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Extinguishing McLennan County COVID-19 'hotspot' would require 'culture of willingness,' local experts say

Extinguishing McLennan County COVID-19 'hotspot' would require 'culture of willingness,' local experts say

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McLennan County hotspot

Note: Each day’s test results may not be reported until days or weeks later. Results since July 16, in gray, are preliminary and may be revised pending results.

McLennan County remains a COVID-19 hotspot, and experts say it will take more than masks alone to change that.

The county avoided a worse outbreak of COVID-19 early on, but as of a July 14 White House Coronavirus Task Force report, it and the city of Waco remained areas of high concern, the county showing more than 100 cases per 100,000 residents and a testing positivity rate of more than 10%, the latter standing closer to 20%. The county has seen 35 residents die of COVID-19 so far, and another 72 residents had tested positive as of Saturday, a total of 3,957.

Dr. Rodney Richie, a pulmonologist who has practiced in Waco and parts of the Midwest, said the race to contain the disease was over before it started in the United States.

“Of course it starts at the top,” Richie said. “There should have been national leadership that was lacking, but at the very least we needed the states to impress upon people the need for wearing masks, and that’s been slower to come on.”

Richie said the key to fighting viral infections is to identify and diagnose each infected person and then to find everyone who came in contact with the infected person. But that strategy only works when the process plays out much more quickly than McLennan County, or any county in the nation in Richie’s opinion, has managed.

“First of all, you need an adequate number of tests, you’ve got to get them in a very short period of time, and you have to have enough contact people,” Richie said. “We didn’t meet any of those criteria.”

Contact tracing is most effective if test results come back within 48 hours, but becomes less so after that point as the infected person potentially comes in contact with more and more people.

“This never worked for this infection, and so what we saw was overwhelming infection, starting in New York,” Richie said.

By last month, Waco-McLennan County Public Health District officials said they had identified family “clusters” that accounted for many of the local cases. By earlier this month, they had identified more than 20 such clusters. Officials in neighboring Bell County saw similar spread among people who were well-acquainted.

“Close contacts, close friends, we’ve seen individuals that work together in close quarters become clusters. That’s very typical,” Bell County Health Authority Dr. Janice Smith said during a press conference last week.

Bell County has joined McLennan County in requiring K-12 schools to postpone in-person instruction until next month. Smith said a “community effort” is the only way to reverse the course of the virus’ spread.

“I think we are seeing some improvement in the last few days and I think part of that is that we’re finally, finally wearing masks and appreciating the social distancing. We’re farther out from holidays that bring people together,” Smith said. “But if people want their kids back in school, they really, really need to follow the guidelines. That’s the only way this is going to work.”

The other method of containing the virus would involve more shelter-in-place orders or other forms of enforced isolation. The city of Waco enacted shelter-in-place orders and closed nonessential businesses in March, along with other hard hit areas like Harris County and Dallas County. Texas Gov. Greg Abbott followed with a statewide stay-home order in early April, then started reopening businesses by executive order April 27, eventually including in-store retail and dine-in restaurants. Abbott allowed bars to reopen later on but has since reversed course.

It can take as long as two weeks for an infected person to show symptoms, meaning the effects of a decision like reopening businesses or the city’s mask order become apparent only after a matter of weeks, with lagging pursuit of treatment and lagging return of test results delaying evidence of the effects even further. Richie said the initial closing of businesses might have worked too well, giving McLennan County residents a false sense of security. Reopening in late May and early June just felt like a return to normal.

“I think Mayor (Kyle) Deaver did a really nice job of closing us up early and completely, but I think the governor was just encouraging people to open up,” Richie said. “In my opinion right now the golden key that’s going to allow us to open up is mask-wearing.”

Masks, a safety measure that quickly became politically fraught, would greatly reduce the spread if everyone wore them. When combined with social distancing, a focus on avoiding enclosed indoor areas and proper use of masks to cover both the mouth and nose could make a major difference.

