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CHELAN-DOUGLAS HEALTH DISTRICT APPLICATION FOR MOVEMENT BEYOND PHASE 1

Submitted Friday, June 5, 2020

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Local Approval Process and Required Documentation 1. See health officer recommendation on the following pages

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2. Local Board of Health action.

The following page provides documentation of the required Board of Health action in support of this proposal.

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RESOLUTION 2020-005 OF THE CHELAN-DOUGLAS HEALTH DISTRICT BOARD OF HEALTH REGARDING SAFE REOPENING DURING THE COVID-19 PANDEMIC

Whereas the Chelan-Douglas Health District Board of Health is committed to protecting our community from the threat of the COVID-19 pandemic; and, Whereas the time has come for gradual reopening of activities limited by the Governor’s orders, but a sudden and disorderly reopening of such activities could produce unnecessary health risks during this pandemic; and, Whereas businesses and organizations wishing to resume more normal operations must do so gradually and must take care to implement social distancing and other safeguards so long as the COVID-19 pandemic cannot be controlled through effective vaccines and/or medications; NOW THEREFORE BE IT RESOLVED that the Chelan-Douglas Health District Board of Health: Section 1: Accepts and endorsed the recommendation of the Chelan-Douglas Health Officer Malcolm Butler, MD, that the Board of Health request reopening measures moving toward Phase 2, but not including all Phase 2 measures, as defined in the Governor’s Safe Start Washington Phased Reopening County-By-County document of May 31, 2020; and, Section 2: Accepts and endorses the specific measures outlined in the Health Officer’s memo of this date, and urges the Chelan and Douglas County Boards of Commissioners to promptly approve these measures and the accompanying application submitted to the Washington State Department of Health.

RESOLVED this 5th day of Jun, 2020. APPROVED:

ATTEST/AUTHENTICATED:

Barry Kling, Administrator Approved by unanimous vote of the Board of Health. Members in attendance: 8 Members absent: 0

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3. Hospital Information: Chelan-Douglas Health District is providing the information requested in items

3.a. through 3.d. below from WA HEALTH data. Information for individual hospitals and the confirmations required of hospitals in item 3.e. appear in the following pages for every hospital in the Health District. Note that Confluence Health operates both Central Washington Hospital and Wenatchee Valley Hospital, both in Wenatchee, while Cascade Medical is a small hospital in Leavenworth and Lake Chelan Community Hospital is a small hospital in the City of Chelan.

a. 70.1% of licensed hospital beds in the Health District are occupied as of 6/4/2020 b. 0.8% of licensed hospital beds in the Health District are occupied by suspected or confirmed

CO”V”ID-19 cases as of 6/4/2020. c. Central Washington Hospital and Wenatchee Valley Hospital and Clinics report into WA HEALTH

seven days a week, while Cascade Medical (Leavenworth) and Lake Chelan Community Hospital report only on weekdays.

d. Hospitals have at least as 14 day supply on hand for the following PPE:

It is also worth noting that our hospital capacity, especially at Central Washington Hospital, has been sufficient in recent weeks to allow overflow ICU patients from Yakima to be cared for in CWH’s ICU. This is further addressed on pp. 20-21.

Hospital PPE Supply

Burn rate per day

Days On Hand

LCCH N95 7650 50 153

Surgical masks 5400 100 54

Face Shields 370 5 74 Gloves 27200 200 136 Gowns 860 10 86 Confluence N95 17020 1006 17

Surgical masks 136800 1850 74

Face Shields 2433 4 608 Gloves 970000 31800 31 Gowns 7501 10 750 Cascade N95 4050 19 213

Surgical masks 29605 248 119

Face Shields 849 11 77 Gloves 230500 420 549 Gowns 3375 53 64

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4. Documentation is provided on the following pages showing approval of this application by the Chelan County Board of Commissioners and the Douglas County Board of Commissioners.

