The Latest on the Local Actions and Reactions to COVID-19

State health commissioner Dr. John Hellerstedt (r) briefs the House Public Health Committee chaired by Rep. Senfronia Thompson, D-Houston (l) (Photo by Jana Birchum)

Against the backdrop of worsening conditions globally and nationally wrought by the novel coronavirus that causes COVID-19, local officials and healthcare providers are conveying a sense of preparedness and confidence, mixed with sober concern.

This week, the world watched as the entire nation of Italy went on lockdown due to the coronavirus, while dozens of countries reported having new or additional cases of the disease that was first identified in China in December. Thirty-eight states and Washington, D.C., now report at least one case of COVID-19, and 36 deaths have been reported from the disease nationwide. Most of the fatalities (29) are still in the state of Washington, where a number of residents of a skilled nursing facility in the town of Kirkland have died.

The spread has been rapid, experts say, because the virus is new to humans who have no developed immunity against it. It is believed to have "jumped" from bats, a legacy it may share with two other recent and concerning coronaviruses — SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome). Other coronaviruses cause the common cold.

In Austin, the cancellation of South by Southwest, announced last Friday, was still a bit of a shock, even amidst the backdrop of other cancelled events and conferences, new travel policies and restrictions, and even heightened cleaning regimens. No cases of COVID-19 have yet been identified in Travis County. While an undisclosed number of individuals have been tested – mainly because of their travel history in recent weeks – Austin Public Health (as the Chronicle went to press on Wednesday, March 11) continued to report that no one has tested positive.

Local officials' decision to cancel the huge international event came under the authority of a disaster declaration issued last Friday and renewed on Tuesday. The declaration allows the local authorities to prohibit mass gatherings that don't meet new and more stringent requirements for safety and health, that have been established in response to concerns over the virus. As of press time, events in Travis County expected to attract mostly Texans, such as Rodeo Austin and Luck Reunion, have been allowed to go on. Other events are continuing to be reviewed.

Coping with an outbreak

This week also saw an outpouring of new information about what is known of the trajectory of COVID-19, and who is at most risk of severe illness and death from the disease. Concerns have been raised in Austin and across the state that while we haven't seen one yet, we all must be prepared for a "surge", or sudden spike of patients, at local hospitals and healthcare facilities, as has occurred this week elsewhere.

At the Texas Capitol on Tuesday, March 10, the House Committee on Public Health, chaired by Rep. Senfronia Thompson, D-Houston, heard five hours of testimony about these concerns. The question is whether facilities can handle the number of patients they may get – some of whom may have COVID-19 and some of whom may need treatment for other serious illnesses or injuries, but all of whom could be impacted by shortages of equipment, supplies, space and healthcare workers. In particular, shortages of trained healthcare workers – who may need to be quarantined themselves if exposed – could significantly handicap response to an outbreak.

Presenting an update to Travis County commissioners on Tuesday, Austin Interim Health Authority Dr. Mark Escott also detailed the importance of proactive preventive measures to avoid suddenly overwhelming hospitals and other elements of the healthcare system. "When we have an unbridled increase in cases suddenly, as happened in Wuhan [in China], it exceeds the capacity of the healthcare system, which means we are going to see excess death. When we can draw that out over time, when we can utilize our resources effectively we can take better care of people and mortality will significantly drop," Escott said.

In other words, death is not inevitable, even for the most vulnerable, but mortality is at least in part dictated by the level of care available to those patients when they need it. The more that communities can do to slow the pace of the spread of the disease, experts say, the better their healthcare systems will be able to cope.

The availability of COVID-19 tests and the capacity to process them remain points of contention. Despite claims from the White House this week that essentially anybody who wants to be tested can be tested, those on the front lines say this simply isn't true. Within Austin and Travis County, people are encouraged to call first before showing up to a healthcare provider or hospital if they have symptoms they think could be COVID-19, said Bryce Bencivengo with the city of Austin's Office of Homeland Security and Emergency Management. Providers, in consultation with Austin Public Health and the Texas Department of State Health Services, (DSHS) will determine if testing is warranted in specific cases, he said, and patients who are well enough will be released but are asked to self-quarantine until test results are known.

Understanding the risks

Part of the reason for this protocol is that lab testing capacity, though recently improved and still expanding, is still lacking in Texas and nationwide. Right now there aren't enough tests available for everyone who might want to be tested, Escott told the Commissioners Court on Tuesday. "We are getting multiple calls every day from clinicians around the community," he said, and those cases must be triaged. "I want to make sure that we're not testing the twentysomething-year-old who's concerned because they met somebody from Italy, so that we can test that individual who has a fever that's unexplained that lives in a nursing home."

