Coronavirus and Local Health Departments: Where the Rubber Meets the Road

by Cynthia Morrow, MD, MPH


Coronavirus LHDs Cynthia Morrow

EDITORIAL NOTE: The situation regarding Novel Coronavirus is still rapidly evolving. For the most current information, please consult the websites for Centers for Disease Control and Prevention or the World Health Organization.

On January 30, 2020, the World Health Organization (WHO) declared Novel Coronavirus (2019-nCoV) to be a “Public Health Emergency of International Concern” (PHEIC). On January 31, Health and Human Services Secretary Alex M. Azar II, declared a public health emergency for the entire United States. In the United States, such a declaration serves the purpose of providing more flexibility for personnel resources at the local, state, and tribal levels. Unfortunately, such a declaration also carries with it the potential for unintentionally stoking the public’s fears about the disease.  

As concerns about 2019-nCoV continue to spread across the globe, it’s not hard to imagine what health departments across the country are doing. In emerging infectious disease outbreaks, local health departments are at the front line, where the rubber hits the road. Every day, public health directors and their staff train and prepare for these events. And as much as we hope to avoid public health emergencies, it is imperative that when such emergencies do happen, we seize the opportunity to truly serve as our community’s chief health strategist. So how do we do that? At the local level, I have found it most helpful to apply a four-pillar public health response to emerging infectious diseases including:

  • Surveillance
  • Risk Communication
  • Non-Clinical Interventions
  • Clinical Interventions
Surveillance

When an outbreak of infectious disease is suspected, the first step in surveillance is identifying the case definitions to be used in the investigation. It is common to have different definitions in use simultaneously. With respect to 2019-nCoV, in the United States, the CDC is currently using the terms “Confirmed Case” and “Persons under Investigation” or PUI. (See text box.) The WHO’s case definitions for 2019-nCoV include:

  • Confirmed case: A person with laboratory confirmation of 2019-nCoV infection, irrespective of clinical signs and symptoms.
  • Suspect case:
    • Patient with severe acute respiratory infection (fever, cough, and requiring admission to hospital) AND
      • No other etiology that fully explains the clinical presentation AND
      • A history of travel to or residence in China during the 14 days prior to symptom onset.
    • Patient with any acute respiratory illness AND at least one of the following during the 14 days prior to symptom onset
      • contact with a confirmed or probable case of 2019- nCoV infection
      • worked in or attended a health care facility where patients with confirmed or probable 2019-nCoV acute respiratory disease patients were being treated.
  • Probable case: A suspect case for whom testing for 2019- nCoV is inconclusive or is tested positive using a pancoronavirus assay and without laboratory evidence of other respiratory pathogens.

At a minimum, robust surveillance systems require adequate laboratory capacity, informative technology to support timely collection and analysis of data including laboratory findings, and personnel to do all of the necessary appropriate tasks, including monitoring and follow-up for persons meeting the above definitions. At this time, state and local health departments identify PUIs and notify the CDC’s Emergency Operations Center for assistance with indicated diagnostic testing. All testing for 2019-nCoV is being conducted through the CDC.

Risk communication

Effective, timely, appropriately measured risk communication is a fundamental responsibility of all public health agencies. With respect to 2019-nCoV, China’s ability and willingness to share detailed information to WHO and WHO’s capacity transform that information into detailed situation reports, as well as guidance documents, has facilitated risk communication across the globe. The CDC has played a similar role in the United States. Despite the strengths that both agencies have demonstrated with respect to risk communication, there are still significant challenges. One example is the miscommunication, or perhaps mistiming of communication, about the infectious period, specifically with respect to the question of potential transmission prior to onset of symptoms. I believe that conflicting messaging is both understandable and unfortunately quite predictable when information is unfolding as quickly as it has been over the past few weeks, but we need to continue to improve communication challenges to have as consistent messaging as possible. The current messaging around this question seems to strike a balance between acknowledging uncertainty while still providing practical information. At this time, WHO’s response to the question is “According to recent reports, it may be possible that people infected with 2019-nCoV may be infectious before showing significant symptoms. However, based on currently available data, the people who have symptoms are causing the majority of virus spread.” 

