WUPHD’s role in launching ‘non-pharmaceutical interventions’ in Copper Country

Before 2020, the Western Upper Peninsula Health Department wasn’t focused on surveilling and testing for highly-contagious viruses like COVID-19.

“I mean, those are definitely missions of the health department,” said Tanya Rule, WUPHD’s director of environmental health, who works out of the Hancock Office. “But this is a whole new disease we’re dealing with, and obviously nobody working here has ever dealt with a pandemic before.”

For almost a year now, many of their normal duties have been pushed to corners of the day while the bulk of Rule’s five local employees’ time is spent on COVID-19-related activity.

Rule’s environmental health department was mostly focused on well and septic permitting, system inspections, and building permits. Many other inspections, like for swimming pools, campgrounds, and tattoo parlors, are also done by contract with the state of Michigan. The health department also responds to emergencies like the 2018 Father’s Day flood, toxic spills, and does educational outreach for things like Lyme disease and radon.

Going into 2020, Rule had planned to be spending time outside of those regular duties digitizing her department’s records, speeding up E.coli testing at beaches, and updating the local sanitary code.

Paper records made response to the 2018 Father’s Day Flood more difficult as they were trying to figure out what water supplies and septic systems might be compromised. Rule said they purchased specialized software in 2019 to be able to lay those records out on a map.

“And so we are working on inputting all of our data into that, so it can be used for public health purposes and also just be accessible to the public,” Rule said. “Because people ask us for data all the time.”

The sanitary code revision has been a four-year project, all but halted due to COVID-19.

“The only local code that we have here is our Superior Environmental Health Code that regulates on-site septic systems,” Rule said. “Every other code that we regulate the public under is a state code.”

Other health department plans to expand healthy eating, asthma prevention, marijuana education, and substance abuse programs were all put on hold. Instead, they’ve been making sure the necessary things, like construction and operating permits, are taken care of while putting focus on the COVID-19 response.

When the first COVID-19 shutdown happened early in 2020, WUPHD’s staff was working to learn as much as they could and create website content and documents to share with the public and with schools and businesses to educate them on compliance and safety.

“Starting in March, my staff conducted 742 field visits at local businesses in our five counties,” Rule said. “These were not regulatory visits.”

Rule said they visited schools, restaurants, bars, grocery stores, hardware stores, campgrounds, pools—any public place—and brought information about COVID-19 safety and prevention.

Since there were not any safe drugs or vaccines available, education focused on ‘non-pharmaceutical interventions’, or NPIs.

Dr. Kelly Kamm has a doctorate in epidemiology from the State University of New York at Buffalo, and a master’s degree in microbiology from John Hopkins School of Hygiene and Public Health. She works as assistant professor of kinesiology and integrative physiology at Michigan Technological University. Among her research foci are rural health, hand hygiene, and the social determinants of health.

Kamm said that treating a sick person with an antiviral or antimicrobial pharmaceutical is a great way to keep them from infecting other people by shortening the amount of time they have the disease and are infectious. However, there’s currently no known safe treatment for COVID-19, so NPIs are necessary instead.

“So those are the things like hand washing, the social distancing—it’s all these behavioral things that we can do—wearing a mask, keeping ourselves healthy through other ways…” Kamm said. “Those are what we consider those non-pharmaceutical interventions.”

Kamm said Copper Country may have been spared early infection simply because there weren’t many people coming into the area at the time. Students weren’t returning from other areas, and there are no major airports like those in big American cities that saw many of the early outbreaks.

“So rural areas in that case were protected a bit,” Kamm said. “The problem becomes—in terms of safety—that rural areas are very underserved in terms of healthcare.”

Urban areas like Detroit, Grand Rapids, Milwaukee and Chicago have multiple hospitals in close proximity, so it doesn’t take long to get transferred from an overcrowded hospital to one with spare capacity. The hospitals of the Upper Peninsula are much more distant from each other, smaller, and have less of a labor pool to draw from.

“Our job market for anything is just much tighter and harder to fill in if people are out,” Kamm said. “If you want to have visiting nurses, where are they going to come from?”

Kamm said normally there are benefits to living in a smaller, close-knit community, too. During the Father’s Day floods, people came out immediately to help each other, because they know that other help is distant and could take a long time reaching them.

