How Colorado caught COVID-19

The March 5 news conference announcing Colorado’s first confirmed case of COVID-19 was over.

The governor and the director of the Colorado Department of Public Health and Environment returned to work. Colorado’s first positive coronavirus patient left Summit County with a friend under orders to quarantine himself as he recovered in the lower elevation of Jefferson County.

But back in Silverthorne, the crisis was just beginning.

“I am wondering if you can help me,” the director of Summit County’s Health Department, Amy Wineland, wrote to her counterpart in JeffCo just before 6 a.m., the morning after the first case was announced. “We are trying to confirm that the unit number of the condo complex they stayed in was 2800. Can you please help confirm this?

“CDPHE is not returning our calls.”

During those lost 13 hours, thousands of cars passed through Silverthorne in either direction on I-70 as people who may have had contact with that first known patient went home from ski resorts in Summit and Eagle counties.

All while the health director at ground zero was unable to confirm the spelling of the patient’s name or where he stayed at Keystone, much less coordinate or participate in any effort to trace his contacts in the mountains.

Colorado’s state government began preparing for an expected pandemic in 2000, when the legislature created an epidemic response committee and gave the governor broad powers to fight a viral disease. And as COVID-19 approached, the state prepared CDPHE’s lab to be the central hub for testing and began to coordinate among state and local agencies.

But when COVID-19 arrived, chaos reigned and plans developed over years of tabletop exercises were almost immediately “overwhelmed,” according to the head of CDPHE.

State and local public health officials acknowledge that the communications problems with county public health agencies that started that first night continued for weeks, and, though now improved, still exist today.

“They had run through drills and we understood the concept,” Gov. Jared Polis said in an interview about advance preparations by state emergency officials. “And I had been through drills on what a contagion event might look like. We didn’t know what this particular pandemic would look like.”

A CPR News review of more than 2,000 pages of emails, text messages and memoranda from the weeks before the coronavirus reached Colorado through the first days of the state’s response found numerous instances of confusion, complacency and a lack of preparation.

In interviews with more than a dozen disease and disaster experts, all agreed that the rapid transmission of the disease contributed to early missteps, whether local, state or federal. Many applauded the state’s public response to the crisis after the virus arrived.

“Honestly, as an infectious disease epidemiologist living through the pandemic of our lifetimes, I’m glad I live in Colorado,” said Molly Lamb, with the Colorado School of Public Health. She was referring to Polis’ science-based approach, including the symbolism of regularly wearing a mask in public.

“New guidelines come up from [Centers for Disease Control and Prevention] and the next day Governor Polis is standing at the podium wearing a face mask saying, ‘CDC says we should do this, we should do this.’ That’s impressive,” Lamb said.

Colorado, however, has emerged as the only state in the nation ranked in the bottom 15 for both population density — which should make it easier to control the spread of the virus — and in the top 15 for COVID-19 deaths per 100,000 residents.

That could be because of the state’s popularity as a winter destination. Or because visitors passed through both densely populated Denver and widespread ski resorts, said Glen Mays, chair of the Colorado School of Public Health.

“States like Colorado where we had multiple points of entry, multiple places where the disease was seeded, resort areas and population centers, and then mixing between those areas that can also kind of accelerate the spread,” Mays said.

Whether caused by circumstance or ineffective planning, the result is seen in the statistics. Louisiana is the only state west of the Mississippi with a higher rate of COVID-19 deaths per 100,000 residents than Colorado, and Colorado has more than 400 more deaths than even Arizona, a state with a larger and older population.

As Colorado now moves well beyond the peak of coronavirus round one, the lessons learned in the early days of Colorado’s response serve as a guide to what went wrong and how those mistakes can be avoided as the state prepares for a feared second round of the virus, possibly during the next flu season.

