Today, Dr. Josh Ennis, Humboldt County’s deputy health officer, took questions from the media on the recent death of a local 38-year-old person who tested positive for SARS-COV-2, surveillance testing, what counts as a death attributable to COVID and much more.

He started off the session with an impassioned plea for people to stay vigilant in the face of a third peak of infections, nationwide.

Video above. Rough transcription below.

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Good afternoon. Would you like to start out by addressing community?

Yeah, I’d love to.

I’d just like to take a moment to talk a little bit about where we’re at right now in the pandemic. So over the past month or so, as you know, we’ve been tracking a lot of things, including how much disease is in the community, how many hospitalizations we’re seeing, how many deaths we’re seeing. We have seen a steady uptick in the number of hospitalizations. There have been a handful of cases hospitalized fairly consistently for at least the past month, and there has been a clear, very slow and steady increase in hospitalizations. And what we know from that is that there is generally more disease circulating out amongst the community. It has been a very slow and steady increase.

You know our day-to-day numbers may not reflect that and I think there are a couple conclusions that maybe can be drawn from that. Number one, the disease is still out there even despite our numbers looking very low and small. The disease is still out there and a large number of people are asymptomatic or have very mild symptoms that they chalk up to other conditions such as allergies, we commonly see headache and then atypical symptoms such as vomiting and diarrhea. And so if you look at the entire list of symptoms that COVID-19 can cause, it’s a huge spectrum and so I would encourage the public to, if they have an unusual new symptom and it fits with that list of COVID-19, to consider getting tested.

Right now we are so far into this that people are becoming really tired. We are in a, what is shaping up to be a third wave across the country, and at this point it is affecting many very rural areas in the mountain Midwest, and they’re seeing rates of disease that are accelerating even more than we’ve seen with the prior two waves.

And so I know we’re all tired of this. The state has released more guidance allowing more people to mix and come together that does assume more risk and so I would just like to underscore the same things we’ve been saying all along. They’re re-borne in every guidance that comes out, but it’s really some very basic things that lets us resume the new normal, that lets our businesses stay open, it lets our economy stay healthier, and that’s frequent hand washing and hand hygiene, it’s keeping distance from folks, it’s living the the number of different households you bring together, it’s also universal masking. It really does make a difference it’s not a hundred percent but it really does make a difference in slowing and preventing transmission, you know.

So it’s these very basic things that are going to let us continue to move forward and I know we’re tired, I’m tired of it, but we’re doing great with it and let’s not become complacent now.

The Lost Coast Outpost asks, “The CDC has expanded its definition of close contact to include anyone who has been within six feet of an infected person for 15 minutes or more over a 24-hour period. Does this affect how the county undertakes contact tracing? Will it greatly expand the number of people who are asked to quarantine?”

This changing in the operational definition will impact how many people are asked to quarantine. The county has approached identical situations to what was reported out by the CDC that prompted this change. And that’s that some people may have lots of frequent, smaller interactions that cumulatively, over a 24-hour period, add up to more than 15 minutes. And so you know they have more and more cumulative exposure but they weren’t sitting for more than 15 minutes in a single given time. And so we have on occasion considered that as increasing risk of exposure.

You know the shift here, though, with the CDC now defining it this way, necessitates that more people are likely going to qualify for that definition and in what has previously been kind of a gray area where we would take the whole picture to push us one way or the other when making quarantine decisions. You know one situation that immediately comes to mind where this could have a dramatic impact is is the in-person school setting. You know there’s bringing people together, there’s frequent probably very fleeting interactions within six feet, but cumulatively throughout the day it’s possible that it adds up to more than 15 minutes and so I think we can be more mindful when we talk about restructuring how we conduct business in situations such as this, such as in-person schooling, but this definitely has the potential for increasing the number of people who would be considered for quarantine as a result of this operational definition change.

