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Since the beginning of the COVID-19 pandemic, Montana has been the safest state in the Lower 48. Despite early projections of hundreds of deaths and a shortage of ICU beds, the state’s initial outbreak peaked with a daily caseload of 23 on April 1. The state was able to not only flatten the curve, but also go farther than any other state in stalling the virus’s spread, with new cases zeroing out in late May.
But over the past week, Montana has seen its largest surge of cases. On Thursday, the state reported 37 positive cases, the most in a single day. The daily caseload was back to 23 on June 24. The state currently has more than 200 active cases.
Even with the recent upswing, “Montana is still the safest place in the country,” said Dr. Laurel Desnick, Park County Health Officer. The state still has the lowest infection, hospitalization and death rates per capita in the Lower 48, according to the Centers for Disease Control. The largest ongoing outbreak in the state is in Gallatin County, with 34 active cases.
The shutdown bought Montana public health officials time to prepare, said Dr. Greg Holzman, state medical officer. Medical professionals learned more about the virus. Health care providers were able to secure testing supplies and personal protective equipment. Businesses had a chance to install social distancing measures and plexiglass.
With the state’s economic reopening, now in phase two, an increase in reported cases was expected. Now it is happening. The question, health officials told Montana Free Press, is what happens next? Will the state learn the lessons of its success so far? Or will new small clusters lead to larger outbreaks? The answer depends largely on Montanans’ willingness to stay home when they’re sick, wear masks in enclosed public spaces and maintain social distancing, Holzman said.
“We’ve done extremely well,” Holzman said. “But we’re in the third inning of a nine-inning game. And who even knows if we’re there?”
‘CLOSURE DEFINITELY SMOTHERED THE DISEASE’
Health experts across the state say the state’s relative success in limiting the virus so far is attributable to a combination of factors, some of which were beyond their control.
“It’s the million dollar question,” Holzman said. “Nobody can be 100% sure why.”
The most effective measure in limiting the spread, health officials agreed, was quick action to shut down businesses and schools statewide. Gov. Steve Bullock declared a state of emergency before the virus arrived in Montana, and closed schools just two days after the first documented case, earlier than states including New York and New Jersey. The state’s stay-at-home order was implemented March 28, the day after the highest daily caseload prior to this week.
“The most important factor was the willingness to respond early and take it seriously,” says Matt Kelley, Gallatin City-County Health Officer.
“Our closure was early,” said Ellen Leahy, Missoula City-County Health Officer. “And you can see when you look at the epidemiological profile from state level, the closure definitely smothered the disease up until the time it started reopening.”
But the shutdown was never designed to be permanent, and the goal was never to eradicate the disease. The idea was to slow transmission so as to not overwhelm hospitals with a dense influx of critical cases. In early April, projections suggested that 268 Montanans would die of Covid-19 by August 1, and that the state’s late-April caseload peak would require 129 ICU beds — 44 more than the state has. That never happened.
“From a public health standpoint, that’s one tool in the toolbox, but it’s a sledgehammer,” Holzman said. “We knew a lot less about the virus and had a lot less ability to control it. By putting in the stay-at-home order, it helped suppress it overall.”
‘NO GREAT PLAYBOOK’
When a new disease first hits, health officials look to tools they know have worked in the past, said Jim Murphy, chief epidemiologist for the Montana Department of Health and Human Services.
“There’s no great playbook when you’re dealing with something that’s new, that’s only been around for six and seven months,” he said.
Holzman said medical experts learn what tools work by examining other examples.
“When is it shedding the most? How’s the infectivity? What are the respiratory and cardiac effects? All of that is stuff we’re learning more and more about each day,” Holzman said. “But the core public health principles like quarantine and isolation have been around for a long, long time.”
Murphy said a comparable disease immediately came to mind: pertussis, also known as whooping cough. Pertussis, a highly contagious bacterial disease that, like COVID-19, is frequently spread by droplets emitted by infected people, is the most recent infectious disease outbreak Montana has had to deal with in recent years.
Pertussis, which generates symptoms similar to the common cold before becoming more serious, typically takes more than three weeks for patients to begin showing symptoms, so health officials employ a similar contact tracing strategy as with COVID-19. Pertussis patients typically infect between 12 and 17 people, while COVID-19 patients infect about 5.7 people, according to the CDC.