Among CPR’s findings:

• While signs of trouble were growing from Washington state to Washington, D.C., Colorado’s governor’s office said little publicly about the pandemic in February, and preparations were largely confined to increasing the number of meetings and preparing the state lab. Staffers only began to inquire about the possibility of conducting a drill for the response to COVID-19 in the waning days of the month, just a week before the virus was confirmed here.
• Colorado’s fragmented public health system, with a state agency and 53 independent county or multi-county departments, created confusion and animosity among government entities as they chafed over big elements of the response including testing capacity, communications plans and press releases.
• Like others across the country, Colorado’s state lab was quickly overwhelmed, taking up to 10 days to turn around results in early March — a delay that frustrated even Polis. Still, it wasn’t until private labs came online that results got to doctors, patients and state and local health departments more quickly. In text messages on March 5, county officials mocked Polis’ claimed testing capacity of 160 tests a day as CDPHE struggled to handle half that many in a day.
• CDPHE was in the midst of an overhaul of its disaster response operations, and the agency’s director of emergency preparedness and response announced he was leaving the agency just days before the first case was announced.
• As the virus approached, the state made no effort to secure additional protective equipment for first responders, health care workers, hospitals or nursing homes. The lack of masks, gloves and gowns, and the competition for supplies with other states and the federal government would become an important issue as the number of cases grew.
• When the CDPHE director called an emergency meeting of the epidemic response committee, four of the emails sent to committee members bounced back because they were sent using outdated contact information.
• Contact tracing of positive patients, at least in some counties, was abandoned early as hours were lost to poor communication and the virus got out of control. That essentially ended efforts at containment before they began, despite the emphasis placed on tracing by state health officials. Instead, slowing the virus through extreme social distancing orders became the focus.

On March 3, Polis called his first news conference to discuss COVID-19 and the state’s preparations.

“We are prepared to protect the health and safety of Coloradans if and when Coronavirus comes to Colorado,” Polis said in the accompanying released statement.

But in the critical weeks before the governor made that confident statement, no state purchases were made for protective equipment for health care workers. Accurate and consistent testing remained limited. No warnings were given to the public about the broad sweep of the impacts to come.

In terms of concrete actions, including supply purchases, it amounted to a lost February at the federal, state and most local levels. That set the stage for a chaotic March and the institution of draconian social distancing measures that would wreak havoc on Colorado and the nation’s economy.

While Polis acknowledges that the state’s response, particularly the search for needed equipment, really didn’t ramp up until after that first first person who tested positive was identified, his office disputes the characterization of February as a lost month. They point to the opening of an emergency operations center, coordination among state agencies and a series of meetings as signs that the state was taking the approach of the virus with the seriousness it deserved.

Even those closest to the state’s response say they did not anticipate how the virus would lay waste to plans created over years.

“I think everybody was just quickly overwhelmed,” said Jill Hunsaker Ryan, executive director of CDPHE. “I mean, it was just sort of overwhelming and all-consuming.”

Early Warnings

There have been outbreaks in the past that spooked the state into preparation mode. Anthrax in 2001. SARS in 2002. H1N1 in 2009. Ebola in 2014. Pandemic response plans were written and supplies of masks and gloves stockpiled.

The impact of those diseases pales in comparison to COVID-19, but with each event, experts continued to warn that coronaviruses could spark a global pandemic.

The state’s pandemic response plan calls for the CDPHE, with a $616 million annual budget to monitor everything from air and water pollution to personal prevention and wellness, to run point on the response to protect the public.

CDPHE’s Office of Emergency Preparedness and Response is where the disaster experts were housed. For years, they ran regular tabletop exercises and maintained two supply caches for gloves, gowns, masks and other supplies, one in the Denver area, known as the Kaiser Cache, and one in Grand Junction.

As COVID-19 drew closer to Colorado, CDPHE was in a state of transition. The chief medical officer, Eric France, the highest ranking medical doctor at the agency, was hired just four weeks before the first case was identified. CDPHE’s director of the Emergency Preparedness and Response office, Dane Matthew, was already looking for a career plan B after the department had altered his job duties.

Just before that, the “Kaiser Cache” of supplies close to Denver had been dismantled and consolidated on the Western Slope in Grand Junction, after a loss of federal funding.

Matthew said in an interview the supplies in that cache were so old that they wouldn’t have been much good anyway. A lack of basic supplies became a crisis in Colorado and across the globe as the coronavirus spread rapidly.

On Jan. 27, CDPHE put out its first news release about the coronavirus, emphasizing that it was nothing to worry about. By then, the state had tested three people with symptoms who had recently traveled from China. All were deemed negative for the coronavirus.

