CLEVELAND, Ohio — The number of confirmed novel coronavirus cases is still only “the tip of the iceberg” when it comes to the community-level spread of the disease, Ohio Department of Health Director Dr. Amy Acton emphasized Sunday, as she soberly shared the figures, including hospitalizations and deaths.
On the ground in Cuyahoga County, public health officials have finessed a way to get a clearer understanding of the number of people here with COVID-19, the disease caused by the coronavirus. They’ve created a tracking system that gets in front of that daily snapshot — a picture obscured by a bottleneck of lab results and shortages of test kits and sample swabs that have narrowed testing to only health care workers and the sickest patients.
Relying on time-tested methods for tracing the spread of disease – calling and interviewing people, gathering their contacts, recording symptoms – they started last week to compile a list of “presumed” COVID-19 cases.
As of Monday, the Cuyahoga County suburbs had 149 cases of the coronavirus, not including the 36 cases reported separately by Cleveland city health officials. Statewide, there were 442 confirmed cases, 104 hospitalizations and 6 deaths.
Using the in-house system, county public health workers and physicians identified an additional 26 presumed cases of the disease in the county as of Monday morning. Presumed cases include people who have developed symptoms of the disease after being in close contact with a known positive case but who have not been tested themselves.
‘An exponential growth’ of potential cases
Pretty quickly after the first COVID-19 cases came in earlier this month, the county board of health staff realized that they would need to look beyond the number of confirmed cases, Romona Brazile, deputy director of prevention and wellness, told The Plain Dealer.
The board of health turned to its growing team of “disease detectives,” doctors and residents who call patients with confirmed cases and compile lists of their contacts: people the confirmed cases worked closely with, sat next to in church or relatives in their home. And the nurses and medical students who reach out to those contacts.
If those contacts have or later develop symptoms of the virus, which can include a fever, chills or shortness of breath, they are presumed to have the disease. And the cycle continues.
“It’s just an exponential growth of people,” Brazile said of the contacts they’re tracking.
The presumed cases are being treated as COVID-19 cases, Brazile said, meaning people are being given strict isolation instructions and are mailed a letter by the county to share with first responders, if needed.
Not every local department is taking these additional tracking steps but as cases increased in Cuyahoga County, Brazile said, “we needed to put in another step to limit exposure.”
A new level of disease tracking
Tracking the path of disease isn’t new for the county; disease investigators there do it regularly for influenza, sexually transmitted infections and viruses like West Nile.
But that work and the “public health warriors” – as Board of Health Commissioner Terry Allan dubbed them – who do it are usually behind the scenes, invisible to most citizens.
Romona Brazile, director of prevention and wellness for the Cuyahoga County Board of Health. Brazile, a registered nurse, has worked for the department for 18 years and said the scale of the operation to track COVID-19 is "once in a lifetime."
Brazile has been working almost every day for the past month to keep up with the spread of coronavirus throughout the community. She is part of a 50-person team at the board of health, all of whom are working long hours.
“The scale of this is not even in comparison with anything we’ve had to do before, said Brazile, a registered nurse who has worked at the board of health for 18 years.
The work is urgent; the public health workers want to reach as many people with possible exposure as quickly as possible to assess and quarantine right away, Brazile said. “That way, if they start experiencing symptoms, they have already reduced their exposure,” she said.
Tracking presumed cases is also an important stand-in because many people with symptoms don’t need to be tested; public health officials have said up to 80% can safely treat the virus at home. That reserves limited tests for those who are hospitalized and health care workers.
During a Monday press briefing, Acton urged primary care doctors to follow the lead of public health workers and to ask patients with symptoms of the virus about others who live in the home. She said physicians should give instructions for anyone sick to isolate and anyone exposed to quarantine.
“You don’t need a test to do that," she said.
Like many things related to this pandemic, Cuyahoga County’s disease tracing system is adjusted daily, sometimes more often, as additional cases come in and the capacity to handle them shifts, Brazile said.
Initially, health departments tracked travelers referred to them by the state for symptoms of the disease. Travel restrictions have since reduced those cases.
Before the number of cases surged, public health staff were able to check-in daily with patients who had been exposed to the virus to record their body temperatures and the progression of any symptoms.
Now, the work has shifted to tracking the symptoms and spread among the confirmed and presumed cases, she said.
Those patients are given a private phone number to call, which is monitored around the clock by medical students who can connect them with a physician, if they develop symptoms or their condition worsens.
Dr. Adeola Fakolade, a Cleveland preventive medicine physician, works in Parma Monday as part of the Cuyahoga County Board of Health's COVID-19 response.