Escott's remarks also underscore the growing understanding among public health experts of who is put in the most danger by COVID-19. "The people who are at greatest risk are those older and who also have serious longterm health conditions like diabetes, heart disease, or lung disease," said Dr. Nancy Messonier, the director of CDC's National Center for Immunization and Respiratory Diseases, in a March 9 tele-briefing. "Starting at age 60, there is an increasing risk of disease and the risk increases with age. The highest risk of serious illness and death is in people older than 80 years. People with serious underlying health conditions also are more likely to develop serious outcomes including death." Children and young people (ages 0-19) have so far largely been spared serious outcomes from COVID-19, but they can carry and spread the disease.

Back at the Capitol on Tuesday, no one who testified said that there were already major problems in the state. At that time, Texas reported 14 cases of COVID-19, all in the Houston area and all travel-related; since then, the number has jumped to 21 and now includes cases in Collin, Dallas, Fort Bend, Gregg, Harris, Montgomery, and Tarrant counties. As well, Lackland Air Force Base in San Antonio has also housed a number of passengers transported from cruise ships and is slated to receive more, but those individuals have for the most part been kept strictly under quarantine.

However, several who appeared before Thompson's committee did express concern about shortages of supplies and equipment, and possibly hospital bed capacity, on the horizon. Donna Boatright, CEO of Rolling Plains Memorial Hospital in Sweetwater, said some supplies were already getting hard to obtain, partly due to supply chain issues and a heavy flu season that has already been taking its toll. She noted that her staff have had to place hand sanitizer and face masks behind the registration desk to prevent them from being taken by the public.

Eric Martinez, an emergency medicine physician assistant in Houston and president of the Texas Academy of Physician Assistants, said he was concerned about potential shortages in personal protective equipment, such as masks, for frontline health workers. Such equipment is already in limited supply, he said, and is being rationed. "I urge you to take every measure possible to prevent the shortage of PPE in Texas," Martinez told lawmakers.

"Texas Must Fight Back"

Dr. John Hellerstedt, commissioner of DSHS, opened the hearing with a stark message. "Texas must fight back. The novel coronavirus, which is the cause of the COVID-19 disease, is a challenge that everyone in Texas must take seriously," Hellerstedt said. "Texas must show the world how this is done." Providing more than an hour of testimony, he described what is known about the disease, why it presents such a threat, and how the state is poised to respond. He emphasized that making the necessary changes in behavior and taking the necessary precautions might not be easy for the public to accept, but that these actions were necessary if the state wants to avoid the worst. Hellerstedt acknowledged that the things being done in response to COVID-19 are new "in living memory" but stated that the threat posed by the virus warrants the kinds of levels of containment and mitigation that are being implemented.

Back in Austin, city and county officials are taking proactive steps even as they lean into already established training and readiness. Commander Mike Benavides, public information officer with Austin/Travis County Emergency Medical Services, said his department is already well-prepared for a surge. For instance, the department has a year's worth of N95 face masks based on the current usage or "burn rate," but even with an increased rate, he estimates they would have enough for eight or nine months. These masks are specifically designed to protect wearers from exposure to infected particles in the air or in fluids.

Screening patients and visitors is one way local healthcare providers are responding to the threat of COVID-19 and working to prevent emergency rooms and hospitals from being overwhelmed. Such practices also prevent vulnerable patients from being unnecessarily exposed to the virus, which can be more deadly to those who are already ill. Dr. Ken Mitchell, chief medical officer of St. David's HealthCare, said in a statement, "On Monday, March 9, in an abundance of caution, we began restricting access to our facilities to a limited number of entrances, where all patients and visitors entering our facilities are being verbally screened with a three-question survey that follows the Centers for Disease Control and Prevention (CDC) guidelines. Necessary precautions are taken based on their responses to the survey questions."

Dr. Christopher Ziebell, emergency department medical director at Dell Seton Medical Center (Photo by David Brendan Hall)

Dell Seton Medical Center, the city and county safety-net hospital, encourages the public to check with providers and/or public health officials before seeking emergency care for those they think may have COVID-19 and to explore options for "virtual care," according to a written statement from Dr. Christopher Ziebell, emergency department medical director there. It also states, in part, "Our infection control specialists also work closely with the CDC and local public health authorities to stay updated on any additional measures we need to consider implementing as we all learn more about this virus and how to stop it."

Austin Public Health has also designed flyers to be posted at city and county healthcare clinics that warn visitors who have a fever of 100.4 F or higher, a cough and/or shortness of breath to call for assistance rather than entering the clinic, and to wear a mask. Healthcare workers are also advised to "mark and isolate" patients suspected of having COVID-19, discuss symptoms and travel, and consult with Austin Public Health about testing.