“State public health officials from the Colorado Department of Public Health and Environment say the risk to the general public is low for novel coronavirus in Colorado,” the release began.

It continued, quoting the state’s leading epidemiologist, Dr. Rachel Herlihy, saying, “It’s understandable that people may be worried about the appearance of a new virus, but the health risk to the general public in Colorado remains low.”

Not all experts agreed.

At the same time CDPHE was downplaying the threat, numerous groups that monitor global health conditions, including the Program for Monitoring Emerging Diseases, and the New England Journal of Medicine, issued increasingly dire warnings about the spreading virus from China. “Considerable efforts to reduce transmission will be required to control outbreaks if similar dynamics apply elsewhere (as the virus spreads),” the New England Journal reported on Jan. 29. “Measures to prevent or reduce transmission should be implemented in populations at risk.”

In Eagle County, the experts didn’t wait for the state or federal government. By January, preparations for the coronavirus were well underway. Officials at Vail Health had started to pay attention to the virus in late December as warning signs began emanating from Wuhan, China, where the disease originated.

One flash point was when China shut down Wuhan, a city of 11 million people, on Jan. 23.

“It was very clear this was a major issue,” said Chris Lindley with Vail Health. “There was never a thought in our mind that this was not a serious thing.”

As the news from China in January grew more dire, Vail Health began to make large personal protective equipment orders, for “tens of thousands of N95 masks,” according to a spokesperson for the health network.

In hindsight, Lindley said the early work turned out to be necessary, given that Vail is a destination for international tourists and the spread of COVID-19 coincided with peak ski season. “So, I think we got seeded with the virus very early. I’m certain that the virus was in this community early January. And started slowly spreading.”

Other hospitals were also preparing. Experts at UCHealth were spooked enough that they added a question to intakes, asking if the patient had traveled to Wuhan. If they answered ‘yes,’ the patient was put in a room for further questions and testing.

“And so probably late December or early January, we first started seeing reports of this pneumonia of unclear origin that was happening in Wuhan, in China. And the severity of the illness certainly made you wonder what was going on and certainly caught my attention,” said Dr. Michelle Barron, an infectious disease expert at UCHealth.

The fact that the information coming out of China was murky only added to concerns that the disease could be worse than official reports were letting on.

It turns out Barron was not just being paranoid, but she admits she had no idea what COVID-19 would become.

“This escalated to beyond anything any of us anticipated.”

Neither Barron nor Lindley expressed their concerns to state officials about the lack of protective equipment or the need to treat the coronavirus as more than a “bad seasonal flu.” Both said they were focused primarily on getting their own organizations ready.

The Colorado School of Public Health and the state now agree with Lindley that the virus was likely already spreading in Colorado in January. The latest state data shows more than 120 cases already in the state by March 1, days before the first confirmed case.

It may have arrived here along with international travelers, who continued to pour into Vail and Aspen, long popular with wealthy skiers from all over the world. More than 270,000 international travelers passed through Denver International Airport in January alone.

By the end of January, the state said it began monitoring COVID-19. CDPHE activated its emergency operations center, held regular meetings, and sent a basic health warning out to medical providers and local public health agencies. And the state lab began purchasing testing supplies they believed they would need should the disease enter Colorado.

The amount they purchased — supplies for 1,000 tests — would not have been enough to get through a single morning once the virus took hold here.

Pivotal Weeks

It was difficult for state experts to see the magnitude, because of testing problems not of their making that started almost immediately. On Feb. 7, the state lab received test kits from CDC, but the kits did not give consistent results because of technical problems. It wasn’t until Feb. 27, almost three weeks later, that the CDC and the Food and Drug Administration made the necessary adjustments to the tests, according to CDPHE.

The governor’s office argues that the federal government impeded the state’s testing response by providing testing materials only to state labs, in effect making them the sole conduit for testing. It wasn’t until several days after the first case that those regulations were loosened to allow private labs to begin testing.

On Feb. 13 there were 60,000 confirmed cases worldwide, 13 confirmed U.S. cases. That same day the Governor’s Expert Emergency Epidemic Response Committee met. On the agenda: “Hot Topics in Infectious Disease … Novel Coronavirus.” The allotted time: 10 minutes.