Information and data experts at the board are working on a way to track both confirmed and presumed positives electronically, but for now they have developed a system of paper forms that are placed in different bins or drawers to track cases and a giant whiteboard paint wall to keep up with contact counts, case counts, hospitalizations and clusters.
The board is also using geospatial systems to begin mapping lab-confirmed and presumed positive cases, said Dr. Heidi Gullett, medical director for the county board of health during a Monday press briefing. That information hasn’t been shared publicly out of caution for privacy issues, officials said.
Maps have helped disease investigators keep an eye on clusters, or the spread of the virus geographically in the county.
Disease clusters could be, for instance, a family that has multiple members in the same household. Or a number of people who attended the same social event. Or a health care worker who has interacted with a number of patients.
The team also is monitoring any confirmed tests in high-risk places, like nursing homes and assisted living facilities, Brazile said, and providing special instructions on how to isolate those patients and look for symptoms among other patients or staff members.
“We are going to investigate even if it is only one case,” Brazile said.
Officials want to prevent the widespread transmission of the virus among patients and staff members that has occurred in nursing homes in other states, including Washington and Illinois.
The ‘local curve’
Their tracking method isn’t precise, it isn’t a medical diagnosis, officials said, but it’s the best possible way to start figuring out what the “local curve” for coronavirus might be.
The county is exploring a few different ways to map and examine the “local curve,” including the use of geographic mapping of lab confirmed and presumed positive cases.
For some, eager for more information on where clusters might be or how the disease is spreading, it can be frustrating that more details have not been shared with the public.
“I think we always have to balance between adequately addressing a public health problem, providing information people need to take care of themselves and protecting individuals’ privacy,” Brazile said.
The “denominator”
Another hurdle is what public health officials have referred to as the “denominator” problem: knowing the total number of tests performed in a county or statewide for the virus.
Under normal circumstances, laboratories would be reporting positive, inconclusive and negative results, Gullett said.
But with the quick ramp-up and tests results coming from hospitals and private labs and physicians’ offices, it became “impossible” to continue to enter all positive and negative tests into a statewide data system, Gullett said.
Acton acknowledged Monday that lab results from private labs handling COVID-19 were “lagging quite a bit” and that the state doesn’t know how many people in total have been tested. She encouraged hospitals to immediately report data on positive tests to the state health department and the U.S. Centers for Disease Control and Prevention.
Gullett said health officials are working with local hospitals and private testing labs to try to get an accurate count of the total number of tests, in order to find that denominator and calculate the percent of tests that are positive.
But not all of the hospitals are sharing their testing information publicly, and what is shared may not be suitable for an “apples to apples” comparison. However, hospitals are sharing positive cases with the state.
University Hospitals said it has performed 850 coronavirus tests and has a 4% rate of positive tests. The Cleveland Clinic and MetroHealth have declined to provide specific numbers to The Plain Dealer.
An additional complication, Gullett said, is that not every sample collected by a hospital or a physician is tested for coronavirus. The collected samples are first tested for other respiratory infections, like influenza and RSV, which can have similar symptoms.
The tests for COVID-19 were limited further last week after there was a shortage of testing supplies, namely the cotton swabs used to collect samples.
Adding somewhat to the confusion is that hospitals use the term “presumptive positive” to refer to tests that they have found to be positive but have not yet been confirmed positive by the state.
Understanding onset and symptoms
County health officials, in addition to tracing confirmed and presumed COVID-19 cases, are starting to track the symptoms that the people they interview have experienced, Gullett explained. It will help them, eventually, better understand the progression of the disease and its effect at the population level.
This is a new disease, Gullett said, “We want to understand this virus and how our immune system responds to it.”
Brazile said that while information is not yet concrete, nurses and doctors are getting a sense from their many interviews for how the disease can progress.
In general, complications happen in the second week after symptoms begin, health officials have found. In addition, symptoms can change rapidly from the onset of the disease.
Anecdotally, nurses are learning that for some, the earliest symptoms for those who develop COVID-19 are more of a general malaise. People “don’t feel like themselves” for a few days or a week before developing other symptoms, Brazile said. COVID-19 also seems to be different in that the respiratory symptoms aren’t generally sniffles associated with things like seasonal allergies but are more in the lower respiratory system.
Coronavirus also can feel similar to a seasonal flu, of which there are a lot of positive cases as well.
“We may not be able to tell the difference at first,” Brazile said.
That’s why their message is simple. If people have symptoms: “Stay home,” Brazile said.
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