The Lost Coast Outpost asks, “As regards to the local 38-year-old man who recently died and who tested positive for the virus at autopsy, what more can you tell us about what is known about his cause of death? Did he experience abnormal blood clotting or any other know,n but unusual presentations of the disease?”

So, from the Public Health side we do not have access to the same level information as does the Coroner’s Office. So anytime there is a death that is given to the, assigned to the Coroner’s Office, they undertake the investigation and so they, you know I’m not in that office, I don’t know all of what their process looks like, but you know they have several different tools at their disposal to investigate the circumstances surrounding any death. On the Public Health side, again you know we try very hard to think about what level of information is appropriate to release while honoring the privacy and the private health information of the decedent as well as their surviving family.

And so you know in in this particular case, I don’t have access to the majority of what this question is asking about and you know I feel that it is likely, at this point, inappropriate to release it as the sheriff noted the other day that they have an open investigation.

The Redheaded Blackbelt asks, “Questions have been raised about the numbers of deaths with COVID. Many people believe that only a small number of deaths are actually COVID deaths and the rest of the over 220,000 deaths in the U.S. have other causes and COVID was only present at the time of death, not a major contributing factor. Could you address this in light of what you know about the situation nationally and in particular with the man in his 30s who died with COVID recently in Humboldt County who reportedly had a serious health history? Could you clarify if an autopsy was done and if the autopsy or other indications indicated that COVID was the primary cause of death, a contributing cause of death, or only present but not contributing? And explain, if the latter, the reasoning for including him in the Humboldt County COVID deaths.”

Sure. There’s a lot of moving parts to this question so I’ll start with the the easier questions and kind of move to some of the bigger scope of this question.

So first of all clarifying whether an autopsy was done or not I’d refer that question to the Coroner’s Office. They would have answers or choose to release information at their discretion about a lot of the things that are asked at the end of this question about cause of death contributory, etc. So I can tell you that the state reporting system, if someone tests positive at the time of death, it is reported to the state system as a death in someone who also tested positive. The system is not designed to attribute cause of death. Now you might ask, well what if the cause of death clearly had nothing to do with COVID-19, say they’re asymptomatic from COVID-19 and so we’ve actually reached out to the state to clarify how that would be handled. Now getting to the the bigger question here about COVID deaths and the number now being north of 220,000 across the the country. Leading public health experts — now, I won’t say 100 percent of them because you know certainly if you have a lot of different minds thinking about the same thing you’re never gonna get a hundred percent consensus, right? — but the vast majority of them believe that this number is actually an under counting of all COVID-related deaths and there are a few reasons to think that.

So you can look at the number of excess deaths over a certain time period and compare that number to those that are definitively related to COVID-19 or tallied as related to COVID-19 and there has been a clear excess. Now some of those may have been due to deferred health care or people being afraid to seek care for their non-COVID related things such as a heart attack or a stroke, there are ways to adjust for that. And so again after adjusting for those things, looking at and comparing those numbers, the vast majority think that we’re under counting deaths, if we’re off one way or the other.

Now I will speak also to another item here that some people attribute these deaths as being inflated because people had other pre-existing conditions and whatnot. There have been some really misleading statements out there talking specifically about comorbidities and, you know, deaths being falsely attributed to COVID-19. Now in many of these cases, these are very common things that many, many people that you and I know, have which aren’t in the vast majority of cases a really big deal. It might be high blood pressure that’s very well controlled with a single medication, it might be diabetes that’s well controlled with a single medication. These might be seemingly very minor things that sure, they are technically a comorbidity, but they would be listed on a death certificate.

And so it’d be really inappropriate to look at all death certificates that carry COVID-19 and say that you know most of them are not due to COVID-19 because there is a comorbidity such as high blood pressure or diabetes listed. The reality is though that when a death occurs it’s not as simple as putting your finger on the one thing that caused it. There can be many different things that cause it and one disease process can play off of another and so sometimes it might be a combination of these two or three things that all come together in the perfect storm and cause death. And so we can be left in scenarios, as a provider who’s worked in the acute care setting, sometimes you don’t know and you just cannot put your finger on the one thing that caused the death and there are lots of shades of gray in between.

