Cynthia Wilson remembers learning of Nevada County’s first death from the novel coronavirus, reported on April 3, 2020. In that moment, the county director of public health nursing recalled thinking, “This is bad.”
Until then, most local cases of COVID-19 had been in people who had picked up the virus overseas and came down sick after returning. But this was an early case of “community spread,” with the virus moving among members of a family. Nurses in the county Public Health Department had been in daily contact with the family, monitoring members’ symptoms and tracking the contagion in a bid to limit its spread. Then, the virus infected an elderly grandmother who already had health issues. She died.
“We were just, ‘Yeah. We got to get a handle on this, and this is going to be what happens in our county a lot,’” Wilson recalled thinking. “It’s heart-wrenching to be talking with the families.”
Cynthia Wilson, R.N.
Nevada County director of public health nursing
– Master of Science in nursing science and healthcare leadership, University of California, Davis
– Registered nurse
– Certified public health nurse
– International board-certified lactation consultant
Wilson has been a nurse for 43 years, including field work in Kenya and South Africa, and time in labor and delivery and intensive care units. As director of public health nursing here, Wilson oversees staff who provide a medical safety net for people who might not get health care otherwise. Programs address issues that improve the overall health of all residents, including caring for women and children, children in foster care, and minors with special health needs; providing low-cost immunizations; helping people manage chronic diseases such as diabetes; outreach to seniors; and the family and reproductive health clinic in Truckee.
In addition, public health has been seen more and more as a key part of emergency preparedness. That started after 2001, with that year’s terrorist attacks and anthrax bacteria sent through the U.S. Postal Service. So, Wilson and staff are partners in the region’s preparedness program: Many agencies and organizations together practice their responses to emergencies that affect the public’s health, such as wildfires, power failures, hazardous waste spills, paralyzing snowfalls and pandemics.
In Nevada County, the yearly drive-through influenza vaccination clinics at the county fairgrounds serve the additional purpose of practicing for a public health emergency. In addition, county public health nurses have worked at emergency shelters set up for people displaced by local wildfires and 2017’s Oroville Dam crisis. Critiques after each event have led to better preparations, including building up staff and supplies, a keener focus on specific health needs amid disasters, working more closely across county departments, and creating a registry and vetting system to bring volunteer disaster workers into the mix, Wilson said.
But the COVID-19 pandemic “wasn’t exactly like what we had prepared for,” Wilson continued. “We had to do some pivoting… I’m tired of the word ‘pivoting.”
“People are alive who would not have lived through this because of the work of our Public Health Department.” — Nevada County Director of Public Health Nursing Cynthia Wilson
One case, many ripples and the end of daily contact
The four steps of isolation, quarantine, active case management and contact tracing are effective and time-proven ways of limiting the spread of disease, according to the National Association of County and City Health Officials. They are especially useful when little is known of a disease and how it spreads. They have been proven time and again to reduce suffering and death.
In the early months of the pandemic, Nevada County’s public health nurses spent much of their time working these four steps to slow the spread of COVID-19. Active case management keeps them in contact daily with sick people and those who had been exposed to them.
Until late May 2020, Nevada County had a fairly low rate of spread, with 41 total cases, according to the county’s COVID-19 dashboard. Experts have attributed that low rate to the lockdown and the department’s active case management.
“We had been in lockdown since March,” Wilson recalled. “By Memorial Day, people were fed up with that… People just started doing what they wanted to do on a holiday weekend, and it made us feel like, ‘This is going to be bad about the middle of June.’”
Sure enough, on a Saturday a couple weeks later, Wilson got a call: A man had tested positive. While he was unknowingly infectious, he had held a large gathering at home.
“So I spent my entire Saturday talking to him, getting the list of the people who had been there, then making contact with them to say, ‘You know, you’re a contact in a COVID case,’” Wilson said. She spent the next several weeks making daily calls to members of the extended family and circle of friends, locally and across three states. “It was just dominoes, people getting sick or at least having a positive test.”
