together on things,” Pomaville said. “I believe that our law enforcement and fire agencies have a much better understanding of us. And I believe that our local elected officials have gotten incredible insight into public health so they are armed with good information to ask good questions to really understand how public health is funded and how we leverage it as we go forward.”

Dr. Vohra said before the expected surge of COVID-19 cases to come, “It’s time to take a breath take a look around and say ‘Okay, what’s the lessons that we've learned? How can we sustain this going forward?’ Because we have such a strong public presence right now and we really can capitalize on this energy and this momentum.”