After a long journey at sea on the Westerdam cruise ship, which was denied entry at ports across Asia over fears of the coronavirus, Holley Rauen finally returned home to Florida on Wednesday night. Moments later, she discovered that she had joined a cast of thousands who are being meticulously tracked by local health officials across the United States.
As Ms. Rauen’s plane from overseas touched down, one message was already waiting on her phone, from a nurse at the local public health department in her Florida county. Should she develop a fever or cough over the next 14 days, she should report it immediately, the nurse explained when Ms. Rauen called back.
“I was so impressed,” said Ms. Rauen, who is herself a retired public health nurse from the same health department in Lee County. “We are really truly in uncharted waters.”
Preventing the spread of infectious disease is the essence of public health work, but the scale of efforts by state and local health departments across the country to contain the virus known as COVID-19, experts said, has rarely been seen. Since early February, thousands of people returning to the United States from mainland China, the center of the outbreak, have been asked to isolate themselves at home for 14 days.
Local health officials check in daily by email, phone or text. They arrange tests for people who come down with symptoms, and in some cases, groceries and isolated housing. There is no centralized tally in the United States of people being monitored or asked to remain in isolation, and they are scattered across the nation’s nearly 3,000 local health jurisdictions.
People arriving from mainland China are added each day, while those who have completed 14-day “self-quarantine” periods are released from oversight. In California alone, the department of public health has been monitoring more than 6,700 returning travelers from China, while health officials in Washington State have tracked about 800, and officials in Illinois more than 200.
The nationwide mobilization is taking a financial toll, health officials say. The cost to local health departments is unknown, but some experts say it has reached into the tens of millions. Even as the first of 34 confirmed coronavirus patients in the United States have recovered in recent days, health officials say they are preparing for what some fear could still be a much wider outbreak. Worldwide, the virus, which is known to be highly contagious, has infected 75,000 people and killed more than 2,000.
“All hands on deck are being pulled into this,’’ said Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, a nonprofit organization that represents public health agencies across the country. “If it really blows up, at some point, it could overwhelm state and local health departments. ’’
So far, officials say, the containment effort in this country has been largely orderly. The only known transmission of the virus in the United States has involved people in the same household. But no matter how effective health workers are in monitoring their charges, “there will always be some leakage,’’ said Dr. John Wiesman, the Secretary of Health in Washington State.
In Washington, where the first coronavirus patient in the United States was confirmed on Jan. 21, health officials tracked down and monitored 69 individuals with whom the man had come in contact, including work colleagues, health workers and other patients present in a clinic he visited when he first felt sick. Still, there have been issues. One person the man had been in contact with and who had developed symptoms of illness flew on a plane to Wisconsin during the 14-day period when she was supposed to be isolated at home.
“There is no way, with something this large, that you can make it seal-proof,’’ said Dr. Wiesman, who has started twice-weekly conference calls with the chief health officers in every state and territory to share tips and seek advice on how to manage the shifting challenges of the coronavirus response. While enforcing total compliance with isolation orders may not be possible, Dr. Wiesman said, “We have to try for 80 to 85 percent, and hopefully that will work.’’
Federal authorities are in charge of setting guidelines to manage the danger, such as deciding how much risk a returning traveler poses and who should be tested for the coronavirus. But the day-to-day work putting those policies in place and tracking thousands of people falls to the vast, decentralized network of local health departments across the country. Travelers’ data, culled from federal customs officials, is passed on to state health agencies, who farm out lists of people returning from China to local health departments.
In the Chicago area, public health officials are using an electronic monitoring system originally developed to track the measles to monitor more than 200 travelers. Each day, they receive a link asking their temperature and symptoms.
The costs associated with containing the virus have reached more than $150,000 a week for the Chicago public health department alone, according to its commissioner, Dr. Allison Arwady. Among the costs: $17,000 for a quarantine facility at an undisclosed location for people who can’t isolate themselves at home. So far, fewer than five people have used it, she said.
“If you are quarantining them under a legal order, you have to think about food, their medications, their communication needs and their mental health,” she said.
Some jurisdictions have negotiated with hotels to host people who may harbor the virus. Washington State has RV’s.
Ruth Jones, public health commissioner in Quincy, Mass., a town of about 100,000 people south of Boston, says that her department has been receiving lists of between three and 10 people each day who are returning from China and are being asked to stay isolated from other people. Quincy’s two public health nurses and two translators have been working long hours to call them and make sure they understand how to monitor and report any symptoms.
“It’s overtime for our nurses,’’ Ms. Jones said. “It’s been extremely busy,”
Local officials in places that have had confirmed cases have been under particular strain. In Madison and Dane County, Wis., a local health staff of 160 has been forced to rearrange its operation to focus on monitoring anyone who may have been exposed to a resident who tested positive for the virus after falling ill and remains in self-isolation.
“We’re in this new normal, but it’s not normal,” said Janel Heinrich, the county’s director of public health.
Along with monitoring individuals who are seen as at risk of having been exposed to the virus, state and local health officials have been scrambling to prepare for worst case scenarios in the months ahead. State officials in Washington said they will hold a webinar next week to brief school superintendents on best practices for cleaning and planning for home schooling should schools need to shut down.
“People are doing contingency planning,’’ said Julie Sullivan-Springhetti, spokeswoman for the Multnomah County Health Department in Oregon, which has devoted resources to preparing a regional hospital system for a potential case. “Just like we plan for the Cascadia earthquake, which may or may not happen in our lifetime.”
As for the returning passengers from the Westerdam, the cruise ship, passengers at first thought they had no reason to worry about the coronavirus because no one on the ship had traveled through mainland China during the outbreak. But after passengers began leaving the ship to head home, an 83-year-old woman was reported to have tested positive on a layover in Malaysia, creating confusion and chaos.
Erin Carney, 70, a retired nurse and midwife from Mendocino County, Calif., flew out on the same flight as the woman who was reported to have tested positive, though questions have been raised about that finding and the C.D.C. has since said that other passengers do not need to isolate themselves.
Given the initial reports of a positive test, Ms. Carney called hospitals to figure out what she and her partner should do.
“The person that we spoke to read the C.D.C. guidelines and thought that everything seemed fine and we didn’t have to self-quarantine,” Ms. Carney said. “They said, ‘If you have symptoms, go see your doctor.’”
But then a nurse from the Mendocino County Health and Human Services Department called Ms. Carney. She recommended that they quarantine themselves at home, and offered to supply groceries.
“We had kind of talked about doing that anyway,” Ms. Carney said. “They’ve called every day since.”
Nicholas Bogel-Burroughs contributed reporting.