Meeting minutes show Herlihy, the state epidemiologist, gave an overview presentation that was short on what the risk to Colorado turned out to be. The mantra passed along both publicly and privately by Colorado’s public health experts remained, you are at low risk, wash your hands regularly.

“The data was unclear,” said Herlihy in an interview. “We were working on preparing for a pandemic and transmission in the U.S. and we were taking those steps, but we weren’t exactly sure at that point what exactly we were preparing for because we didn’t have the data on severity and transmissibility.”

By that time, China had shared considerable data, including the genome of the coronavirus. The CDC was still weeks away from providing data on the virus’s transmissibility, but authorities in much of the world were watching with alarm as the virus swept through a cruise ship off Japan, with the number of cases growing from 10 to 176 in eight days. On Jan. 30, researchers in Germany had begun to raise concerns about asymptomatic transmission — spreading of the virus by a person not showing symptoms — though it was speculative at that point.

Herlihy said that in mid-February, behind the scenes, the state was working to prepare. The department was “developing procedures and protocols” for investigating cases, should the virus hit Colorado. She said the state was also working on infection control strategies, particularly with health care providers.

On Feb. 19, Ryan told the state Board of Health, “Currently, the novel coronavirus is looking like a bad seasonal flu with its fatality rate and severity.”

While there’s still a lack of good data because of limited testing, the best information shows the coronavirus is orders of magnitude more deadly than seasonal flu.

“Well, I wasn’t at that meeting, of course, and this is considerably worse than the flu,” said Polis in a recent interview.

In an interview with CPR News on April 21, Ryan said when she appeared before the Board of Health she went with the best information they had at that point.

“We’ve just never seen a novel disease like this,” she explained. “We didn’t realize the asymptomatic nature of transmission until recently. I think we didn’t realize how severely ill some people can get from it, where they’re hospitalized much longer than someone would be hospitalized with the flu.”

At the same time in February, Polis was seeing and hearing little that would have prompted a more aggressive response. On Feb. 9, while at the National Governors Association winter meetings in Washington, D.C., he attended a private session with federal health officials, including Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

“While this is a serious public health matter, the risk to the American public remains low at this time,” read a news release after the briefing. “The federal government will continue working in close coordination with state and local governments to keep it that way.”

On Feb. 20, a day after Ryan told the State Board of Health coronavirus was looking like a bad seasonal flu, Gov. Polis met with President Donald Trump in Colorado Springs. Polis told Colorado Matters the only thing he discussed, other than small talk, was potentially locating Space Command in Colorado.

Another nine days passed, the first confirmed U.S. death occurred, and the global warnings grew louder. By the end of the month there were more cases outside of China than inside. Italy alone had more than 1,500 cases. Researchers examining the genetics of the virus reported that Washington state cases appeared related, pointing to possible community spread.

CPR News asked Ryan if the state had made any purchases, whether for PPE or testing supplies or additional capacity, in January and February to prepare. She spoke about the presence of state and national stockpiles. In a follow up to CPR, CDPHE provided a timeline that shows in late January the state lab made some supply purchases for testing. But it wasn’t until March 19 that the department made its first request to the federal government for personal protective equipment.

The state said it worked through its state cache located in Grand Junction first. Additionally, the governor’s office said they didn’t have budget authority to make large purchases of equipment. The general assembly was in session, but the governor’s office sought no emergency funding in advance of the arrival of the virus.

And there were already reports of shortages, almost a month before the request for federal supplies. A Feb. 28 situation report from CDPHE includes a bullet point that reads: “In response to ongoing reports of PPE shortages and requests for guidance, we are forming a health care mitigation branch within our response to engage stakeholder workgroups and develop these resources.”

The lack of protective equipment had a cascading effect throughout the system. It’s needed for health care workers in order to obtain nasal swabs for testing. Limited PPE equals limited testing. It’s needed in emergency rooms where everyone showing symptoms needs to be treated as a possible coronavirus case. It’s needed for elective surgeries and routine treatments of immunocompromised patients. It’s needed in nursing homes, where re-using protective equipment can spread infection throughout the facility.