And so it’s not so simple but the general consensus is if anything, this is an underestimate and any statements that say this number is falsely inflated as a result of the comorbidities are simply not true and maybe just have a misunderstanding or a flat out disregard for how complex it can be to attribute death sometimes in the face of other comorbidities. 

The Redheaded Blackbelt asks, “In regard to the COVID deaths locally, will you be adding any data to the county dashboard which would reflect demographics of the COVID deaths similar to what the state is making public, see screenshot from California COVID website attached, and if not please explain the reasoning?”

So first of all, any data that’s available through the California COVID website, when we were first building out our own local dashboard we thought hard about how much value it brings to present more or less the same data that the state already has. And after a lot of deliberation over this we we felt that it would be best to put our energy elsewhere to information and data that supplements what’s available through the state, rather than recreating the wheel of sorts. And so that was the reason that we chose to not put the exact same or nearly identical information directly on our local dashboard, because it’s already available through the state website.

Now,   the first part of this question asks about demographics of the COVID deaths, and there’s already a fair amount of demographic data available on the state website. I would maybe ask the question, you know, what other additional demographic data would be helpful to know about that is actionable? And I would say that if you look at where the cases are occurring, if you look at those demographics, you look at the occupational settings, it’s the same trends and same groups and same themes that are occurring, whether that’s higher case rates, whether that’s deaths, and so it it doesn’t add a whole lot of value in our opinion to go digging and sorting that information at this point with the deaths in Humboldt County.

Additionally the numbers are so small that it’s very likely to misrepresent what’s really going on.

Reporter Daniel Mintz asks, “At Tuesday’s Board of Supervisors meeting it was reported that the county is addressing a cluster of COVID-19 cases related to a place of worship. How many cases are in this cluster and what are the circumstances of transmission? How large was the gathering or gatherings at the place of worship, were people indoors or outdoors, wearing masks, distanced, etc.”

So again, if we feel information is in the interest of the general public needing to know we release that information. I will speak generally about place of worship guidance that the state has and you know the guidance that’s out there is a reiteration of the things I talked about at the very beginning. It’s that you structure things to try and keep your distance, you encourage mask use, discourage high-output activities such as forceful singing, you also exercise hand hygiene. These are things that we know really slow and limit transmission. Naturally when you bring people together into place of worship that assumes more risk and we know that. Our experience is that if the appropriate measures are put in place it’s not going to prevent 100 percent transmission but it does perform fairly well.

Now, with the specifics of this case, you know I’m not at liberty to say what happens at this particular place of worship, I’ll tell you though that it being referred to a cluster means that it’s more than a handful of cases and it has spread beyond just the place of worship and has resulted in hospitalizations as well. So this is something of great concern. Anytime you bring more people together, there is more risk involved, and so the more we can just move forward with the basic precautions, the more it’s going to help mitigate that risk and allow us to continue doing things we want to continue doing.

Reporter Daniel Mintz asks, “At this point how well is the county doing with surveillance testing and getting a broad enough range of residents tested to document the extent of community transmission?”

This is the million-dollar question — are you testing enough people? So I’d say our county, because of the timing if we look back seven or eight months ago, we’ve generally been doing well. I can tell you that if you look at a few different items I think we are still falling short of how much testing we really need to be doing and that’s largely being limited by capacity at this point. We still need more testing, that is that is for certain.