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Application Narrative 1. Epidemiology of COVID-19 in Chelan-Douglas Health District As of June 3, there have been 437 cases in our counties – 261 in Chelan County and 176 in Douglas County. In the last 14 days, there have been 70 new cases in Chelan (90.7 per 100,000) and 42 in Douglas (96.7 per 100,000). There are two patients hospitalized, and have been 9 deaths throughout the outbreak (6 in Chelan, 3 in Douglas). Hispanic residents have been disproportionately affected, accounting for 84% of cases and about 30% of total residents. In the last two weeks, 27% of cases did not have an epi link to any other known cases.

Confirmed COVID-19 Cases in Chelan-Douglas County of Residence

Confirmed Positive Cases

New Cases in Last 24 Hours

New Cases in Last 7 Days (5/28 – 6/3)

New Cases in Last 14 Days (5/21 – 6/3)

Currently Hospitalized

Total Deaths

Chelan 261 0

16 (20.7 per 100,000)

70 (90.7 per 100,000)

2 6

Douglas 176 2 (4.6 per 100,000)

12 (27.6 per 100,000)

42 (96.7 per 100,000)

0 3

Total 437 2 (1.7 per 100,000)

28 (23.2 per 100,000)

112 (92.8 per 100,000)

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Date Reported to Health District

Cumulative Confirmed Cases COVID-19 In Chelan-Douglas

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2. COVID-19 Testing Sites There are a total of six testing sites in the two county area. They bill insurance when possible but none turn down anyone on the basis of inability to pay. Central Washington Hospital in Wenatchee has two testing sites, one at the ED and the other a drive up location across town from the ED. Other testing sites include Cascade Medical Center in Leavenworth, Lake Chelan Community Hospital in the City of Chelan, and Columbia Valley Community Health (CVCH) in both Wenatchee and city of Chelan. CVCH is an FQHC serving underserved populations and their testing sites are open to anyone, regardless of the ability to pay, as follows: Wenatchee Monday-Friday 8:00 AM -8:00 PM. Saturday 8:30-4:00 PM. CVCH Chelan Monday-Friday 8AM-8:00 PM. We promote testing for contacts and we have asked the DOH contact tracing unit, which is currently contact-tracing most of our cases, to include promoting contact testing in the script used. Individuals wanting testing are advised to call a local provider or call the Confluence or CVCH hotline.

3. Median number of days from onset to specimen collection over the past four weeks:

• May 4 – May 10: 4.4 days • May 11 – May 17: 2.7 days • May 18 – May 24: 3.3 days • May 25 – May 31: 3.3 days

4 17 20 30 32 66 33 67 44 82 330

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3/16/2020 -3/22/2020

3/23/2020 -3/29/2020

3/30/2020 -4/5/2020

4/6/2020 -4/12/2020

4/13/2020 -4/19/2020

4/20/2020 -4/26/2020

4/27/2020 -5/3/2020

5/4/2020 -5/10/2020

5/11/2020 -5/17/2020

5/18/2020 -5/24/2020

5/25/2020 -5/31/2020

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Date Reported to Health District

Confirmed COVID-19 Cases in Chelan-DouglasBy Week Reported

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4. COVID Tests over Previous 4 Weeks

COVID-19 Tests Performed in Chelan-Douglas, By Date Performed May 4 – May 10 May 11 – May 17 May 18 – May 24 May 25 – May 31 Positive Tests 52 53 61 33 50X Positive Tests

2600 2650 3050 1650

Percent Positive 8% 8% 11% 6% Negative Tests 508 627 476 496 Total Tests 634 680 537 533

Percent positive over all four weeks (May 4 – May 31) = 8.3%

5. Contact Tracing

a. Chelan County 77, 200 Douglas County 43,429 Total Population: 120,629 Total Contact tracers Needed = 18

i. Total Health Department Staff Trained= 15 Total, 11 FTE ii. Other county/city staff trained and ready: 0 iii. 11 total, 7 FTE iv. 18 FTE trained and ready. v. Most cases were turned over to DOH May 18, 2020. Training will depend on their

schedule vi. We do not have a gap vii. Letter has been requested from DOH contact tracing group

b. Total Number of Cases in past two weeks: 112

Percent reached within 24 hours: 65.2 %

c. Total number of close contacts 447. Percent of cases reached in 48 hours is 95%

d. N/A. State c-t unit doing most of our c-t work, and neither we nor they have been reaching out daily. State and CDHD c-t will begin doing this next week.

