As the threat of a new coronavirus emerged in early February, California assembled a group of public health officers whose primary mission would be tracking down travelers from overseas and monitoring them for signs of COVID-19.
It was likely the state’s first, best chance to beat back the pandemic and forestall community spread.
But the California Department of Public Health’s efforts was hindered by a number of setbacks, including faulty data provided by the federal government and a lack of resources to investigate local cases, officials said in a new study published by the U.S. Centers for Disease Control on Monday.
The study provides a window into an early obstacle for the state’s public health response.
The travel monitoring program was launched just as hundreds of evacuees from Wuhan, a Chinese coronavirus hotspot, were expected to arrive at Travis Air Force in Solano County. By then, flights from China were being directed to 11 airports, including two in California.
In the first seven days alone, the U.S. Centers for Disease Control and Prevention notified the state of more than 4,000 people arriving from China.
The team of about six staff from California, among them epidemiologists and other personnel, worked over a seven-week period that ended on March 17 — the day after several counties declared shelter-in-place orders. They were supposed to determine where an incoming traveler was going and alert local public health officials.
They screened more than 11,000 travelers from China and later Iran, sending notices to 51 local health departments throughout the state. However, local officials were only capable of following up and checking in on these people “if the resources permitted.”
Smaller departments were asked to investigate only a handful of travelers, but others received hundreds of names to monitor. The CDC study does not make clear how many cases were investigated after the traveler left the airport, or which health departments were less capable of keeping track of them.
The state found a number of errors in the data, including incorrect telephone numbers, duplicate records and, in some cases, people who did not reside in California. They also found errors in names and dates of birth which made tracking people down more difficult.
Researchers blamed the faulty data collection on U.S. Customs and Border Protection.
A spokesperson for the federal agency referred questions about the collection of health information and health screenings back to the CDC and the Department of Homeland Security’s contract medical personnel.
“U.S. Customs and Border Protection has followed CDC guidelines at all ports of entry since the beginning of the COVID-19 pandemic,” a customs spokesperson said in an email. “CBP officers identify travelers who … exhibit symptoms of COVID-19 and refer such travelers to the CDC or DHS contract medical personnel who conduct the health screenings and capture traveler contact information.”
Public health officials declined to comment Monday.
‘Labor-intensive,’ mixed results
Researchers characterized the travel monitoring endeavor as “labor-intensive” and the results appeared to be mixed.
By April 15, the public health department could only match three of the 11,574 travelers identified to one of the confirmed cases of COVID-19 reported to the state using names and dates of birth.
Two patients had traveled from Iran and were tested several days after arrival. A third patient, however, came from China but was tested on March 30, nearly 6 weeks after returning to the United States, and nearly two weeks after the travel monitoring program stopped.
On February 26, the CDC confirmed that the nation’s first COVID-19 case of unknown origin was found in Northern California. At that point, health departments faced a question of how best to deploy resources, researchers said.
“Once community transmission was documented in several California counties, local health jurisdictions needed to weigh the effectiveness and costs of continued traveler monitoring for an imported disease against the implementation of mitigation measures to slow local disease transmission and allow health care systems to prepare for increased caseloads,” researchers said.
The program ended 20 days later. Researchers said travel monitoring could be useful in the near future if there are other waves of the disease once the data issue is corrected and there’s enough staffing.
Effective for Ebola, not COVID-19
There are few mentions of traveler monitoring programs in medical research databases other than those created after the Ebola virus outbreak in West Africa five years ago.
State health departments across the country, including California, adopted similar travel monitoring protocols involving border patrol for that epidemic. But the diseases are nothing alike, health officials said.
Volume, for one, was a major issue.
State researchers said during a typical week during the Ebola outbreak 21 travelers were monitored in California over 17 months. During a typical week for COVID-19, 1,431 travelers were monitored each week for nearly two months, according to the public health department.
Ebola patients were visibly sick, but coronavirus patients can have no symptoms at all.
Other public health officials agreed. Dr. Richard Danila, an epidemiologist with the Minnesota Department of Health said the Ebola traveler monitoring program was “tightly controlled.”
“It was a completely different situation,” Danila said in an email. “U.S. officials were on the ground at airports in Liberia, Guinea, and Sierra Leone. All travelers were funneled into five U.S. airports.”
Danila, who helped author a study on the Ebola traveler monitoring effort in Minnesota, said travelers from affected areas were screened again and after the first 3 weeks given a free cell phone.
“The health departments where the travelers were ultimately traveling to were given the contact information, including telephone numbers,” Danila said. “As a result, we were able to reach almost 100 percent of all travelers to our state.”
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