And as late as March 4 local public health agencies were confused about what equipment was needed to gather samples.

That lack of basic supplies would become a crisis in Colorado, and across the globe as the coronavirus spread. The state was forced onto the open market to compete with the rest of the world, dozens of other states and the federal government for masks, gloves, gowns and swabs. And any hope of relying on the national stockpile evaporated as it was quickly depleted.

“I can say that we put in requests from the Strategic National Stockpile, and we did go through that pretty quickly,” said Susan Wheelan, director of El Paso County Public Health. There were just “not enough supplies to meet all of the different requests.”

As all that was looming, the public was largely uninformed by official channels about state preparations for the coronavirus.

Throughout the month of February, the governor, who’s prolific on social media, mentioned the coronavirus once, commenting on a tweet from someone else about the need for humane treatment of animals.

Two weeks after Trump restricted travel from China and as the virus took hold in Washington state, Polis’ personal Twitter feed remained its usual mix of science retweets, dad jokes and observations about life. His feed from the governor’s office was largely focused on legislative initiatives.

All of the epidemiologists that CPR News contacted for this article gave Gov. Polis high marks for his response to the outbreak throughout March. COVID-19 has been described as the perfect disease in terms of asymptomatic transmissibility, and many experts said delays in response are understandable given the speed with which it spread.

“That’s certainly a major part of it,” said Glen Mays, with the Colorado School of Public Health. “This is a highly infectious disease. It’s got high reproduction rates, significantly higher than what we see in influenza and other kinds of infectious diseases.”

“Certainly the direction that we were [getting] from public comments of the president, from others, is that there was no cause for alarm at the state level yet,” Polis said in an interview. “And we didn’t have any cases. We knew we might see cases, but we always hope for the best.”

Emails from the governor’s office in late February, reviewed by CPR News, show scant mention of COVID-19, and no emails apparently to or from Polis.

One email string on Feb. 25 from Colorado’s congressional delegation urges a conference call because of “the shifting (more alarmist) tone CDC has adopted, thought it might be useful to check in w you all.”

The next day, Feb. 26, a staffer for the lieutenant governor, Kacey Wulff, sent an email to the National Governors Association asking for pandemic simulations to address COVID-19.

A representative from NGA responded that they didn’t have any to offer, and instead pointed the governor’s office staffer to the Colorado Division of Homeland Security and Emergency Management.

Wulff would eventually be shifted to chief of staff of the governor’s COVID-19 Innovation Response Team.

The next day, on Feb. 27, Polis posted on Facebook, looking for dining recommendations in Aurora. Within three weeks, he would order every restaurant in the state to close their dining rooms.

On Feb. 28, a budget staffer with a Master of Public Health degree wrote an email asking about potential safety training for Capitol workers given the potential for COVID-19 to reach the U.S.

“I know this sounds a bit doomsday preparations, but … it is better to be prepared and informed for a situation that hopefully never happens.”

As February gave way to March, Colorado’s health officials got a warning that the coronavirus could alter life as we know it. It came not from a scientist at the CDC, an epidemiologist at CDPHE, a university professor tracking the disease or a local public health official, but from a software consultant and venture capitalist, who is also a photographer, in Boulder.

She had family in Wuhan, some who had died from COVID-19, and so had a unique perspective to share.

“I think Colorado needs to take Corona Virus more seriously,” wrote Ning Mosberger-Tang on March 2, after receiving an email introduction to Ryan from the head of the Colorado Department of Human Services, a friend. “We need to inform people, test more aggressively, reduce large gatherings, take preventative measures in health facilities, and pay special attention to places where older people or people with existing conditions congregate, etc.”

Ryan wrote back later that night: “The public health system in Colorado is prepared to respond when we see our first case … CDPHE has an entire division devoted to emergency preparedness and responding to disease outbreaks with our federal and local partners is something we do on a regular basis.”

Mosberger-Tang’s email was the only clear warning contained in thousands of pages of records reviewed by CPR News from the governor’s office, CDPHE, and local health departments in the weeks leading up to Colorado’s first case.