e. N/A – see d. above.

f. Yes, we conduct case and contact investigations 7 days a week. 6. Isolation and Quarantine Facilities

a. One facility: Fairfield by Marriot. Contract with the hotel established through joint effort of both counties using Commerce Department funding.

b. Hotel

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c. 50 room, with option for up to 100 d. zero cases at this time e. March through June 30, 2020 f. Existing contract provides for extension. g. Laundry Services provided by the hotel, food services are provided by “Beyond Creations

Catering” located at the Town Toyota Center under contract with Chelan County. Other support services provided by Serve Wenatchee, a local ecumenical organizations, under contract with Chelan County.

7. Linking people in I/Q with resources

a. Health Department nurse and community health worker connect I/Q residents with resources. b. N/A c. Follow-up by CDHD staff.

8. Capacity for outbreak investigations in congregate living settings and workplaces.

a. 6 nurses 1 Spanish Speaking Community Liaison, 1 Regional Epidemiologist, Health Officer b. 1,575 Test kits are held in reserve. Testing is conducted by Confluence Health (hospital) and Columbia Valley Community Health (FQHC) teams. c. Testing kits are available mainly from DOH or other state sources. Inconsistency of these supplies is a limiting factor.

9. Outbreaks/clusters over Last 4 Weeks

Facility Facility Type

First Case Reported

Last Case Reported

Number of Cases

Inconclusive Tests

Negative Tests

Total Number Tested

Cashmere Convalescent LTC 5/4 5/6 2 0 0 2

Dovex H2A Housing 5/10 5/30 10 pending* pending* pending *

Prestige Colonial Vista LTC 5/15 5/15 5 0 42 47 North Distribution Repac Line (Stemilt)

Fruit Packing Line 5/21 5/22 32 2 39 73

*mass testing 6/3

10. Protecting disproportionately affected communities. Our Latino community clearly suffers disproportionate effects from the COVID-19 pandemic. We are currently partnering with Okanogan and Grant County Health Districts to provide Hispanic Radio (five stations across all four counties) public service announcements in Spanish on health-related information from mid-May to mid-September. We are using mobile device (cell/tablet) “billboard” ads. We have been providing a Spanish COIVD-19 hotline 7 days per week since mid-March, we use Spanish speaking

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Contact Tracers, we translate everything on our website and all other COVID-19 messaging including social media into Spanish. We have billboards in Spanish and Radio PSA’s. We have distributed information at Spanish speaking grocery stores, provided Spanish radio interviews, provided training and education to Spanish speaking groups on proper hand washing and social distancing. We use CDC, DOH, Mexican Consulate and CDHD educational materials. We collaborate with Columbia Valley Community Health and our Community Health Workers to provide COVID-19 education in agricultural settings (orchards, camps, etc.) as well as at local grocery stores and through churches. One of our Board of Health members who is also a Chelan County Commissioner has personally visited almost all of the fruit packing warehouses in the area and have observed their efforts to contain this disease and protect ag workers. CDHD is aware that L&I has been very proactive and has imposed strict guidelines, and CDHD has tracked L&I’s efforts to enforce them. Our plan also includes more of the above mentioned (radio, billboards, printed materials) and social media in Spanish. We have recruited and trained a group of 15 Latina community health workers to do on-the-street and in-the-church community education on COVID. In spite of these extensive efforts we are continuing to look for ways to enhance the effectiveness of our messaging to the Hispanic community, and have formed an advisory group of community leaders to help direct our efforts. In just the past few days we have received many letters of concern from an organized group of citizens concerned about this issue – organized in the sense that the letters are nearly identical – and are reaching out to them to welcome them into our efforts and benefit from their help and advice. Additional information recently received regarding farmworker outreach and the concerns of the Latino community will be submitted within the next 3 days, which we believe will be helpful in making a considered decision about this proposal. 11. Additional Information We believe that additional information is needed to evaluate the approach to reopening proposed in this application. Morbidity and Mortality – It is notable that in spite of our relatively high incidence rates we are experiencing relatively low COVID-19 morbidity, mortality and hospital utilization. Although we have had a total of 437 cases, there have been 9 deaths, for a case fatality rate of 2%. During the month of May, when we confirmed 231 cases and saw two deaths, the case fatality rate was 0.87%. Asymptomatic cases make up 31% of our lab confirmed cases. COVID hospital utilization during the month of May has been low in spite of our relatively high population case rate, especially in recent weeks, as the chart on the following page shows. We are not sanguine about the potential of COVID-19 to produce much more severe results, but our health care system is not currently stressed in spite of having had nearly 450 cases so far.

