COVID-19 in Greene County: Interview with an epidemiologist
- Published: April 26, 2020
Interviews in this series
Editor’s Note: This article was updated to fix an error. The first peak of COVID-19 in Greene County was on March 24th, not March 4th.
Earlier this week, the Yellow Springs News spoke with Dr. Don Brannen, an epidemiologist at Greene County Public Health. Brannen spoke about COVID-19 spread in the county, the role of the health department in contact tracing to contain the disease and differences between Greene County and Ohio as a whole.
Brannen has worked at the county health department since 2001. In his role, he investigates outbreaks of infectious disease and monitors the general health of the county. He has a doctorate in public health and graduate degrees in both epidemiology and hospital administration. He was the Greene County Medical Reserve Corps Unit Leader from 2004 to 2019.
The interview was edited for length.
Yellow Springs News: Dr. Brannen, you shared with me in an email that the midpoint for coronavirus infections in Greene County was March 27 and that half of the number of cases to have occured to date did so by March 25, which you said was preliminary data until more information comes in. Does that mean that COVID-19 has peaked in Greene County?
Dr. Brannen: We’ve seen two peaks here in Greene County, one is March 24th, and the other was a little bit later, around April 4th. We’re hoping to see that continue and move downward toward zero through May.
Yellow Springs News: So why did Greene County peak in late March when the State of Ohio as a whole was estimated to see its peak of confirmed cases around April 19?
Dr. Brannen: I think it’s because we were able to do contact tracing and isolate those cases early on. Our county is set up so people drive everywhere instead of everyone walking, which is typically not a good thing. But in this case it seemed to work to our advantage to not have that congregation.
Yellow Springs News: Why two peaks?
Dr. Brannen: We typically see two peaks. First there’s the larger peak, then after that large peak the virus finds its way into the pool of remaining susceptibles. We call it a camel hump, with the smaller hump in the back. Those groups seem to be a little isolated and similar to one another. The virus will eventually find them. Now that we’ve gone through that second peak, it’s very hopeful, because of the seasonality of coronaviruses* in general. The ones we usually track, we [Greene County] typically stop seeing cases right around May. But in Ohio we see cases through June 1. That’s why they say it may be until June. They’re hedging their bets.
Yellow Springs News: So does that mean the coronavirus was in Greene County earlier than we thought, perhaps back to February?
Dr. Brannen: I can give you the exact date. The onset date of our first case was March 4. [Editor’s Note: More recent data from the Ohio Department of Health shows a case with an onset date of March 1].
Yellow Springs News: Can you tell me about the contact tracing that the county has done?
Dr. Brannen: There are 136 people so far that we’ve tracked as of today. And we’re still tracking new travelers returning from abroad. The CDC notifies us of cases. Those earliest of cases in early March, we weren’t notified by the CDC of them — we tracked them ourselves. We tracked their first contacts. If we don’t have a vaccine, what we would do moving forward is we would track the first ring of contacts, and then we would track the contacts of the contacts.
Yellow Springs News: Would you track down everywhere a person went and contact those folks as well? Say they went to a restaurant or store, would you alert those folks?
Dr. Brannen: It would be the close contacts of the close contacts. So you were either face-to-face with the person, or six feet or closer to them for 30 minutes or longer. And it would be during the incubation period of the disease. We would look back to 14 days before.
If we do the ring contact tracing, we do the first ring, then the outer ring. It’s almost doing a trace-back of their movement. If we do that we can actually be very effective at limiting transmission because we can find them, make sure they’re isolating.
Yellow Springs News: Does the county have enough manpower, and testing, to do this level of contact tracing?
Dr. Brannen: Typically what we would do is have our medical reserve corp and citizen corp volunteers. In the past when we had [viral] outbreaks of dozens or a hundred people, we’ve asked other health departments for help. We also in the past have used medical residents we’re hosting.
