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April 22, 2020 News » Cover Story

Local bridge club gives rise to first contact trace of COVID-19 death and a scramble to notify players statewide 

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click to enlarge ELENA TRAPP WITH ASSETS FROM SHUTTERSTOCK.COM
  • Elena Trapp with assets from Shutterstock.com

Roughly 100 people, at tables of four, sat within a foot or two of one another, passed cards back and forth and ate popcorn out of the same bowl.

That was in late February at a tournament held by Unit 360 of the American Contract Bridge League in Colorado Springs.

In a blue single-story metal building at 901 N. 17th St., bridge players from across the state — Englewood, Castle Rock, Denver, Monument, Fort Collins, Vail, Salida and Pueblo — took part in the multi-day event hosted by the Colorado Springs club.

During that tournament, a female player from Colorado Springs in her 80s was experiencing symptoms of COVID-19, the disease caused by the novel coronavirus.

But that was roughly a week before the first case of COVID-19 was identified in Colorado — on March 5 in Summit County. At that time, there were no stay-at-home orders, social distancing or face-mask recommendations in place. In fact, the news of a disease now sweeping the nation had barely bubbled above the surface in Colorado, and questions have been raised about whether the state was prepared.

In fact, the state’s lack of capacity to process virus tests might have played a vital role in COVID-19’s spread in El Paso County.

Two weeks after the tournament, on March 13, that elderly female player became the state’s first COVID-19 fatality, and three others who had contact with her have since died.

That first death brought an unprecedented challenge to El Paso County Public Health — to trace the woman’s recent contacts, potentially hundreds of people — and to do so under excruciating time pressure.

Those hundreds of people could have infected thousands more, especially given the two-week lapse between the woman’s exposure to other bridge club members and her death.

Ironically, elements of the game of bridge that posed such a deadly risk, sitting at tables of four in a structured tournament, would later enable epidemiologists to identify and warn those who were likely exposed. That’s because the bridge club followed the common practice of recording every hand played and by whom.

At least one observer with ties to the bridge club — a microbiologist who holds a doctoral degree from Harvard University and authored a textbook on virology — criticizes Public Health’s performance. Although she recognizes that local officials faced a tough task due to lack of national leadership and a dearth of essential resources, such as COVID-19 testing, Colorado College associate professor Phoebe Lostroh raises questions about when the calls were made, testing or lack thereof of those exposed, and whether those contacted were given clear and complete information.

Public Health officials defend their handling of the notifications, which were based on staff exercises for pandemics that date to 2001. They also defend their response in a difficult situation. Only after the woman died on March 13 was it confirmed she had the virus, triggering an aggressive effort by Public Health to put together a sizable contact tracing team to reach every person who might have been exposed in February.

“This is not our first rodeo,” says Public Health’s medical director Dr. Robin Johnson.

But Johnson acknowledges Public Health could have done a better job in delivering messages and providing information to those potentially exposed. She notes that some avenues of outreach and interplay of public/private partners, now up and humming, were being installed simultaneously with Public Health being put to the test.

click to enlarge Dr. Robin Johnson, El Paso County Public Health - COURTESY EL PASO COUNTY PUBLIC HEALTH
  • Courtesy El Paso County Public Health
  • Dr. Robin Johnson, El Paso County Public Health

Contact tracing is the bedrock of public health management, and often can mean the difference between a handful of deaths due to early containment or a raging pandemic that claims thousands of lives.

The concept is simple: Track who “patient zero” had contact with to determine who needs care after contracting the disease, or isolate them and any others who were exposed to patient zero or someone else who has since become ill.

The goal is to corral the spread.

While that sounds rudimentary, in practice its success relies on substantial investment in public health resources, especially personnel, to wind through contact chains of a large event.

To do that, epidemiologists, which National Public Radio dubbed “disease detectives,” interview the patient, or in the bridge club’s case, the patient’s family, to chart the patient’s movements and identify her contacts. That means they’re thrust into a world of unknowns, because, in the case of COVID-19, the person at issue could have spread the disease for weeks without showing symptoms.

While these detectives can wind up contacting businesses, hotels, airlines, restaurants, transit operations and others, in the elderly bridge player’s case, it became apparent fairly quickly that those who attended bridge club events posed a huge threat.

“Public health workers contact each of these people to explain their risk, offer screening for the infection and conduct regular monitoring for symptoms of the infection,” NPR reports.

