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Coronavirus

Colorado’s coronavirus surge swamps public health workers who track case counts, exposures

County health departments have switched to abbreviated questionnaires and robocalling. They spend hours hunting for duplicates in the case count.

P.J. Parmar, a family physician, tests a patient for the coronavirus in the parking lot of his clinic in Aurora on April 15, 2020. The medical clinic is part of the Mango House, a shared space for refugees and asylum seekers. (Moe Clark, The Colorado Sun)
  • Credibility:

Colorado’s daily flood of new coronavirus cases is overwhelming the local public health officials who work to accurately count cases and inform anyone who might have been exposed by each new contagious person. 

It’s become impossible to keep up. 

The Colorado Sun checked in with public health workers in several counties to find out how their ability to conduct contact-tracing has changed in the last few weeks as cases have spiked and if they’re confident in their case tallies. 

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The state has reached its worst point to date in the pandemic, with thousands of new cases reported each day. The statewide count moved past 240,000 Wednesday. 

A common theme across Colorado public health: Many businesses are failing to self-report outbreaks, as required by law, and people who receive positive test results need to inform anyone they might have exposed because contact tracers can’t get to them all.

“We don’t have eyes on every corner,” said Christine Billings, emergency preparedness and response coordinator for Jefferson County Public Health. 

Here are answers to three key questions:

How many of these “new” cases are just the same people being recorded multiple times?

None.

While every positive test result gets reported to the state, both the state and local public health agencies have a fairly extensive process making sure that one person with, say, three positive tests in a short timespan doesn’t get entered into the data as three new cases.

“‘A case’ is not a positive test result, it is a person with a positive test result,” the state health department wrote in an emailed statement to The Sun. “Even if a person tests positive multiple times, they are defined in the data as a case.”

That data all gets reported to a system called CEDRS, for Colorado Electronic Disease Reporting Systems. The acronym is pronounced “cedars.”

Each case has a name, date of birth and home address attached to it, and there is a system to catch duplicates, said Nicole Harty, an epidemiologist with Routt County Public Health.

County health departments also scour the reports for their counties as part of the normal investigation and contact-tracing process. But this can also help them catch duplicate entries that might have slipped past the state system, Harty said.

In larger counties, some of this work is even automated.

Raz Al-Jaf, a medical assistant who works at Ardas Family Medicine, documents coronavirus test results in the clinics system on April 15, 2020. (Moe Clark, The Colorado Sun)

Jefferson County Public Health epidemiologist Kate Watkins said she has written a program that looks for similar names, dates of birth and addresses so she can spot duplicates in her data. When she finds one, she notifies the state to delete the duplicate record.

“I spend a lot of my day actually making sure we don’t have duplicate cases in the system,” Watkins said.

Because it’s important to have accurate data as soon as possible, public health officials review the data daily to correct any errors. Margaret Comstock, regional epidemiologist for the Pueblo Department of Public Health and Environment, said the work has gotten harder as case numbers have swelled, with more than 8,000 people now having tested positive in Pueblo County since the pandemic began.

“It’s very time-intensive,” Comstock said. “Believe it or not, even with 8,000-plus cases, we will recognize those names.”

Are businesses, churches reporting outbreaks? 

Under state law and a pandemic-specific public health order, businesses and organizations are required to report outbreaks among their staff to local public health authorities. But it’s clear from talking to several health departments that compliance — and enforcement — is haphazard. 

Coronavirus is so widespread at this point that epidemiologists in some counties no longer have time for the detailed casework they were doing back in the spring and summer. They are more often relying on businesses, churches and other organizations to report outbreaks, rather than using detective-like skills to trace them back to the source. 

“Businesses are supposed to, by law, report to us if they have an outbreak if they have two or more cases,” said Watkins, at Jefferson County Public Health. “Whether or not they do, that’s another thing.”

In Lakewood, for example, a church whose pastor announced during a sermon that “20 or 30 families” had COVID-19 is not listed on the state’s outbreak list. Jefferson County received a call from the church in late October, and public health officials spoke to church leaders in November, but the church has not been listed publicly as having an outbreak. An outbreak is defined as two people with COVID-19 not living in the same household who test positive within a two-week period. 

Julianna Sandoval, 24, pauses for a COVID-19 nasal swab test from Dr. Sarah Rowan from Denver Health Medical Center. Rowan and other medical staff administered a free drive-up COVID-19 testing in the parking lot of Abraham Lincoln High School on November 7, 2020. (Kathryn Scott, Special to The Colorado Sun)

New Hope Ministries Pastor Ray Chavez told his congregation in a Nov. 11 sermon that one of their members was in intensive care, struggling to breathe. “There are about 20 or 30 families in this church right now that are out with the COVID,” he says in a YouTube video. About a dozen people, including a choir in red robes, are standing in the church behind him. No one is wearing a mask. 

