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By the time the first U.S. case of COVID-19 was confirmed in Washington state on Jan. 20, it had already infected hundreds of people in China and had spread to Japan, Thailand and South Korea.
While the Washington State Department of Health had prepared a plan for the arrival of the virus that detailed how the state would obtain tests from the Centers for Disease Control and Prevention, what type of messaging it would release to citizens and how it would train staff at local health centers to handle the virus, it assumed it still had weeks before the disease would reach the U.S.
“In three days, the plan was trashed. We went through every step,” Marcia Goldoft, a clinical epidemiologist with the Washington State DOH, told Yahoo News. “I don’t think anyone involved has ever seen anything go this fast.”
Though President Trump has often asserted that the coronavirus pandemic “surprised the whole world” and that “nobody knew there would be a pandemic,” state health departments and the CDC are tasked with doing just that.
To anticipate events like the coronavirus pandemic, the CDC established the Epidemic Intelligence Service, its elite “disease detective” training program. Over the course of two years, EIS officers receive immersive, on-the-job training — either at CDC headquarters, where they’re assigned to focus on specific disease areas, or at state and local health departments around the country — to investigate every aspect of an outbreak like this one.
When a new disease emerges, such as COVID-19, EIS officers aren’t studying pathogens in a lab; they’re the ones sent out into the field to figure out where it came from, who it’s been spread to and how to stop it from traveling farther.
As part of her EIS training, epidemiologist Michelle Holshue had been placed at the Washington State DOH. So, when the phone call came in about a man with symptoms of a “novel coronavirus,” Holshue — who spent two months studying Ebola in West Africa as a nurse with the United States Public Health Service — sprang into action. By then it was Jan. 19 and the virus, now officially named SARS-CoV-2, had been spreading rapidly through China. With new cases appearing in Asia each day, she and her colleagues knew it was no longer a question of whether the virus would appear in the U.S. but when.
The patient, an otherwise healthy 35-year-old, had shown up at an urgent care center in Snohomish County, Wash., 50 miles north of Seattle, complaining of a dry cough, fever and nausea. Most important for Holshue, he had just returned from a trip to visit his family in Wuhan, China, where the virus had been traced to a live animal market.
With pertinent symptoms for COVID-19 and a history of travel to Wuhan, the man was considered to be a probable case. Nurses took two swabs from his nasal passages and overnighted them to the CDC in Atlanta, which — at the time — was the only facility in the country with access to a test.
Within 24 hours, it came back positive.
‘Pay attention, people; it’s here’
The CDC notified the Washington DOH of the positive test result on Monday, Jan. 20, Martin Luther King Jr. Day. Only a few staff were on call that Monday, but by Tuesday, local officials, epidemiologists like Goldoft and physicians had already mobilized to begin tracking the disease.
Since Washington was the first state in the nation to identify a positive test result for COVID-19, the most critical step soon became pulling together everything that was known about the case. Holshue was tapped for the job. Working long hours from the Washington DOH headquarters (and sometimes, her own apartment), she pieced together a list of all the patient’s recent contacts, then phoned the urgent care nurses who had seen him and the hospital X-ray technicians who took images of his lungs. She then gathered information on the more than 50 people who had come in contact with the patient, who was, by then, in quarantine.
“Different people had different pieces and we couldn’t see the whole picture,” said Goldoft, who worked with Holshue on tracing the patient’s contacts. “What happened in the outpatient? What happened in the inpatient? Every piece of this first case had to be pulled together — and no one person had it. We didn’t know what was going on and it was all moving so quickly. It sounds simple but it was a huge amount of work.”
Goldoft said they were concerned about the virus’s spread, so Holshue did the calls remotely rather than conduct in-person interviews, reporting back to a team of physicians, scientists and Washington state officials. Twelve days into the patient’s illness, when the symptoms dissipated, she worked nights and weekends with others in the department to compile the first report of what they saw.
In a paper later published in the New England Journal of Medicine, Holshue and her colleagues wrote that there were “several aspects of this emerging outbreak that are not yet fully understood, including transmission dynamics and the full spectrum of clinical illness.”
Goldoft, who is also an EIS alum, said that her team took the first case as a call to action.
“It doesn’t mean anything in terms of probabilities or frequencies. It’s just one case,” Goldoft said. “But it means: Pay attention, people; it's here. Doctors, start looking for it; start testing.”