But Lostroh says based on her conversations with bridge club members, they weren’t contacted for days and then didn’t fully understand some of the messaging. Some weren’t sure how to get reliable additional information.

Lostroh, while a member of the club, didn’t participate in the tournament. While on leave from her CC post, where she’s taught since 2003, she was in Virginia working with the National Science Foundation (NSF) to review proposals for molecular and cellular biosciences projects and make funding recommendations. (Lostroh has since returned to Colorado Springs but still serves the foundation, which, since COVID-19 took root, has issued a call for proposals to the scientific community for ideas for “very quick funding to help solve the epidemic,” using $19 million from the Coronavirus Aid, Relief, and Economic Security Act recently adopted by Congress to fund them, she says.)

“Many of the players were not called for days and days, if not weeks,” says Lostroh, who notes her opinions are her own, and not necessarily those of CC or the NSF. “Because some people who played at the club after the tournament were not called for weeks, it was difficult to have confidence that everyone exposed at the center was called. We don’t have any confidence the people who were in contact with her were called. I don’t know if county health is understaffed, but the contact tracing was not being done quickly.”

Testing also was confusing. Lostroh says her bridge friends told her they were advised if they needed to be hospitalized, they would be tested. But if not, they were told to isolate and report if they developed symptoms.

“A bridge partner of someone who died, she had all the symptoms except fever and couldn’t get the test for a week,” Lostroh says. “Not everyone gets every symptom, which was published in the medical literature before March. I think there’s a situation where many people had it who weren’t able to get tests. We don’t know the size of the outbreak of the bridge club. When the bridge club people were getting sick, there were drive-thru places to get tests. But they were running out of tests. These elderly people, with at least some symptoms, absolutely could not get tested.”

Lostroh lays a big part of the problem at the feet of the federal government.

“The scarcity of reliable tests in March, for an epidemic that started in 2019, is a national disgrace in addition to a tragedy,” she says. “Health care providers across the United States, including in Colorado, were forced to ration testing exclusively for patients requiring hospitalization and for health care workers with symptoms.”

(It’s well documented by the national press that the Trump administration dragged its feet in recommending steps like social distancing and marshaling and distributing needed supplies across the country.)

Lostroh estimates, based on detailed records kept by the bridge club, that 277 people were probably exposed — not necessarily by patient zero, but by others who subsequently became infectious and didn’t know it. Ultimately, at least 33 people who played at the bridge club from Feb. 28 to March 12 contracted the disease, she says.

“We keep a record of who plays,” she says. “There’s a record of who played Feb. 28 to March 12 — even exactly what tables they sat at and who they played with.”

Lostroh says some aspects of the duplicate bridge card game likely enhanced the spread of the disease. That’s why it would have been better to have contacted everyone who played there after Feb. 28.

“Local health officials may not have understood the aspects of playing duplicate bridge in a club that exacerbate the spread of respiratory infections. You’re sharing these cards and boards back and forth. People are eating popcorn out of a common bowl,” she says. “This should have been used to prioritize who should have been called and when.”

She adds while it was a good idea to call those at the tournament first, other people also should have been called quickly because most players at the tournament continued to play at the club for weeks.

Lostroh got so many questions from fellow bridge club members — she spent two to four hours a day fielding calls — that she set up a web-based forum to provide answers, each labeled with a source, such as a scientific study or the Centers for Disease Control and Prevention.

“Everyone who had played in the bridge center from Feb. 28 until March 3 should have been called within 24 to 48 hours, and all those people would have gotten a test then and there,” she says. “And everyone would have known who had it, or didn’t and could have self-isolated if necessary.”

The Colorado Department of Public Health & Environment website reports 35 people across the state had experienced the “onset” of the illness as of Feb. 28. On March 13, when the first bridge player died, the state reported 955 cases in the onset stage.

Lostroh also says, based on calls she received, that at least some of the time, the bridge players did not understand that people can spread the disease without having symptoms. “That was a critical message,” she says. “I was getting questions from people even after Public Health called them: ‘Phoebe, can we spread this without symptoms? Could I have given it to someone without knowing I had it? Oh, they didn’t tell us that.’”