A woman who answered the phone at the church Wednesday declined to give her name but said New Hope Ministries is “following every guideline.” She said she did not know why the outbreak was not listed by public health officials.

“There’s an outbreak everywhere,” she said. “It’s not just us.” 

Health officials said that when they discover outbreaks at restaurants, gyms, churches or other businesses, it’s often because a tipster — someone other than the business owner — called to complain. Back when they had time for detailed casework, public health officials were identifying outbreaks that, in many cases, had not been reported by the workplace or event where they occurred.

In Routt County, businesses are reporting outbreaks “sometimes,” according to Harty, the epidemiologist. “The more common scenario is that during the course of a case investigation or contact tracing, public health learns of connections between cases,” she said. 

Tri-County Health Department, which includes Adams, Arapahoe and Douglas counties, cannot keep up with outbreak investigations and is investigating only those at the top of the priority list. A Littleton restaurant owner told The Colorado Sun he had to shut down for several days this fall because 12 employees had COVID-19, yet the restaurant is not listed on the outbreak list. 

Similarly, Pueblo County contact tracers aren’t keeping up with outbreaks in real time. “We are still doing it,” said Alicia Solis, program manager for community health services. “We are not up to date on it.” 

As they try to catch up, the division is forwarding tips about potential outbreaks and noncompliance issues to its emergency preparedness division, which investigates and cites businesses for violations. “We’re trying to tackle it from two different ends,” Solis said. 

She wishes businesses “would take the initiative” when they know a worker has tested positive and exposed others. They should send employees home with instructions to isolate, Solis said. 

“What’s happening is businesses are waiting and saying, ‘No, you can keep coming to work until public health calls you and notifies you,’ even though they know you were a contact,” she said. 

Is contact tracing even useful with such communitywide spread?

At the start of the pandemic, Jefferson County contact tracers tried to interview everyone with a positive coronavirus test. Where did you go in the last 14 days? Were you around people with cold-like symptoms? Name the people you spent time with at work, at the gym, at church, they asked. 

Now, as the number of coronavirus cases in Colorado has reached more than 241,000, there isn’t time for that. 

Jefferson County switched to an abbreviated questionnaire to track cases and no longer asks where a person went during the prior 14 days. Trying to pinpoint where someone contracted the virus is nearly impossible now that an estimated 1 in 41 Coloradans are contagious with coronavirus. 

“Trying to identify where they have picked it up in the 10 places they went in the two weeks before they became sick, it’s just impossible right now,” said Watkins, the epidemiologist. 

Health departments in rural areas, including Routt County and the Northeast Colorado Health Department in Sterling, said they are still able to do case investigations and, in many instances, notify employers and other contacts who might have been exposed. Other counties, though, are relying on people to inform their contacts because public health workers can’t call hundreds of people per day. 

Colorado Gov. Jared Polis receives a coronavirus test in Wheat Ridge on Monday, May 18, 2020, to show Coloradans how quick and easy it is. Polis says everyone in Colorado who has coronavirus symptoms can now be tested. (Jesse Paul, The Colorado Sun)

Pueblo County changed its protocol last month and stopped calling people who might have been exposed to coronavirus. The system now works mostly via technology. 

A person who tests positive will get a robocall and text letting them know their test result. If that person provides names and phone numbers for others they might have exposed, the county will robocall or text those contacts and inform them they should quarantine. 

“We’ve come to the point where we can’t do the actual contact-tracing for everybody,” said Solis, the Pueblo epidemiologist. “We’ve started asking the cases themselves to reach out to their contacts and think about where they’ve been, who’ve they’ve been in contact with.” 

The emphasis on community responsibility was mentioned by several health departments. The daily case count in Colorado is the worst it’s ever been, and public health officials said they are spending much of their time teaching the public — or advising doctors and labs to tell their patients — what to do if they get a positive test result.

Text friends. Tell coworkers and anyone else they saw in the two days before they got symptoms or a positive test. Also, stay home.

Nine months into the pandemic, “COVID fatigue” has set in and people are letting down their guard, said Billings, at Jefferson County Public Health. 

“The recommendations that worked really well in the beginning, people are just tired and there is some weariness about that, so those just fall by the wayside,” she said. “It’s weird and awkward to be in a space where you are with your friends that you’ve known for years and wearing masks and staying 6 feet apart. That’s not natural human behavior.”

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