The public health response to both diseases is essentially to keep sick people out of circulation, thereby limiting the spread of the virus.
That public health principle — keeping sick people away from well people — became the state’s go-to strategy to limit the spread in March, when little was yet known about COVID-19. Murphy said he referred to Montana’s Spanish Flu outbreak of 1918 for guidance.
“We haven’t had to do this stuff at a broad scale for 100 years. Based on other experiences that are similar, how would I apply this in 2020, instead of 1918?” Murphy said. “Some of the same tools worked.”
Contact tracing techniques are used daily by public health officials, just at much smaller scales than their current COVID deployment, to limit the spread of sexually transmitted diseases, for instance.
In addition to shutdowns and contact tracing, Park County’s Desnick also credited the state’s 14-day quarantine for out-of-state travelers, which limited the spread when infected people arrived in the state. The state began reopening in late April, but the travelers quarantine wasn’t lifted until June 1, when Yellowstone National Park reopened.
Tourists have not been a large source of transmission, state epidemiologists said. Instead, the virus has largely been brought home by Montanans visiting other states or out-of-state relatives and friends visiting Montanans. That’s because Montanans are more likely to interact with — and therefore spread the virus among — locals than with tourists, who are more transient.
Montana’s success in containing the virus can also be partly attributed to logistical factors.
Health officials across the state agreed that the state’s location, the timing of the virus’ arrival, and the distance between the state’s population centers all helped Montana limit the spread.
Montana’s location in the country’s interior, far from the West Coast, where cases were spreading from China, and the East Coast, where cases were spreading from Europe, led to limited spread here. Location also explains why it took longer for the disease to arrive in Montana in the first place, Leahy said. By the time Montana started to see significant amounts of the virus, the state had started to shut down.
“We witnessed others in the U.S. getting hit, and that’s a pretty good, fair warning to make it real and make it relevant,” Leahy said.
Additionally, while some communities, like Gallatin and Yellowstone counties, had larger outbreaks of more than 100 people, those locations are far enough from other communities that significant spread did not occur, Kelley said.
“We’re helped by the fact that we have space between population centers,” Kelley said. “People can get out and exercise and maintain behavioral health wellness without being right on top of people.”
A major factor in dampening the case count is the state’s lack of a meat packing facility-type outbreak. Such facilities, where lots of employees work in close quarters, have so far been a leading vector of spread in rural America, according to an analysis by the Food and Environment Reporting Network. Counties with meatpacking plants have double the COVID-19 rate of those without plants, according to an analysis by the nonprofit Environmental Working Group.
“When you can keep the numbers low, it’s easier to keep on it,” Holzman said. “Once they start to get out of hand, it’s harder to keep it low. I’m not naive enough to say there might have been a little bit of luck.”
‘WE KNOW MORE NOW’
Perhaps no one in Montana knows the importance of early detection more than Blair Tomsheck, director of the Toole County Health Department. Tomsheck oversaw the county’s response to an outbreak in an assisted living facility in March and April that resulted in 29 cases and six deaths.
That outbreak has been among the worst in the state so far, but while it was happening, the state lacked testing supplies and knowledge about how the virus spreads. Today, state and local health officials are better prepared, Tomsheck said.
“We know more now. We’ve learned more now,” she said. “Nobody really knew much of anything about it. We were flying by the seat of our pants.”
For example, contact tracing quickly became the most important strategy for limiting the spread, Tomsheck said.
“I had the phone glued to my ear,” she said. “It can make or break getting ahead of the virus.”
In the first outbreak, close contacts had to be instructed to self-isolate and then monitored for symptoms. Only those who got sick received tests. Now that more tests are available, anyone who is a close contact can be tested for COVID-19, whether they have symptoms or not.
Toole County recently registered its first two cases since that initial outbreak ended. The two cases, connected with travel to an area experiencing an outbreak, were quickly identified, isolated and contact-traced. All close contacts were tested. Early detection was immeasurably helpful, Tomsheck said.
“Two cases is a lot different. It’s a lot more manageable. You can get deep into the story [while contact tracing], the whats, the wheres, the hows. You can investigate a lot better,” she said. “Not to say we didn’t do a good job, but it was more rushed. Now, we can get through every little nook and cranny.”