Since news of the woman’s death went public March 14, some have blamed the bridge club for spreading the disease in El Paso County, according to Lostroh and El Paso County Coroner Dr. Leon Kelly, who has taken on a Public Health role during the crisis. So it’s no surprise a club spokesman refused to comment to the Indy.

It’s worth noting that at the time of the bridge tournament, there were no guidelines in place for social distancing, hand-washing, face masks and the like.

click to enlarge Phoebe Lostroh, microbiology associate professor, Colorado College - COURTESY PHOEBE LOSTROH
  • Courtesy Phoebe Lostroh
  • Phoebe Lostroh, microbiology associate professor, Colorado College

Gov. Jared Polis didn’t declare a state of emergency until March 10, and didn’t start closing high-traffic businesses until March 14.

“The bridge center is very organized and civic-minded and cooperated in every way,” Lostroh says. “The leaders at the bridge club are heroes who had the foresight and good judgment to close the club on March 12, even before the governor closed high-traffic businesses. By doing so, they saved many lives.”

County officials have repeatedly praised the club and the woman’s family for cooperating with authorities.

Last year while teaching at CC, Lostroh focused her classes on the influenza pandemic of 1918, which killed at least 50 million people worldwide. “If I had assigned my undergrads to write an essay about what not to do, that is exactly what happened in Colorado, and the United States more generally,” she says.

El Paso County authorities missed a two-week window to start notifications simply because nobody knew the elderly bridge player was infected. Only after her death did a test confirm she had COVID-19.

Asked why authorities didn’t know the woman, who was in the hospital at the time of her death, had the disease earlier, Public Health spokesperson Michelle Hewitt says via email, “COVID was not known to be circulating in El Paso County at the time of her illness onset; in fact, there were very few cases outside of the mountain communities at that time.”

Kelly says the test may very well have been conducted days before her death but the results not yet known.

“She died in the morning and it [test results] came back a couple hours later,” he says. “That was when we were having folks [spend] days in the hospital before tests were coming back. The state lab was overloaded.”

State data show that in the three days before the woman died, the state lab processed only 328 tests. That comprised the vast majority of tests in the state. Only after March 13 did commercial labs gear up.

Kelly admits he was unfamiliar with the game of bridge, and after it became known the evening of her death that she’d played at the bridge club, he contacted a friend, asking her to “tell me how it works.”

The friend explained how cards are passed from player to player, he says. In response to his question of how many people could have touched the cards, his friend’s horrifying response was, “It could potentially be all of them.”

“At that point, it became clear that in the time frame we had to work through this, we weren’t going to be able to tell all people they were a part of it,” Kelly says in a phone interview.

The first step, on the night of March 13, was for Public Health to establish a call center, Kelly says, so that when the information was released publicly the next day, people would have a number to call for information.

On March 14, the county went public with the woman’s death and information about the bridge club in a news release and during a news conference attended by Gov. Polis. It was a scattershot approach designed to reach as many people as possible, Kelly says.

Meantime, Kelly and Public Health officials had a terrifying realization.

“It wasn’t just the bridge tournament. Many of these individuals had other social groups. They have lunch together, tea together, they go out as couples. So much time had passed,” he says. “By the time she died and we had a positive test, we had 15 days from when that original contact could have happened. We’re out three gestation periods. People could have contacted another group of people. Quickly we realized because of that time, this had spread out much further than we would hope if you got to it right away.”

Up to 150 people from across the state participated in the tournament, Kelly says. “Then you have numerous public health departments involved,” he says.

State health officials conveyed that message to those other counties, while El Paso County officials laid a plan for local notifications.

Also on March 14, Kelly and Public Health frantically gathered personnel to contact everyone they could identify as having been exposed. “You reach out to those contacts,” Kelly says. “If they’re well, tell them to quarantine, ‘you need to monitor your symptoms.’ We spent all morning Saturday morning, and formulated a plan of how to manage it.”

While making those calls from the Pikes Peak Regional Office of Emergency Management (OEM), authorities encountered more bad news. Some bridge players had subsequently attended choir rehearsals, widening the circle of those at risk. Officials called choir members on March 15.

“Through the course of this, we contacted 300 individuals from the ramifications of the bridge tournament,” Kelly says. “There were some in the hospital [who were] associated with the bridge tournament.”