While public health and healthcare professionals likely rely heavily on both WHO and CDC resources during a public health emergency, at the local level people often rely on their local health director to provide an accurate assessment of the risks their community is facing. In responding to an outbreak of an emerging infectious disease, where information is continuously evolving as more data become available, a local, credible, trusted voice can have a significant impact on the perception of risk. At a minimum, all public health directors should have training on risk communication; in the ideal scenario, a health communication and/or media professional is part of the administrative team and is available to assist with risk communication.  

Non-clinical interventions

Non-clinical interventions can include a wide range of options from promoting respiratory hygiene and hand washing, to isolation and quarantine measures, to even cordoning off cities or regions (eg, 2019-nCov and Ebola). The extent to which options are effective at decreasing the transmission of an emerging infectious disease, especially when clinical interventions are not available, is highly dependent on the specific agent determinants of health including but not limited to mode of transmission (eg, droplet), infectious period (currently thought to be 2-11 days for 2019- nCoV), and the R0 (the average number of additional people infected by a given person with the disease, currently estimated to be 1.4-2.5 according to WHO).

Important aspects of risk communication during an emerging infectious disease outbreak include keeping the risk at the local level in perspective and empowering people who may feel helpless and frightened.   With respect to the former, the CDC’s assessment is “For the general American public, who are unlikely to be exposed to this virus, the immediate health risk from 2019-nCoV is considered low at this time.” For the latter, even when no clinical intervention is available (see below), it is important for local health directors to communicate what people can do. Today, local health directors can emphasize the importance of respiratory hygiene and hand washing to reduce the risk of a wide range of respiratory illnesses, including influenza for which there are still high levels of activity throughout the United States.

Clinical interventions

In any public health emergency, the local health department is very likely to be involved in the distribution, and potentially management, of clinical interventions that are effective at preventing further transmission of disease. An example of this is vaccine distribution during the 2009 H1N1 pandemic. Two more common examples though include health departments distributing hepatitis A vaccine during an outbreak of the disease or facilitating the distribution of antibiotics to close contacts of people who have been exposed to meningococcal meningitis. With respect to 2019-nCoV, at this time, there is no known clinical intervention to prevent the disease, and treatment options are limited to supportive care.

Effective and efficient implementation of the four pillars requires leadership, just-in-time training for health department staff, teamwork within and between public health agencies, and partnership within the community — with the healthcare delivery system, the media, the academic and research institutions, and so many others. And the relationships that we create between emergencies are instrumental in helping us serve our communities when they need us most.  

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As with community health improvement, we are stronger if we work together. If you are interested in sharing your story, please contact Dr. Cynthia Morrow at cbmorrow@vt.edu.


Cynthia Morrow, MD, MPH

Dr. Cynthia Morrow, a former local health director for Onondaga County, NY is currently teaching at Virginia Tech Carilion School of Medicine and at Hollins University. Previously, she was the Lerner Chair for Health Promotion at Syracuse University. Her prior academic positions include Professor of Practice in the Department of Public Administration and International Affairs at Syracuse University and an assistant professor with the Center for Bioethics and Humanities as well as with the Department of Public Health and Preventive Medicine at Upstate Medical University. Dr. Morrow served as Commissioner of Health for Onondaga County during which time she earned numerous awards from community-based organizations. She is a consulting editor for the Journal of Public Health Management and Practice and is also an editor of three books, including Bioethics, Public Health, and the Social Sciences for the Medical Professions; Public Health Administration: Principles for Population-Based Management; and JPHMP’s 21 Public Health Case Studies on Policy & Administration. She is a graduate of Swarthmore College (BA) and Tufts University School of Medicine (MD, MPH).