Deaths to Date: sex age dx date date of death M 91 3/23/2020 Wenatchee 3/23/2020

F 84 3/26/2020 Wenatchee 3/28/2020 M 92 3/29/2020 Wenatchee 4/8/2020 M 84 3/23/2020 Wenatchee 4/9/2020 F 93 4/6/2020 Wenatchee 4/9/2020 M 91 3/23/2020 E. Wenatchee 4/12/2020

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F 68 5/3/2020 Bridgeport 4/26/2020 M 58 5/5/2020 Wenatchee 5/9/2020 F 79 5/1/2020 E. Wenatchee 5/12/2020

CDHD and its health care partners will actively monitor the disease burden in the two counties and, in collaboration with the health care and business sectors, remain ready to reverse proposed reopening measures as needed to respond to significant surges in COVID-19 activity, until the burden of disease again decreases. Our efforts to monitor the course of the epidemic will include the testing of convenience samples (such as the testing ongoing at Confluence of all patients scheduled for procedures), along with others to be determined as testing capacity grows in a reliable manner. The point is not that these samples represent the entire community, but that their fluctuations are likely to reflect trends in the local epidemic. We are also working to implement a statistically valid prevalence study, but so far this effort has been hampered by the high level of hostility among vocal members of the public. Although these people are a minority, health workers now fear going out into the community to offer testing as part of a random sample. We are working to develop alternative strategies capable of producing a representative sample and hope to collaborate with statewide efforts to develop better estimates of COVID-19 prevalence.

Because of low COVID hospital utilization in recent weeks, CWH has been able to accept overflow patients in its ICU to assist facilities in Yakima. A Proactive Business Community Committed to COVID-19 Prevention The business community in our counties has demonstrated a remarkable level of commitment to safe reopening. The Wenatchee Valley Chamber of Commerce joined with the Chambers of Commerce from other cities in the area to form a Recovery Council for the express purpose of supporting the safe and responsible reopening of local businesses. The Council developed a Reopening Toolkit, drawing on guidance rom DOH, CDC and other reliable sources, and has established an active partnership with CDHD to work with businesses on reopening plans. This is not a business community wanting to undermine COVID-19 prevention

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COVID Bed Use CWH

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measures, but a community ready to make COVID-19 protections an integral part of their operations for many months to come as we await vaccines and effective medications. Our two counties are supporting this effort by, among other measures, purchasing 50,000 masks for use by members of the public. More details on the Recovery Council can be found at http://wenatchee.org/covid-recovery-council, and the following list of its members gives a good sense of its scope: Co-chairs:

Mayor Jerrilea Crawford, City of East Wenatchee

Mayor Frank Kuntz, City of Wenatchee

• Barry Kling, Chelan Douglas Health District

• Bob Bugert, Chelan County Commissioner

• Bob Siderius, JDSA Law • Charlotte Mayo, Springhill Suites • Chuck Zimmerman, Ogden Murphy