About 20 people gathered to make calls, working Saturday into the night and again on Sunday. Kelly says it’s unrealistic to staff year-round for such contact tracing, so additional help was enlisted from the coroner’s staff, OEM and members of the Medical Reserve Corps, a network of community-based people from local organizations formed under the auspices of the Office of the Assistant Secretary for Preparedness and Response in the U.S. Department of Health and Human Services.

Everyone was called, though some didn’t answer their phones, so workers left voicemails.

The following week, officials identified additional bridge players who were present on other days and who tested positive for the virus. That triggered an additional round of contact tracing, Kelly says.

Public Health also sent letters to nine bridge club members suspected of having the disease, advising them to isolate for up to 10 days, and eight letters to members identified as exposed, advising to quarantine for 14 days. Letters weren’t sent to everyone, because many members told officials they didn’t require a letter, Hewitt says. (From that point until April 11, Public Health issued another 285 isolation letters and 302 quarantine letters to other people and institutions.)

All of those contacted were given explicit instructions on how to isolate and quarantine. The script used for the calls and the letters also specified that “persons infected with COVID-19 may be contagious prior to symptom onset... .”

Those efforts identified 25 people as ill; those people have since recovered or are in the process of recovering, Hewitt told the Indy on April 11. Ten other contacts were hospitalized.

Within four days of the call effort, COVID-19 claimed its second bridge club victim on March 19, a man in his 60s. Two others subsequently died — a female in her 80s on March 23 and a male in his 70s on March 28, Hewitt says.

Kelly says the contact trace effort never identified how the first victim became infected.

click to enlarge Dr. Leon Kelly, El Paso County coronor - COURTESY CORONER'S OFFICE
  • Courtesy Coroner's Office
  • Dr. Leon Kelly, El Paso County coronor

For Public Health, the contact tracing was a first under such urgent conditions. “We have never had a contact tracing at this level before,” says Lisa Powell, Public Health’s emergency preparedness and response program manager. She says Public Health has conducted contact tracing for hepatitis A that spanned two years, and Johnson says the agency has previously used many of the same components of the COVID-19 effort in other tracing efforts.

“Prevention, education, contact tracing — all those other skills we bring to bear are those things we would be using in a hepatitis A outbreak or other investigation,” Johnson says. “This is within what Public Health trains for, and yet it is the first pandemic that has been experienced since the 1918 influenza pandemic with this type of rapid global stretch.”

The department also used the same tracing techniques during the 2009 H1N1 influenza spread, for example, Powell says.

She adds that the agency installed emergency plans for a pandemic years ago and that pandemic planning has been “on the table” since 2001. In fact, Public Health participated in a nationwide exercise two years ago that involved a pandemic.

Powell says, “Even if you’ve been practicing it for years, it’s still pretty surreal.”

As for the bridge club, Johnson says contacts went well beyond the members themselves. “To be sure,” she says, “we were tracing all potential people who could have come into contact with them. We did know who had been at the tables and where their seating was. But because of the nature of those tournaments, it was important to extend beyond that.”

Public Health relied heavily on community partners, such as OEM and the Coroner’s Office. “While we may be the agency at the tip of the spear,” Johnson says, “we need all of our partners to address whatever is coming down the pike. That allowed us to seamlessly reach out and bring on board some of their resources.”

Kelly notes in an outline of Public Health’s response provided to the Indy that many Colorado counties have quit doing contact tracing due to wide community spread and lack of resources.

But Public Health, he says, continues that practice on high-risk groups and special populations utilizing surge staffing when necessary.

“Because this was what we believed to be our first case of community spread and involved a high-risk population, we acted very aggressively in our contact tracing,” he says. 

Testing, or the lack thereof, lies at the heart of the bridge club story.

When the first victim succumbed, Kelly says, “At that point we did not have the [Federal Emergency Management Agency] testing center up and running yet. The only way to get a test was to have your doctor order a test or go to the ER. You needed a physician’s order to get the test.”

(FEMA opened a testing center March 31 at 175 S. Union Blvd. for health care workers and first responders, and widened the eligibility range on April 5 to include those over age 65 experiencing symptoms. The testing center remains open and eligibility is expected to expand further.)

As for processing COVID-19 tests, “The state public health department was essentially the only lab in the state doing testing,” Kelly says, “so that was the only game in town.” And that lab was significantly backlogged, he adds, meaning hospitals were waiting for 10 days or more to get test results.