“I think with COVID, the problem is really that people aren’t recognizing this as a community issue that we need to address as a community,” Kamm said.

Once positive cases started appearing in their jurisdiction, the WUPHD staff switched to phone calls to ensure they didn’t catch or spread COVID-19. Rule said they made nearly 550 calls, focused on places like nursing homes, hotels, daycare centers, and private medical practitioners. Two health educators who manned the emergency call system at WUPHD, activated for COVID-19 response, were taking upwards of 100 calls per day through the summer, she said. One of her staff assisted them.

Contact tracers were overwhelmed with the number of calls they needed to make in early November, and prioritized those either more susceptible to the disease, or those more likely to transmit it because they were in a congregate situation like a nursing home or school. However, that doesn’t mean others were left abandoned, Rule said. They still got notified and are asked to quarantine and notify their own close contacts, but aren’t interviewed about potential contacts by WUPHD staff.

Rule said that while there are some people who don’t cooperate with the health department’s contact tracing, most of the community is very cooperative.

“People are honest about where they’ve been and who they’ve been in contact with because they want to protect their communities just as much as the next person,” Rule said.

Schools are a big part of the contact tracing and intervention efforts. WUPHD has 20 schools in its jurisdiction.

“And, since the pandemic began… we’ve had to quarantine just over 3,000 students and staff in our 20 school districts,” Rule said.

Someone from WUPHD is in contact with each district every day to discuss exposures, tests and quarantines, with the goal of keeping the schools open.

“Quick identification of a positive, and then getting their close contacts into quarantine and doing virtual school is really a way of preventing the closure of the entire school,” Rule said. “And we have found that to be effective.”

During the past year, WUPHD has also helped greatly expand testing capacity in the area, and offered rapid COVID-19 testing to all the emergency services, schools and other critical infrastructure employees.

“We want to make sure that our emergency services are maintained, and that they don't have an outbreak because we know that our first responder groups are very small,” Rule said. “We don't have the capacity for all the firemen or all the police officers in one agency to, you know, be part of an outbreak.”

Rule said the new testing lab at Michigan Technological University made a huge difference, cutting the wait time for lab results from 1-2 weeks to 1-3 days.

“When we were really backlogged and delayed of[sic] testing,” Rule said. “Sometimes by the time we would get the results, the person's quarantine would be over. So that became problematic with preventing spread.”

The lab was expanded with help from a grant WUPHD received from the Michigan Department of Environment, Great Lakes, and Energy. The grant also supported the wastewater testing pilot, which showed community outbreaks can be predicted in communities as small as MTU dormitories by detecting the increase of virus pieces in wastewater stream samples.

Rule said that 519 businesses in WUPHD’s five-county jurisdiction have been contacted about having a customer or employee test positive during the pandemic.

“So then they are obligated to notify their staff that they had an exposure so that they can further monitor themselves for symptoms,” Rule said.

A handful of exposure sites have been released to the public, but Rule said WUPHD tries to avoid doing that if they can. They release statements in cases where people were likely ignorant to their exposure, and unable to be contacted.

“If we have a way of knowing who was exposed, then there were definitely situations where we didn’t need to do a press release,” Rule said. “We would only need to notify the people who are at risk.”

Once COVID-19 became community-wide, she says the exposure notifications also became unnecessary. Everywhere became a potential exposure site.

“We were really then relying on everyone to do their part by masking, minimizing your exposure to the community, staying home when you’re sick, etcetera,” Rule said.

Rule also helped people develop COVID-19 safety plans for people’s organizations and events who wanted to be sure they were in compliance with the orders at the time.

She said that the small percentage of their time that has garnered the most attention has been consumer complaint investigations.

“We didn’t go out and do any surveillance as far as enforcement activity,” Rule said. “We simply just responded to individual consumer complaints.”

Kamm said that nobody interested public health would desire the shutdown of an economy.

“Poverty is one of the biggest risk factors for poor health,” she said. “But we also don’t want people needlessly dying.”

Kamm said it shouldn’t have to be one or the other, either. If NPIs are used in a way that is effective, no parts of the economy should need to be closed.

“If we can keep this under control, then they’d have more ability to be able to open things up,” she said.

WUPHD’s contract with MDHHS binds them to respond to consumer complaints against facilities they regulate.