Wallace • Dan Sutton, Douglas County

Commissioner • David Olson, Columbia Valley

Community Health • Jim Richardson PhD, Wenatchee Valley

Community College

• Jim Kuntz, Chelan Douglas Regional Port Authority

• Elvis Garcia, Seattle Yoga Lounge • Garry Arsenault, Chelan PUD

Commissioner • Greg Mercer, LocalTel • Greg Oakes, Cashmere Valley Bank • Gustavo Montoya, AgTools Inc. • Jess Monnette, Monnette & Cawley,

P.S. • Josh Stendera, North Cascades Bank • Lee Pfluger, Building NCW • Linda Haglund, Wenatchee Downtown

Association • Mike Wade, Fielding Hills Winery & CMI

Orchards • Rachael Petro, Petro Strategic Solutions

LLC • Sean Flaherty, Wenatchee World • Stu Freed MD, Confluence Health

Retail - In our communities we have seen unanticipated effects of orders which allowed big-box stores having any essential products to sell all of their products. With smaller stores closed, this has concentrated shoppers at these relatively few locations. Crowd control and distancing has often not been managed well. It has also created disparities which have seemed unfair to closed retailers and undermined compliance with the Governor’s orders. One of the most notorious local examples involves small pet grooming businesses which have to remain closed while the pet grooming services within large corporate pet stores continued to operate. Our proposal allows stores selling essential goods to remain open at 50% capacity – providing sufficient access for residents to essential goods – while allowing other retailers to open on the same basis. This will decompress the excessive crowding at big box stores, leveling the playing field and going a long way toward reconciling all retailers to the requirements we still expect them to observe. Decompression of crowding at big box stores will offset the additional mixing that occurs in other reopened stores. We believe the net effect on disease transmission will be neutral, while providing significant progress in relieving some of the real social and economic damage associated with retail closure. Restaurants - There is very substantial evidence that COVID-19 infections spread much less readily in outdoor settings compared with indoor settings. For this reason we believe it is safe to allow outdoor dining provided adequate separation between tables is maintained. This would require occupancy of 50% or less in any available outdoor dining space, and we do not believe the safety of this arrangement would be undermined if restaurants are allowed to expand existing outdoor dining areas with these safeguards in place. For many establishments the cooperation of cities in allowing the use of sidewalks and street closures will be needed to produce any significant outdoor eating spaces, but local mayors

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are committed to such cooperation. Allowing a small increment of indoor dining – 25% of capacity – will not greatly increase COVID risks and will enable restaurants to begin implementing the indoor safety requirements that will be needed in subsequent phases. Taken together, these measures are intended to make it possible for many restaurants to resume operation without excessive reduction in COVID safety measures. Along with the approach we are advocating for retail reopening, we believe our proposals will significantly reduce the adverse impact of business closures without greatly reducing protections against the spread of COVID-19. This will have a material effect on the emotional and economic consequences of our original COVID-19 prevention measures. Yet we remain ready to reduce or reverse these reopening measures if COVID-19 cases should resurge. Conclusion This proposal was developed with significant participation from the medical and business community. Members of the workgroup which produced this proposal include:

Peter Rutherford, MD, CEO, Confluence Health Diane Blake, CEO, Cascade Medical (Leavenworth) Steven Wright, CEO, Chelan PUD Malcolm Butler, MD, Medical Director Columbia Valley Community Health and Chelan-Douglas Health Officer Shiloh Burgess, Executive Director, Wenatchee Valley Chamber of Commerce West Mathison, President, Stemilt Fruit Company The Honorable Frank Kuntz, Mayor, City of Wenatchee The Honorable Jerrilea Crawford, Mayor, City of East Wenatchee Barry Kling, Administrator, Chelan-Douglas Health District

Each member of this workgroup received considerable support and information from members of their organizations’ staffs and from affiliate organizations. Our Board of Health has carefully reviewed these proposals and strongly endorses this application. It should be viewed as a genuine expression of our community – both in its proposals to reopen some aspects of our economy, and in our commitment to do so safely with the understanding that any future surges in disease activity must be met with renewed prevention efforts.