“That was the reality of the situation,” he says. “I can tell you that happened in every single state in America. CDPHE was not alone in that.”

Testing involves more than simply swabbing someone’s nose or throat. Kelly says a lab needs specific machines calibrated to process samples and reagents designed to render results.

Building up capacity doesn’t happen overnight. While private labs began gearing up fairly quickly, it wasn’t until March 25 when private labs overtook the CDPHE lab’s pace in processing coronavirus tests, state data show.

From March 10 to 24, the state lab handled 5,928 tests, compared to private labs’ 3,508. But after that, private labs’ capability skyrocketed. By April 10, they processed as many as 2,435 in one day, or 97.4 percent of all tests, compared to the state lab’s 64. Through April 19, private labs have processed 70 percent of tests, 43,632, compared to the state lab’s 12,766. 

Of all those tests, about 10 percent came back positive. 

A complicating factor in testing for COVID-19, says Kelly, is that the tests don’t always show a positive result in people who don’t have symptoms. Hence, someone can be carrying the disease without symptoms and not test positive.

“If they don’t have symptoms,” he says, “they might be sick but there’s not enough virus to make a positive test. That’s why we only want people to be tested that are symptomatic.”

Johnson notes tests are given when “there are symptoms that would lead you to be concerned.” Testing also can lead epidemiologists to know where it’s spreading and how. “The more information we have, the better,” she says. “A negative [test] is not a wasted test. If it’s negative, we know we don’t have to investigate further that individual’s test for COVID.”

Positive tests, Powell adds, “continue to lead our epidemiologists where we see a breakdown in preventive measures, so we can do that investigation and shore up what we can do in prevention so we can stop further spread.”

Going forward, when some restrictions on the population are relaxed, Powell says, testing will become more crucial. “Testing will be a tool so we can see if there are cases that pop up and intervene in those cases robustly, instead of allowing it to spread, so we would not have to have more severe measures again,” she says.

click to enlarge Lisa Powell, CDPHE emergency preparedness and response manager - COURTESY EL PASO COUNTY PUBLIC HEALTH
  • Courtesy El Paso County Public Health
  • Lisa Powell, CDPHE emergency preparedness and response manager

Kelly says testing is critical as the country reopens for business, but turnaround times need to be immediate, unlike in the bridge club’s case. “We need to be able to identify those who are symptomatic, get results back in a meaningful way,” he says. “We lost that ability in this fight early on due to poor access and critical shortages. Which was why we went to plan B — mitigation.”

Because reopening for business hinges on an ample supply of tests, some, including New York Gov. Andrew Cuomo, worry all states and the federal government would compete for an insufficient cache of tests. Also epidemiologists across the country will be burdened with conducting extensive contact tracing, a labor-intensive task for which some states and counties might not be equipped.

Looking back, Johnson says Public Health’s response and partnerships with other agencies coagulated simultaneously as contact tracing geared up.

Unfortunately, the bridge club, she says, emerged at the “beginning of the conversation” about COVID-19.

“As the conversation became evident and there were increasing resources and [we were] getting people educated on a brand new disease,” she says, “they [bridge members] were at the beginning, walking that road with us. They helped us understand all the resources that need to be brought to bear. Maybe it didn’t occur quite as seamlessly [as it could have.]”

For one thing, Powell suggests, having a call center and crisis line available sooner could have mitigated any sense of confusion among the public for where to turn for information and concerns. (The region’s Joint Information Center opened on March 13, the very day the bridge player died. And the response team didn’t mount a publicly available dashboard of analytics to show the course of the disease until April 16.)

“It is making sure these individuals have resources they can connect with,” Johnson says. “That might be a referral into the resiliency and behavioral health center, a physician, or a friend.”

The virus also has proven to be a foe demanding a higher level of staffing. After the virus invaded the state, Public Health doubled its epidemiologist staff from two to four, and hired a half-time nurse. It also reassigned many of its immunization nurses and other staff to the COVID-19 cause, up to 70 to 80 people, and partnered with the University of Colorado at Colorado Springs’ Beth-El College of Nursing to engage 35 students and five faculty members.

“This is a challenge that is pretty unique,” Johnson says. “But we have come together in the community in the past and made some significant impacts — H1N1, fires or floods. I do believe when we come together and have compassion with each other, having the best intent while we move forward and understanding that we’re all learning in this as well, we can get through anything.” 

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