Norovirus is the major cause of our outbreaks. There’s less and less large outbreaks over the years. The past two were associated with a funeral and a restaurant. Those two outbreaks had about 100+ people associated with them, we did use volunteers from other health departments.
Yellow Springs News: Of the Greene County cases, have you been able to trace where they came from?
Dr. Brannen: We’re at 39 [confirmed cases] and we have classified them generally into categories. About 20% of our cases are associated with [Wright-Patterson Air Force Base]. That’s not unusual. It’s our largest employer, so they should have more cases; 4% are associated with international travel and we have 18% associated with health care workers — people are at risk while taking care of us; and 8% are people who have visited health care facilities. Those could be community exposures as well, but our best guess is that they are healthcare associated; 25% of the cases associated with community exposure, or a close family member.
Yellow Springs News: At some point in mid-March, Dr. [Amy] Acton [of the Ohio Department of Health] said that 100,00 Ohioans were infected, which is about 1% of the population. In Greene County, that would have meant 1,700 cases in mid-to-late March. Do you think we had that many?
Dr. Brannen: Since there’s going to be antibody testing, hopefully soon, over the summer, we hope to get a representative sample of folks. Especially with more people donating blood, that will be screened for coronavirus, so we will have some idea of what the sero-prevalence is. What we expect to see in epidemiology is, after a pandemic, you should have 40 to 60% of the population exposed. After the first two years, it should approach 80-90%, until it stabilizes to 55% exposed on any given year. That is the general rule. This might be different.
Yellow Springs News: Do you think a lot of people were asymptomatic carriers?
Dr. Brannen: I can tell you how many were asymptomatic from our cases. Out of our positives, we had two that were asymptomatic, two of the 39. We’ll see if that percentage holds true.
But increasingly, we’re not being told about the negative cases. If they’re being tested, there is some reason to test them, but typically physicians are waiting longer and longer to report that. Of the 136 who have been tested [as part of the county’s contact tracing], 57% were positive; 42 were negative and 36 were positive.
Yellow Springs News: How much is testing a part of the health department’s strategy? Do you have enough tests available?
Dr. Brannen: A company out of Atlanta just asked my advice about testing. You can’t prescribe universal testing. You can’t go around doing that because you’re going to have a lot of false negatives. You should only have targeted testing of people who are ill, unless you start doing serologic screening. Then you could do mass screenings because it’s already after exposure. That will tell you how many people have immunity. The reason you want to know that is that you are protected to some extent — you won’t get as sick.
There is a difference in getting infected and inoculated. You could have antibodies to the virus, but you could still get infected and be contagious and infect others.
One recommendation is to use a saline spray to wash out the nostrils, or to use a pharmaceutical-grade Neti pot to wash out any virus or bacteria. Some of the good old fashioned prescriptions like steam inhalation or salt-water gargle, they seem to actually reduce the amount of viral load in the throat and [nostrils].
Yellow Springs News: Are there still strict rules about who can be tested for COVID-19? Have those guidelines changed at all since the early days when testing was so limited?
Dr. Brannen: We go by CDC guidance. Having [residents in long-term facilities in a lower tier [as per the CDC] is not a good idea. [Testing for them needs] to be increased along with healthcare workers, in my opinion.
Yellow Springs News: The state is now listing cases associated with long-term care facilities. No long-term care facilities in Greene County have a confirmed case. Are you monitoring those facilities here in the county?
Dr. Brannen: Yes we are. We did have an earlier scare at a facility and we uncovered a different viral outbreak there. It was good that we were looking deep for coronavirus because of the respiratory panels. We had to do a chest x-ray and a respiratory panel to rule out other respiratory viruses. We found we had an HMPV [Human metapneumovirus] infection amongst outpatient clientele.
Yellow Springs News: The initial model the state used, by Ohio State, projected 10,000 cases per day, even with social distancing. Then, they dropped it to 1,600 cases per day at the peak. What accounts for that drastic decline?
