With few cases, Marin looks to ease sheltering

04/15/2020

Marin has successfully curbed the initial spread of the novel coronavirus. With a welcome lull at hospitals and the economic impacts painfully clear, public health officials are planning to slowly relax the order to shelter in place. The move is expected to bring a secondary surge, but it’s one health officials believe the system can handle.

The vast majority of people who tested positive for Covid-19 in the county have recovered. Although the numbers paint only a partial picture because of limited testing, 121 of 171 patients are feeling better. Only two patients were in the hospital on Tuesday, while 27 have gone home. Ten people have died, all over the age of 65.

“This shelter-in-place has allowed us to decrease cases, to decrease hospitalizations and to decrease death,” Lisa Santora, Marin’s deputy public health officer, said on Monday. “That has bought us time for our health care system to prepare for a medical surge and also to blunt the size of the surge.”

The regional shelter order, now in its fifth week, will likely be eased and extended beyond May 3, and allowable activities will be driven by science. 

“We will not return to normal this year. I do not anticipate us returning to normal next year,” Dr. Santora said. “It is a new normal for us, because we still need to buy time to both discover and develop tools to treat this disease, as well as to prevent it through vaccination.”

Hospitals are now operating under the first phase of their surge plans, meaning they have arranged remote consultations, paused elective procedures and increased bed space by two-thirds. Once officials relax the shelter order, the region could increase capacity in anticipation of a moderate surge, expanding to field treatment sites such as fairgrounds and conference centers. 

If the secondary surge were to overwhelm those sites and reach a critical phase, the North Bay Incident Management Team has planned for a scalable site with up to 400 beds, and the state is arranging for thousands more.

Increased testing will be key in establishing a new normal. Marin, like the rest of the nation, has struggled with shortages of testing materials. The latest holdup stems from a lack of nasal swabs; the reagent that detects the virus’s genetic material has also been in short supply. 

As a result, Marin has failed to keep its promise to test anyone with symptoms, but it maintains that goal. As of Tuesday, 2,145 people have been tested countywide. Fewer than 10 have tested positive for Covid-19 in West Marin, according to county surveillance data, but this number likely represents a drastic undercount. (Muir Beach is not part of the West Marin count.)

Based on the presumed rate of transmission and the lack of testing, Dr. Santora estimates that 2 percent of West Marin has had the disease, with most people experiencing mild or no symptoms. 

Antibody testing could be a tool for decisionmakers to understand the extent of Covid-19 in Marin and would shed light on the county’s herd immunity. The entire town of Bolinas will have the option to be tested for antibodies for free next week, which should provide a sample of how coastal Marin has been impacted. Researchers are still looking for the best test to use, so results aren’t expected for at least a month.

At least 70 percent and ideally 90 percent of residents must be immune in order to reach herd immunity, Dr. Santora explained. But research on antibodies is still developing, and reliable tests aren’t yet widely available.

Alongside increased testing, Marin needs enough nurses with time to interview positive patients and contact individuals who should be isolated. The county is still building a team to be ready for a secondary surge.

California is using six indicators for modifying its statewide shelter order. Health officials are looking at the state’s ability to monitor for Covid-19, including by testing, tracing and isolating patients. Hospitals should be able to handle surges, and health officials should be able to protect vulnerable communities, like older adults and the unhoused. The state’s research institutions and biotech companies should make progress on developing therapeutics that could help patients recover more quickly, and businesses, schools and childcare facilities should be able to support physical distancing. Lastly, the state should be able to quickly reinstate the shelter order at any time.

Governor Gavin Newsom’s roadmap to modify the shelter order, released on Tuesday, has no precise timeline, but the indicators will serve as the framework for making decisions, he said. 

He also noted that life in the near term will look different. For example, restaurants could have fewer tables, classrooms could be reconfigured and face coverings could be more common. New opportunities will likely arise to support mitigation.

Public health officials are moving to relax the restrictions under the pressures of the economic fallout of the pandemic. In West Marin, with nonessential businesses closed, the workforce has seen widespread layoffs and businesses have faced dramatic drops in income. Money is slowly materializing from the $2.2 trillion Coronavirus Aid, Relief, and Economic Security Act passed by the United States government on March 27.

State unemployment assistance, boosted by $600 from the federal government, has arrived for early applicants. The $1,200 stimulus for taxpayers earning less than $75,000 is being directly deposited into accounts that the Internal Revenue Service has information for this week, with another $500 disbursed for each child. And banks have awarded a portion of the loans under the payroll protection program, which allows small businesses to take out forgivable loans to pay expenses.

In a town hall on Monday, Rep. Jared Huffman called on the Treasury Department to speed up its distribution of the resources that Congress has approved. “This program is not yet working the way Congress intended, and it’s unacceptable,” he said.

He also urged Congress to do more; legislators have been on recess for over a month after passing three bills responding to the pandemic.

“I think a combination of bringing some of us back to the Capitol with proper distancing, and also using some technological tools, can allow us to do that safely, while also fulfilling our constitutional responsibility,” Rep. Huffman said.

With more time under the shelter order, Marin has improved its ability to work remotely. This week, the Board of Supervisors met virtually for the first time, and a cohort of top health officials held a virtual town hall.

At the event, Dr. Santora recounted her team’s timeline responding to Covid-19. On Jan. 8, she forwarded an email from the California Department of Public Health about a communicable outbreak of pneumonia in Wuhan, China. She told her team that it sounded like SARS, and she started talking with other Bay Area health officials and local hospitals. When China announced on Jan. 19 that some public transportation would be paused, Dr. Santora took that as a sign that this was a bigger issue than it was made out to be, and Marin needed to bring more resources to bear.

“It was really challenging,” she said. “As many of you know today, you are not getting necessarily trustworthy information from China, and so I really had to frame our analysis on the best resources and references that we had available at that time.”

It wasn’t until Feb. 25 that Marin accepted its first positive patient, a cruise ship passenger. This helped the medical system prepare for the cases that cropped up shortly after. Marin cases started coming in from outside China, including positive cases traced back to New York. Community transmission became apparent, and the first shelter order in the nation was issued in the Bay Area on March 16.

 Dr. Santora has been overseeing Marin’s public health response since Matt Willis, the chief public health officer, tested positive for Covid-19 on March 20. He returned to work this week after three weeks away, which included a day in the emergency room from shortness of breath and 12 days in bed with pneumonia.

“I’m relatively healthy, but I’ve needed help for almost everything at home,” he said in a video update last week. “I know that if I were more frail, or older, or if I didn’t have the amazing support of my wife and kids and from our friends and neighbors, things might not have gone as well. This experience reinforced for me how important it is to be taking aggressive action to protect ourselves, our most vulnerable residents and our health care workers.”