“I’m really shocked to hear that. Yeah, that is actually a little scary,” said Mosberger-Tang in an interview. “I was worried, and I would like people to act. I’m a doer. I don’t complain. I want to make things happen. So when I see that the state is not doing enough, I should make sure that I reach out and do my part as a citizen.”

The same day Mosberger-Tang’s email was received, Ryan wrote an urgent email to the members of the Governor’s Expert Emergency Epidemic Response Committee. “I cannot overstress the importance of the advice and guidance … to help Governor Polis make the best possible decision to protect the health of Coloradans.”

The message, which included scheduling information for an emergency meeting to be held in two days, bounced back from multiple emails that were supposed to belong to committee members. Ryan forwarded the email bouncebacks to Dane Matthew to fix. Matthew never responded, and later couldn’t recall that, and said he was out of the loop by then.

“On the books I was still there, but I was largely out of all circulation of things going on,” he said.

March 2 was also a busy day for Polis. He was on a call with White House officials about COVID-19.

But the next day, March 3, CDPHE’s “top-line messaging” to local public health directors remained: “Current risk is still low for Coloradans.” At that point, more than a dozen U.S. citizens had died.

Though there were no confirmed Colorado cases, Polis decided to call a press conference on March 3 to discuss the state’s preparations and reassure the public that Colorado was ready. He also raised the state’s threat level to its second highest category.

Herlihy, the epidemiologist, joined Polis at the press conference because Ryan asked to have a medical doctor present, according to the emails. Herlihy emphasized the need to quickly test and thoroughly trace all the whereabouts of positive cases.

“Our goal after getting a confirmed case is the same as always — to minimize the spread,” Herlihy said at the time.

On the same day of the press conference, Matthew, CDPHE’s director of Emergency Preparedness and Response, announced on Twitter that he was leaving the agency.

Matthew had led CDPHE’s emergency preparedness since 2016. But, he said, CDPHE had reorganized the leadership structure in 2019, and when the incident command structure was launched to respond to COVID-19, “that marginalized my position and I felt it was best to leave,” he said.

For Matthew, state and local authorities were well positioned to handle what he called “normal emergencies.” He worried, though, with focus and money directed to local agencies and local response, that if something bigger happened the state wouldn’t be prepared.

“So it wasn’t until about two years ago that we really started to realize that we need to build a stronger regional as well as state capability,” said Matthew. When asked if the state had achieved that before COVID-19, he responded: “Not at all … a work in progress.”

The state was not alone in a delay in recognizing the true threat. A day after the news conference, the head of Pueblo’s health department wrote to Ryan after she reached out to see how he was handling what she called the “COVID-19 response surge.”

“Yes, we are surviving,” wrote Randy Evetts. “I call it the fear epidemic that we are dealing with currently. I am learning a lot!” He included a smiley-face emoji for emphasis.

When asked in a recent interview what he meant in that email, Evetts said: “There was a lot of fear of the unknown in our community. There was a lot of news stories but there wasn’t much guidance at that point. We did not have testing.”

Quickly Overwhelmed

On March 5, Polis announced that a man who came to Colorado to ski in Summit and Eagle counties had tested positive for COVID-19. The floodgates of the crisis had opened.

The governor said Coloradans should not panic. The state would work closely with local public health agencies to test, trace contacts and quarantine as needed.

“Once we got the first diagnosed case, March 5, is really when we sprung rapidly into action around containment in Colorado and around the social distancing,” Polis said in the interview.

By then, there were likely already more than 100 cases in the state, it’s now believed, and the speed and scope of the spread of COVID-19 revealed fault lines in Colorado’s distributed public health system.

There are more than 50 local public health agencies in Colorado, with varying resources. Local public health offices farther from Denver complain that they have fewer contacts and relationships with CDPHE leadership and that they face inconsistent funding compared to the state.

The system led to confusion.

In the hours after Polis announced the first confirmed case, two different county health departments were trying to trace back the patient’s previous whereabouts, while the state appears to have taken over, complicating the tracing.

The man had skied in Summit and Eagle counties, he fell ill in Summit and moved himself to Jefferson County to recover at a lower altitude.

On March 5, the Summit County Public Health director, Amy Wineland, wrote to CDPHE: “How soon will we hear back from you on the interview?”