And so I can give you a few  specific items. If you look at the symptoms that our local Humboldt County residents have had, on our dashboard the percentage of those completely asymptomatic is somewhere around six or seven percent. Now we know from some larger studies, there was a really large cross-sectional one in the northeast that was done, there’s also some fancy ones that use modeling to look at this, we know that asymptomatic infections are a large part of all those infected. At a at a bare minimum, I put that number around 20 or 25 percent, there are some modeling studies out there that suggest it’s upwards of 50 percent. That’s a big range, you know. I think it’s probably more somewhere in the middle. We don’t know but it is a large percentage of all cases. And so if you compare that you know 25 percent number with what we’re actually seeing locally of six or seven percent, it’s clear we’re missing a lot of asymptomatic cases.

Now, the second part of this is that I mentioned at the beginning that there’s been a very slow and steady uptick in the number of hospitalized cases and you know early on we could correlate large numbers of cases with hospitalizations two to four weeks later. That’s been dis-coupled a little bit lately and so the conclusion I believe is that we have we have a little more disease circulating in the community that is undetected. I don’t want to sound alarmist, you know this is probably low-lying level activity, but the trend is clear in hospitalizations, and so there probably is a little bit of pandemic fatigue going on here and people aren’t as inclined to get tested. And so we need to continue building testing capacity, we need to continue to support decentralization of testing capacity, and we need to bring it out into all pockets of our geographically spread out county and we’re working to support that day in, day out.

The North Coast News asks, “The Humboldt County Sheriff’s Office says it’s begun testing for COVID-19 during autopsies at the request of Public Health. When did this process begin and is it possible the death count could be higher in Humboldt if such postmortem tests would have begun sooner?”

I’d like to just clarify one item here. This this process didn’t begin recently, it’s been available to the Coroner’s Office throughout the entirety of the pandemic and I think maybe what this is referring to is that six, eight weeks ago, we did encourage the use of testing in scenarios that were felt to be appropriate. Prior to that communication and encouragement to test in appropriate scenarios, there were specimens submitted from the Coroner’s Office to Public Health.

Now, the reason we decided to encourage its appropriate use is because it’s another way of having some type of system that’s looking for more disease circulating in the community. And as I’ve already said, based on hospitalizations, we suspect that there is a little bit more disease circulating undetected. And so it is certainly possible that we have missed some deaths but again because of the timing of how many cases there were in the Bay Area versus here when the original Shelter in Place order went in place, we were able to get a lot of things in place, and so I would not suspect that we’ve, if we’ve missed any, it’s not a large number.

The North Coast News asks, “Some have been critical about how COVID-related deaths are reported statistically. For example, the most recent death being discovered during an autopsy. Do you believe the do you believe the way data is represented is adequate?”

I think I’ve spoken a lot about this already. I might just add with the, you know, post-mortem COVID-19 testing, I’ll just expand on that a little bit perhaps. When I say encourage appropriate use, you know I think we can all think of scenarios where it would be appropriate to test. You know if you had a family member who passed away and it was unexpected and you know that they were talking about having a little bit of cough recently, seems like an appropriate scenario to testing.

You know, what we tried hard to avoid is encouraging inappropriate use and we really left it to the discretion of the folks in the Coroner’s Office as well as any pathologists that may be involved with any particular case. And so just hoping to clarify that maybe with this question as well as the previous one, that you know we’re doing things that and making recommendations that would seem very reasonable to any common person who’s an outside observer.

The North Coast News asks, “A California court ordered state corrections officials to cut the population of San Quinton state prison in half due to COVID. It was the site of one of the nation’s worst coronavirus outbreaks with 28 inmate deaths and 2200 infections at its peak, about 75 percent of the inmate population. Nearly 300 employees were sickened and one died. Do you support early inmate release to minimize the impacts of the virus?”

So, I’ve never worked within corrections, I don’t have a good understanding of the correction system and so I really don’t know that I could offer up a well-rounded, thoughtful answer to this question.

From a Public Health perspective, certainly when you have a lot of people in closer quarters, those are conditions where we know that a disease such as COVID-19 will spread quickly and rapidly. Now, whether you know whoever’s making that decision about early inmate release, you know I don’t understand that system enough to be able to weigh in here.