Dr. Brannen: I have a couple different thoughts on this. One is that the exponential that you see during the upswing of the outbreak would have been much higher if the [state’s] stay-at-home order would have not happened. It would have been much higher in the state. The major thing that we’ve seen with the factor in H1N1, 1918 Spanish flu, outbreak is that the communities that stopped school quickly and early were the ones that limited transmission. They also stopped church services and theaters [in those earlier epidemics].
[Scientists] did modeling showing the square foot per person you need to be apart. Three feet seems to be the magical distance. Increase beyond that and you’re safe, for influenza. If you double the distance, you reduce the exposure to one-fourth. With doubling the distance from three to six feet, you make [the risk of infection] almost non-existent. The major reason we saw that decrease was stopping the schools from being open, that’s the reason we haven’t seen the big spike. OSU had the worst case scenario, but clearly, it saved lives.
If this would have happened [in Greene County] 20 years ago, we would have just thought it was a bad flu season. In this case, we now have the PCR test that shows it was a new virus.
Yellow Springs News: What are your thoughts about the reopening of Ohio? How and when do we do so safely?
Dr. Brannen: The Health Commissioner, Melissa Howell, is putting together plans** for Greene County. She foresees it as in stages, so i would defer the plans for that to her. I like the idea of May 1 opening most businesses. It makes sense to me. They are going to be more cautious than [most people] would be. For the smaller operations, I’m sure they can put in place their best efforts. They want their customers to be safe. Businesses, if they’re not being safe, workers are not going to come.
Most people in this episode want to do what’s right. The people I’ve tracked who’ve survived COVID-19, the last thing they want to do is to infect others. In fact, everyone that has survived has asked how can I donate my plasma? What heroes. These survivors don’t want to put your health on the line.
* There remains considerable debate among experts on the seasonality of this specific coronavirus, SARS-CoV-2. See, for example: https://ccdd.hsph.harvard.edu/will-covid-19-go-away-on-its-own-in-warmer-weather/
Dr. Brannen responded in a follow-up email clarifying his comments on the seaonality issue, and addresssing the article linked above: “In regards to seasonality of COVID-19, I am sure it will be similar to other coronaviruses, but each strain does have its own seasonality, with all 4 major strains generally following the same pattern and COVID-19 will eventually also have a similar yet slightly different pattern. The first season of introduction will be different than subsequent seasons. SARS CoV2 was introduced relatively late in the season. So the strategies of stay at home except for essential travel, isolation, and quarantine has maintained a pool of susceptible persons that may allow the virus to linger in the population if reopening occurs too quickly. In regards to the Harvard School of Public Health’s argument supporting the non-seasonality of coronavirus, they ignore to mention that the resurgence was mostly among health care workers as well as violations of some existing societal measures to control SARS CoV1. Besides the minor omission of the role the increased hazards to healthcare workers, and the bit of theatrics about myth busting, I’m in agreement with Dr. Lipsitch. The summary at the end of the article is consistent with the idea that transmission is more efficient in the winter than the summer. However, for this new virus we need to have public health interventions to stop the spread. With new cases being reported of COVID-19 a phased approach to reopening based on science should occur with those businesses able to open that have a lower risk estimate based upon intensity of contact and number of persons potential exposed. Our Health Commissioner is amazing at getting at the right answer. She works closely with other community leaders as well as state and national experts. Public Health officials typically declare an outbreak over after no new cases occur over the course of a period equal or exceeding two incubation periods. In this case 14 days. Over the summer we will closely watch for spread among those most at risk included long term care, residential facilities, and among healthcare workers.”
**In an email from the News for more information on the county’s plan, county health department spokesperson Laurie Fox said it was still in development, but would be based upon federal guidelines, including the following: promote widespread use of face coverings; physical distancing; handwashing; hand sanitizer use; avoiding touching face; proper sneeze and cough etiquette; disinfection; staying home when sick; vulnerable people should protected; no large gatherings; avoid non-essential travel.