Holshue’s paper became a road map for other physicians to follow. “It’s a very medical description: ‘Here’s what the X-ray looked like, here was a blood test, here’s what we saw clinically,’” Goldoft explained. “There was zero experience [with the coronavirus] in the United States. This was experience No. 1.”
In the months since Holshue and the team in Seattle confirmed the first U.S. case of COVID-19, the disease has been confirmed in more than 174,000 more Americans. Globally, more than 826,000 people have been infected. The pandemic is now in full swing — meaning the priorities for EIS officers like Holshue have shifted from confirming the virus is in the U.S. to tracking where it is spreading fastest across the country. Goldoft says Holshue, who is too deeply immersed in the crisis for an interview, has been tirelessly collecting all the information about the outbreak she can gather.
“She’s been down at the quarantine station; she’s met some of the returning travelers from the cruise ships; she’s getting pulled into a lower supervisory role,” Goldoft said. “We need all the staff we can get.”
‘It’s an all-hands-on-deck situation’
On a normal given day, officers in the EIS program are scattered around the globe, working on a wide variety of assignments. But with the U.S. facing a public health emergency, they have all been called on to respond.
“It's an all-hands-on-deck situation,” Eric Pevzner, who oversees the EIS program as chief of the CDC’s Epidemiology Workforce Branch, told Yahoo News.
Pevzner, who was part of the EIS class of 2005, said that during his own training, he was assigned to focus on global tuberculosis, a position that involved working with the World Health Organization and individual countries to help strengthen programs for diagnosing, treating and preventing TB around the world. While many of his projects involved travel to countries in sub-Saharan Africa and Southeast Asia, “where HIV was driving the global TB epidemic,” Pevzner said he was also called on to investigate domestic outbreaks of tuberculosis, such as one that began in 2005 in Washington state that had been fueled by methamphetamine use.
But when a public health crisis emerged in New Orleans in the aftermath of Hurricane Katrina in 2005, Pevzner said that he and most of his EIS classmates were enlisted in the CDC’s response.
“Right now, our officers are all focused on COVID-19,” said Pevzner.
Officers like Holshue, who were already assigned to specific state health departments, are working with their local public health colleagues on a variety of tasks, said Pevzner, “from surveillance, to tracking the spread of disease, helping with implementation of testing programs, collecting data on quarantine, following up with people that might have been exposed and trying to implement better control measures.”
Some EIS officers have also been deployed to quarantine stations around the country, such as those established at certain airports, where they’re tasked with “screening people coming into the United States to evaluate whether they might have been exposed or are at risk of disease, to try and stop any importation of disease into the United States.” Others have been sent to assist with quarantines set up at military bases for cruise ship passengers and Americans returned from China.
Current EIS officers aren’t the only ones responding to the coronavirus crisis in the U.S., however. Many of the program’s alumni, who often go on to work in a variety of public health roles, are also involved in leading the response from the local, state and federal levels.
Dr. Anne Shuchat, principal associate director of the CDC, and Nancy Messonnier, a director at the National Center for Immunization and Respiratory Diseases, are among the EIS alumni at the forefront of the federal government’s response to the pandemic.
“Once trained as a disease detective, you’re pretty much always a disease detective,” said Pevzner.
‘They want to be the first people out to help’
Since the EIS was established in 1951, more than 3,600 “disease detectives” have been trained by the organization. Applicants include physicians, nurses, scientists and veterinarians, all of whom (besides nurses) are required to have a doctorate-level degree, as well as service-oriented volunteer experience.
“Every year that we do application reviews, the alumni that are reviewing these applications all turn to ourselves and say, ‘We would never get in now,’ because every year the group that comes in is just more and more impressive,” said Pevzner. Still, the underlying drive to serve remains a core qualification for anyone seeking to join the program.
“They’re the first people that, when there's a new threat, are calling my phone, sending me emails, knocking on my door — they want to be the first people out to help and assist,” said Pevzner. “Regardless of whatever the threat is, whether it's Ebola, COVID-19, the opioid epidemic, they want to go out there and they want to serve and assist.”
Pevzner told Yahoo News that he’d recently spoken to several officers who’d completed 14 days of self-quarantine after returning from weeks of working on the response to COVID-19.
“They're lining up, ready to go right back out again,” he said.
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