HomeMy WebLinkAboutHealth Officer Recommendations 051420SHealth Officer Recommendations Re: Variance Request to Move from Phase 1 to Phase 2 of Governor
Inslee's Stay Home — Stay Healthy Proclamation
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 70.05.070 (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.
Signed
Thomas Locke, MD, MPH Date
Jefferson County Health Officer