Testing contacts also opens the door to subsequent contact tracking when close contacts test positive, increasing knowledge about how transmission occurs and providing more certainty about the extent of outbreaks. Increased contact testing also boosts the number of positive tests that would otherwise go undiscovered. In recent hot spot Big Horn County, for instance, 35% percent of COVID-positive patients were asymptomatic.
TESTING FOR THE WIN
Increased testing will be the most important aspect of early detection of COVID-19 outbreaks, helping bring the sometimes invisible illness to light, Desnick and Kelley both said. Park and Gallatin counties are conducting surveillance testing of front-line employees in gateway communities that host tourists from Yellowstone National Park.
Bullock has rolled out a plan that calls for 15,000 tests each week, a target that has not yet been reached, though the state has already expanded testing capacity to more than 10,000 a week. As a part of that, each of the eight tribal communities in Montana has had access to surveillance testing, with more than 7,500 tests conducted so far.
The Montana National Guard has helped implement the testing in tribal communities, as well as pop-up testing sites in communities including Great Falls, Billings and Livingston. The National Guard has learned that getting the word out is the most important aspect of the testing, said Major Gen. Matthew Quinn. Once positives are found, local health officials then conduct contact tracing.
“We can prevent a second wave by staying ahead of testing, so it’s, again, maintaining that success,” Quinn said.
Tomsheck said that even with the tools and advantages public health officials have at hand, control of the virus going forward will be largely determined by the actions of the public.
“I think we were afraid of a resurgence. Well, that resurgence is starting,” Tomsheck said. “People are losing interest in staying home and wearing masks. That is obviously how we stop the spread of the virus. We were there, as recently as a couple weeks ago, when our numbers were so small. It was to be expected with opening back up, but as long as people stay vigilant, we can control it.”
THE ‘PUBLIC’ IN PUBLIC HEALTH
Public health officials are most successful when the public is unaware of their efforts, Holzman said. Ideally, public health officials control outbreaks so the public doesn’t have to learn about them.
But COVID-19 is unlike any outbreak in the U.S. since the 1918 flu. Doctors like Holzman and Desnick are at the forefront, trying to convince the public of the role they can play in preventing the spread.
Desnick said that position is a double-edged sword. Last weekend, Park County performed testing on about 1,000 asymptomatic residents, well over 5% of the county’s population. So far, there have been no positive tests. Still, given recent outbreaks, people need to be careful, Desnick said.
“The better job you do, the more people are like, you don’t need to bother,” Desnick said.
She compared public reaction to the virus to a high blood pressure patient who stops taking their pills once their blood pressure is back to normal — and then watches their blood pressure spike again.
“People think we don’t have any cases, so we didn’t need all of this,” Desnick said. “That’s the opposite of true.”
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Much of maintaining that success will rely on people wearing masks, social distancing and staying home if they feel ill, Holzman said.
“If we can stop the transmission of the virus, we should stop the disease in our communities,” Holzman said. “We have the options to do that. We have control.”
Despite studies showing that wearing a mask can reduce infection rates by up to 85%, masks have become a partisan issue. President Donald Trump has rejected masks and eschewed public health guidance in other ways — for instance, by recently proposing to scale back testing in order to artificially reduce reported case counts. Meanwhile, hospitalizations for COVID-19 are increasing in more than a dozen states.
Bullock said some of Montana’s upward COVID trends in recent weeks can indeed be attributed to increased testing and contact tracing, but regardless, the disease remains present in the state. Bullock said wearing a mask should be considered a nonpartisan method for Montanans to help protect their neighbors.
“People should be aware that the virus is still in our midst. We need to continue to take seriously some of the increased numbers,” Bullock said. “You can’t get much lower than some of the zeros we’ve had along the way, but recent cases should be a cautionary warning for all of us.”
Holzman said it remains up to Montanans whether April’s predicted peak was averted or just delayed.
“COVID-19 is here, and it doesn’t look like it’s going to go away any time soon,” he said. “We cannot do this alone. I cannot stress that enough. We might disagree on everything else, but we are all in this together.”
This story is part of continuing Montana Free Press coverage of community responses to COVID-19 supported by the Solutions Journalism Network.