That brought an alarming insight into the near future. Wilson recalled thinking, “Oh, my goodness, we’re going to be in trouble, because people are tired of these measures that we’re asking them to do, and if one case can cause this many ripples, it is going to create a lot of illness in our community.”
Since early in the pandemic, Public Health Department staff already had set aside some of their regular functions to focus on COVID-19 contact tracing and active monitoring. Even employees who are not public health nurses dropped lower-priority tasks to help out. They worked 14-hour days, 7 days a week, trying to keep up.
By the end of July, another round of holiday gatherings pushed the county’s total of reported cases to 299, or nearly 730 percent higher than two months earlier, according to Nevada County data. Wilson knew that her public health nurses could no longer keep daily personal contact with people infected by the virus. She just didn’t have the staff.
The end of active case management marked a worrisome pivot in their ability to manage COVID’s spread, Wilson said.
As virus spreads, case investigations can’t keep up
In early November 2020, the pace of new illness started speeding up even faster. The fall surge had begun.
On Dec. 7, 2020, the county reported a record 134 new COVID-19 cases. The 7-day running average of daily new cases peaked at 61, with a total of 1,776 confirmed cases since the beginning of the pandemic.
Wilson’s nurses could no longer investigate every case. Instead, they prioritized tracing the contacts of people likely to expose the virus to the county’s most vulnerable residents: the elderly, those with conditions that could cause them to get very sick, people living in dense housing, and those with poor access to information and services. They also tracked contacts of children with COVID to limit the virus’ spread to other family members, she said.
This second pivot brought new anguish to her staff.
“We don’t have enough people to investigate every case anymore,” Wilson said. “That is sad and tragic to us, because if we can’t do that, then we aren’t going to have a full picture of what’s going on… of where it’s spreading, how it’s spreading, who is spreading it. We’re only going to see the lab reports for some of our residents and not even be able to talk to them…
“We didn’t feel like we were managing it like we needed to.”
A jar of hope
Another enormously difficult pivot came in January 2021, when the Public Health Department started rolling out newly arrived vaccines. Wilson remembers thinking of that first batch as “a jar of hope” for her staff and the whole community. But this new phase of the pandemic also doubled the nurses’ workload, as they continued to mitigate COVID’s spread while figuring out how to organize public vaccinations.
Nurses quickly saw their drive-through flu-shot clinics did not offer a helpful model, because the new COVID vaccines require 15-minute observation periods. They found a building and brought in additional doctors and nurses to observe people receiving the shots. Volunteers listed in the registry — often retired medical professionals — help out.
Wilson also realized vaccines could be distributed either quickly or equitably. “You can do one, but you can’t do both, at least not at the same time, and we were tasked with doing both,” Wilson said. The same people who already were on the margins and most vulnerable to illness also are among the most difficult to reach, she explained.
The nurses have tried different ways of organizing vaccination clinics and reaching hard-to-reach folks. When one plan didn’t work so well, they would try another. They have recruited trusted community leaders, including health workers who speak Spanish and already work with Latinos in the Truckee area, and found ways to make it easier for people to get vaccination appointments.
A voice brings joy
The department also has special teams of nurses who take vaccinations into residential settings. In February 2021, Wilson was participating in one such clinic-on-the-go when she heard a familiar voice. It was that of a woman who had been Wilson’s main contact for a family she had monitored in June and July 2020. The clinic was being held at the woman’s place of work. Wilson had never met her face-to-face.
“I turned around and introduced myself to her,” Wilson recalled. “Their family had been through an amazing journey. I felt like I was part of helping them heal and recover from what had happened to them, and to keep other people safe.”
“I want to hug you so bad!” the woman told Wilson.
Looking around the residential facility, Wilson recalled thinking, “If she had brought (COVID-19) into this group, that would have been a disaster. So all these people that were now vaccinating can actually sit here and get their vaccine, partly because I was part of the system to protect them early on…
“People are alive who would not have lived through this because of the work of our Public Health Department,” Wilson said.