Richie has been giving guidance to Vanguard College Preparatory School, advising them to open windows and doors and run fans to circulate air as much as possible. But the rooms of most modern school buildings lack windows that open.

“Any indoor setting is going to be problematic,” Richie said.

Even a small breeze is enough to dissipate aerosol droplets in the air carrying the virus, he said.

Richie said masks might be the only way to avoid widespread infection and a more drastic shutdown and shelter-in-place order.

“Practically, masks are going to be the best thing until we have vaccines, assuming vaccines work, which, at that point, is a big question mark,” Richie said.

Richie said RNA viruses, the category the novel coronavirus and influenza viruses fall into, are more prone to mutation than their DNA counterparts.

“My concern is we’re working toward a vaccine based on a virus that was elicited out of Wuhan … but in another six months or nine months it’s conceivable the virus may mutate and no longer be affected by vaccines designed by the original virus,” Richie said.

Texas hotspots

According to a White House document dated July 14 and obtained by the Center for Public Integrity, 11 states, including Texas, are in the “red zone” for test positivity, meaning more than 10% of diagnostic test results came back positive in the previous week. McLennan County and Waco are listed as "red zone" localities in the report.

Richie said the U.S. Centers for Disease Control and Prevention initially was slow to let other American researchers work on their own tests, instead deciding initially to rely on its own tests, which later turned out to be faulty.

In addition, early testing was also restricted to people who had traveled abroad or people who had been in contact with someone who had tested positive, a limitation Richie said proved to be a “huge mistake.”

“Now we’re at the very sad situation of these longs lines of cars that wait six and eight hours to get a test, and it’s just all totally worthless if you don’t get a result back in 24 or 48 hours,” Richie said. “The person doesn’t know what to do. The doctor doesn’t know what to do. You really need a fast response.”

Waco Family Health Center CEO Dr. Jackson Griggs said for McLennan County to get back to pre-June levels of spread would take a drastic change in behavior.

“I think we’re aiming for mitigation of spread, containment when possible in the highest risk areas, but in large part we’re just trying to change behaviors so the virus will slowly decrease in incidence,” Griggs said. “If there was widespread, wholehearted adoption of the kind of behavior change that we’ve been discussing I think we would see a really sizable decrease in the incidents of disease.”

Griggs said getting McLennan County back to the number of infections the county had before the June spike would take a near-universal adoption of safety measures. Individuals would have to fully commit to avoiding contact with members of other households and to wearing masks, and businesses would have to ensure employees are not exposed to contact with the general public for long periods of time. Enclosed spaces would need continual ventilation.

“I think there’s a finite amount of emotional willpower in any community to make widespread behavior change,” Griggs said. “I don’t know that we have yet summoned all of our capacity to make those changes, but I do see a strong effort being made by many and that makes me hopeful.”

Griggs said a less universal effort would still help to contain the spread, but would not be as effective.

“We can keep things very steady, but we may still see a fair number of new cases every day for the foreseeable future,” Griggs said. “To get to where we don’t see new cases every day, we need near-universal adherence to a shared community culture and safety, a culture of willingness to adopt behavior change to protect the vulnerable.”

Griggs said he would estimate McLennan County residents should be tested for the virus at about double the rate they are currently being tested. Even more tests would be required for a proper containment strategy, but he said the resources are not available for that.

“If behavior change happens and prevalence goes down, the number of tests you have to do also goes down,” Griggs said. “It’s a moving target, and it’s not linear. It’s multiplicative.”

The number of tests being performed hinges on the availability of the tests themselves and whether people can afford them, willingness to participate, and an existing infrastructure to distribute the tests.

“America has lacked the infrastructure for widespread community testing, it’s lacked access to tests, which involves a supply chain … and it’s lacked the widespread culture that this is important and that people need to come get tested,” Griggs said. “For containment, we’d need to be testing asymptomatic people. Why haven’t we had a widespread asymptomatic testing strategy in Waco-McLennan County? Well, because across the state and country there’s not infrastructure for that, and only a certain portion of the population would consider it worthwhile to support public health to get a swab stuck halfway into their brain.”

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