Early the next morning, she reached out to Jefferson County, because she heard they were also doing contact tracing.

A few hours later on March 6, Wineland sent another email to CDPHE: “We have down that the case did ride a gondola at Vail. Can you please confirm that they only rode with the friends/fiancé? The gondola rides are longer than 10 minutes and people are in close contact. Also did he rent skis somewhere???”

Wineland declined an interview, but in response to the request from CPR News, she wrote that CDPHE has authority over investigating non-residents.

“As this was the situation and because it was the first case in the state, I think everyone was trying to do what they thought was right,” she wrote, adding that the state took their feedback. “CDPHE staff has supported and guided us in our work and often we interviewed cases together so that we both received the information we needed to do our respective parts of the investigation and contact tracing.”

Testing quickly became the next immediate problem.

Soon after announcing the first case in Colorado, Polis said the state had the capacity to test 160 people a day, but in text messages Summit County officials questioned that.

“I was surprised at the number of 63 total tests for the state when they are saying they can do 160 per day,” reads a text message from Sarah Vaine, assistant county manager of Summit County on March 5 to Wineland. “Seems like they are pretty overwhelmed with way fewer tests than 160.”

CDPHE said in a follow-up response that testing capacity was limited because of strict guidelines from CDC on who qualified for a test.

Interviews and records obtained from local public health agencies point to issues within the state lab as well. In Eagle County, Rebecca Larson, the Disease Prevention & Control Manager at that county’s public health department, wrote on March 5, “talked to CDPHE. Their technical challenges for testing are administrative related, not in testing specimens. Still no official word on our pending tests.”

Ryan initially told CPR News in an interview that “as soon as CDC was ready to provide [needed] supplies to us, we ramped up our ability to do the testing.” But after CPR News told her there were widespread complaints about the state lab’s ability to turnaround results, she responded: “The state lab was not designed to provide all of the laboratory testing in the state for one disease. And so what we very quickly tried to do was … to help the private sector ramp up testing.”

More testing meant more results, and problems surfaced early on in communicating test results to local public health. In a March 7 email from epidemiologist Haley Zachary to her bosses at El Paso County Public Health, she wrote: “We are having a difficult time with the lack and manner of communication [with CDPHE]. Currently, there are 8 reported presumptive positives, EPCPH only knows about one in our county and the initial two which were reported on Thursday.”

“CDPHE has been very demanding in their ‘needs’ from [local public health],” Zachary continued. “But has not been able to offer the same service to us, which makes it very difficult as it feels like a very one sided communication right now.”

While Polis has been inconsistent on the importance of testing, local public health directors insist it’s elemental.

“For any communicable disease, accurate, timely diagnostic testing is going to be the cornerstone of how we fight that disease, how we contain that disease and how we keep our communities healthy and safe,” said Liane Jollon, Executive Director of San Juan Basin Public Health in Durango. “And we’ve had difficulties from the beginning.”

Early on, the state lab was the only place to send a COVID-19 test for results in Colorado. “As testing took place throughout the state, that laboratory became overwhelmed and it was very difficult for them to do in a rapid fashion,” said Dr. Brooks Bock, CEO of Colorado Mountain Medical, during a virtual town hall held in late March.

Eventually, hospitals in Eagle County switched to Quest Labs, a private company, “So we’re getting our results much more quickly and that’s a very positive thing,” said Bock. The state was taking up to 10 days to turn around results, compared to one to two days at the private labs.

And even commercial labs initially had their problems. “None of the labs, as far as we can tell, were designed to do the volume that they needed to do,” said Jollon, the public health director in Durango, in an interview.

A Strained Relationship

Once someone tests positive, traditionally, the next step is contact tracing: Where was the infected person? Who did that person come into contact with? With that information, public health can isolate and quarantine in a more targeted way.

This is mostly the purview of local public health, which is often described as the boots on the ground of the public health system. In the days after the first case was discovered, however, communication broke down between Summit County Public Health and CDPHE.

In an email on March 7, Summit County Public Health Director Amy Wineland wrote to her fellow public health directors in the state, that there’s been “a tremendous lag in getting vital information” from CDPHE. Wineland wrote that CDPHE told her to not have contact with the person, though contact tracing, in most cases, is the responsibility of local public health.