“So, if a member of the public files a complaint against a restaurant, a bar, a swimming pool, campground, a body or establishment—or if it’s about a septic discharge or a contaminated water supply—we always respond to those complaints,” Rule said. “And we have to respond within five days per our contract.”

Rule said WUPHD regulated 427 food service establishments in 2020. Since March, they’ve received 492 COVID-19-related consumer complaints against 60 restaurants and bars.

She said on the first complaint, they would simply make a phone call. Often the establishment was just unaware of the current rule.

“The rules changed—like everyone has been frustrated with—sometimes weekly, every other week,” Rule said.

Rule said only four establishments through 2020 did not voluntarily comply with regulations after being called. After that point, the businesses were referred to the Department of Agriculture and Rural Development, who followed up with enforcement action, starting with a cease and desist order. Three businesses have been fined, one business had their liquor license temporarily suspended, and one facility has had their food service license suspended and continues legal action and appeal.

Asked a series of questions, including why restaurants and bars seem to be most heavily impacted, Michigan Department of Health and Human Services public information officer Bob Wheaton replied with this written statement:

COVID-19 spreads in indoor settings where individuals socialize without masks. When the order was first issued in November, there were 54 known outbreaks associated with bars and restaurants in Michigan. Because about 50 to 60 percent of all COVID-19 cases cannot be tied to a known source of infection, and because tying cases to places where individuals may spend only an hour is difficult, there is an unknown number of further outbreaks not counted in that total. Targeted and temporary closures that include restaurants have been part of successful strategies for containing COVID surges in Western Europe. Other states are now following this approach, and it is supported by leading public health experts nationwide. The department hopes that residents will do the right thing and follow these orders to save lives and protect their family, friends and community from further spread of COVID-19.

Wheaton also shared links to some studies:

This study, published by Nature on Nov. 10, uses mobility data to show that limiting maximum capacity inside “points of interest” like restaurants is more effective at limiting spread than uniformly reducing mobility (total shutdowns).

This article from Bloomberg, based on a Stanford study, highlights similar findings.

This study from the Centers for Disease Control that found, “Adults with positive SARS-CoV-2 test results were approximately twice as likely to have reported dining at restaurants than were those with negative SARS-CoV-2 test results.”

CNBC reported on analyzed credit card data that showed in-person restaurant spending was “particularly predictive” of a rise in new infections three weeks later.

This study, from the Journal of Korean Medical Science, found that under some conditions, SARS-CoV-2 could be transmitted to people as far as 6.5 meters away. That’s more than 20 feet.

MDHHS personnel did not grant me an interview.

Kamm said there are two kinds of “barriers” that keep people from using NPIs to prevent disease, structural barriers and psychosocial barriers.

Structural barriers can be something like the availability of a sink to wash your hands.

“We address that by having hand sanitizer all over the place,” Kamm said. “And that reduces that barrier so it’s convenient for you.”

However, she said in the Upper Peninsula’s climate, hand sanitizer dries out the hands and that can itself become a barrier that needs to be overcome. Some companies are trying to address it with better hand sanitizers that don’t dry out the hands.

Psychosocial barriers are more about feelings and habits.

“If it’s not your habit to wash your hands when you come home from going to the grocery store, it’s hard to learn that new habit,” Kamm said.

Developing new habits can be hard, and even harder when everything else in life is also pushing new stress on us, according to Kamm.

“Any behavior change, even something where we think that it should be easy to do, and it's something everybody knows they should do—It's not as simple as that,” she said. “We know in health behavior that just educating someone doesn’t work.”

She said part of this is just changing social norms. People push back initially but it eventually becomes normal, like when seatbelt use was mandated.

“And there’s always a bumpy road on doing that,” Kamm said.

Kamm said behavior change surrounding the HIV epidemic is a pretty good comparison. After being educated, each individual had to make their own risk-benefit analysis for themselves before deciding whether to change their behavior in any way.

“And when we look at those groups that were more likely to be okay with those behavior changes, those were the groups that saw all of their friends dying, that saw for themselves the horrible impact of HIV-AIDS,” Kamm said. “And we see the same thing in any disease.”

She said most people probably don’t know someone who has died of COVID-19, so that risk-benefit analysis hasn’t hit a tipping point for many. Particularly because those deaths are not evenly distributed in the population. This complicates getting across the message that NPI behavior protects everyone, not just yourself.