CDPHE appeared to cut out the local public health agency, taking control of tracing for non-residents, like the infected patient. But that left the residents of Summit County who may have had contact with the man. Wineland’s email said that it took more than a day to get information from the state on where the person who tested positive had been in the county.

“Locally, this did not do wonders for the community’s trust in our ability to investigate threats to our public’s health,” she said.

One week after the first case was announced, on March 12, local public health directors still complained of a lack of communication with CDPHE. In an email shared with all the local directors, there’s a long list of “unaddressed issues,” including a lack of strategic discussions, community testing directives, consistent guidance on quarantine and monitoring.

There still had been only one call between state and local public health leadership, “and no further calls have been scheduled,” according to the email. And “delays in getting [test] results remains an issue.”

Taken together, all those issues meant there was limited contact tracing throughout the state.

“I think it’s probably a fair criticism,” said Ryan in a recent interview, noting that this is an unprecedented event and there will no doubt be bumps along the way as CDPHE and the local departments work through things they’ve never worked through.

“None of our systems are built for a pandemic like this,” she said, drawing a distinction between the more contagious and deadly COVID-19 and a bad seasonal flu around which much of the training and preparation is built. “Flu has been like our main mental model for this. But I think what we’ve learned is it is very different from flu.”

Many people infected with the coronavirus are asymptomatic, helping it to spread more easily, and Ryan said they didn’t anticipate how severely ill some people would get.

For part of March, Ryan was in isolation with her family in Eagle County after her husband was exposed to COVID-19. She eventually tested negative.

Ryan said her agency has since improved communication with local public health agencies, but she acknowledged strains in the relationship.

“I think we’re working on it,” she said. “The systems still aren’t scaled up to the level they need to be for this response. But I do feel like the communication with local public health has improved a lot to where we’re able to work on these issues together.”

As a former public health director in Eagle County, Ryan said she understands their needs and concerns.

“Believe me, they are partners. We are a system. We need each other.”

When asked if the relationship between local public health and CDPHE has improved, San Juan Basin Public Health director Liane Jollon said: “We are going to need a very good relationship going forward.”

“We can’t reopen our economies. We can’t go back to school. We can’t go back to normal lives without broad testing, broad surveillance, and then really intensive contact tracing, monitoring, and quarantine isolation,” Jollon said. “And that work is carried out typically at the local level. We have to stand up a lot of capacity really quickly. I am hopeful that we will be able to develop the communication and coordination. We need to do this well.”

Getting that right isn’t just about reopening the state before summer, it’s about preparing for a potential second wave of the disease. The stakes are high, given the transmissibility and deadliness of COVID-19.

Two weeks into May, the state is now approaching 1,000 confirmed coronavirus deaths, most in nursing homes and other facilities housing the elderly. That’s the exact “at-risk” population the New England Journal of Medicine was warning would need extra protection back on Jan. 29.

In a statement to CPR News after the interview with the governor, his office emphasized that while they knew the state’s response was imperfect, they were dealing with an unprecedented crisis.

“This is an experience that we have never lived before in our lives and although we had tabletop exercises, experts and systems in place, nothing can quite prepare you for the magnitude of this pandemic,” the statement read. “But at the end of the day, the Governor is proud of the work that the state employees have done to protect Coloradans.”

Ning Mosberger-Tang, who wrote the email warning the virus shouldn’t be taken lightly, hopes the mistakes of the past, the collective moment of disbelief that caught officials at almost every level of the system flat-footed, aren’t repeated.

“We had a warning, right? Basically a gift from China, but we did not take advantage of that extra months to prepare and get ready,” Mosberger-Tang said. “So we are caught almost like off guard, so we don’t have anybody else to blame but ourselves.”

Editor’s Note: This story is based on records from the governor’s office, CDPHE, and local public health agencies in El Paso, Summit and Eagle counties. The agencies charged CPR News a total of approximately $2,000 for searching, processing and redacting those records to remove references to personal health histories. The records were supplemented with more than a dozen interviews of officials in those agencies and national experts.