Dr. Josh Ennis Explains That Covid Deaths Are Under-counted Nationwide, Has No Comment On Recent Covid Death While Investigation Is Pending, And More

For this type of report, the Emergency Operations Center takes the questions from the media, and staff reads them on camera to officials for their response. The resulting video, called a Media Availability, is then provided to news outlets at the end of the day.

Here are some of the main points covered in the October 22nd Media Availability session with a summary of answers from Humboldt County Deputy Health Officer Dr. Josh Ennis, followed by questions we would have liked to ask in response if appropriate.

EOC:  Good afternoon, would you like to start out by addressing the community? 

Dr. Ennis:

Yeah, I’d love to.  I’d just like to take a moment to talk a little bit about where we’re at right now in the pandemic. So, over the past month or so, as you know, we’ve been tracking a lot of things, including how much disease is in the community, how many hospitalizations we’re seeing, how many deaths we’re seeing. We have seen a  steady uptick in the number of hospitalizations.  

There have been a handful of cases hospitalized fairly consistently for at least the past month,  

and there has been a clear, very slow and steady increase in hospitalizations. And what we know from that is that there is generally more disease circulating out amongst the community. It has been a very slow and steady increase. You know our day-to-day numbers may not reflect that and I think there are a couple conclusions that maybe can be drawn from that. Number one, the disease is still out there even despite our numbers looking very low and small. The disease is still out there and a large number of people are asymptomatic or have very mild symptoms that they chalk up to other conditions such as allergies, we commonly see headache and then atypical symptoms such as vomiting and diarrhea. And so if you look at the entire list of symptoms that COVID-19 can cause, it’s a huge spectrum and so I would encourage the public to, if they have an unusual new symptom and it fits with that list of COVID-19, to consider getting tested.  

Right now we are so far into this that people are becoming really tired. We are in a, what is shaping up to be a third wave across the country, and at this point it is affecting many very rural  

areas in the mountain Midwest, and they’re seeing rates of disease that are accelerating  even more than we’ve seen with the prior two waves. And so I know we’re all tired of this.  

The state has released more guidance allowing more people to mix and come together that does assume more risk and so I would just like to underscore the same things we’ve been saying all along.  

They’re reborn in every guidance that comes out, but it’s really some very basic things that lets us resume the new normal, that lets our businesses stay open, it lets our economy stay healthier, and that’s frequent hand washing and hand hygiene, it’s keeping distance from folks, it’s living the number of different households you bring together, it’s also universal masking. It really does make a difference. It’s not a hundred percent but it really does make a difference in slowing and preventing transmission, you know. So, it’s these very basic things that are going to let us continue to move forward and I know we’re tired, I’m tired of it, but we’re doing great with it and let’s not become complacent now.

3 mins 30 secs in:

Question by Lost Coast Outpost:  The CDC has expanded its definition of “close contact” to include anyone who has been within six feet of an infected person for 15 minutes or more over a 24-hour period. Does this affect how the county undertakes contact tracing? Will it greatly expand the number of people who are asked to quarantine?

Answer by Dr. Ennis: 

This changing in the operational definition will impact how many people are asked to quarantine.  The county has approached identical situations to what was reported out by the CDC that prompted this change. And that’s that some people may have lots of frequent, smaller interactions that cumulatively, over a 24-hour period, add up to more than 15 minutes. And so you know they have more and more cumulative exposure but they weren’t sitting for more than 15 minutes in a single given time. And so we have on occasion considered that as increasing risk of exposure.  

You know the shift here though, with the CDC now defining it this way, necessitates that  more people are likely going to qualify for that  definition and in what has previously been kind of a gray area where we would take the whole picture to push us one way or the other when making quarantine decisions. You know one situation that  immediately comes to mind where this could have a dramatic impact is is the in-person school  setting. You know there’s bringing people together, there’s frequent probably very  fleeting interactions within six feet, but cumulatively throughout the day it’s possible that it adds up to more than 15 minutes and so  I think we can be more mindful when we talk about restructuring how we conduct business in situations such as this, such as in-person schooling, but this definitely has the potential for increasing the number of people who would be considered for quarantine as a result of this operational definition change. 

5 mins 55  sec in: 

Question by Lost Coast Outpost:  As regards the local 38-year-man who recently died, and who tested positive for the virus at autopsy: What more can you tell us about what is known about his cause of death? Did he experience abnormal blood clotting, or any other known but unusual presentations of the disease?

Answer by Dr. Ennis: 

So, from the Public Health side, we do not have access to the same level information as does the Coroner’s Office. So anytime there is a death that is given to the, assigned to the Coroner’s Office, they undertake the investigation and so they, you know, I’m not in that office, I don’t know all of what their process looks like, but you know, they have several different tools at their disposal to investigate the circumstances surrounding any death. 

On the Public Health side, again, you know we try very hard to think about what level of information is appropriate to release while honoring the privacy and the private health information of the decedent as well as their surviving family.  And so you know, in this particular case, I don’t have access to the majority of what this question is asking about, and you know, I feel that it is likely, at this point, inappropriate to release it as the sheriff noted the other day that they have an open investigation. 

7 mins 40 sec in:   

Question by Redheaded Blackbelt:  Questions have been raised about the numbers of deaths with COVID. Many people believe that only a small number of deaths are actually COVID deaths and the rest of the over 220,000 deaths in the US have other causes and COVID was only present at the time of death not a major contributing factor. Could you address this in light of what you know about the situation nationally and in particular with the man in his 30’s who died with COVID recently in Humboldt County who reportedly had a serious health history. Could you clarify if an autopsy was done and if the autopsy or other indications indicated that COVID was the primary cause of death, a contributing cause of death, or only present but not contributing. And explain, if the latter, the reasoning for including him in the Humboldt County COVID deaths.

Answer by Dr. Ennis: 

Sure. There’s a lot of moving parts to  this question so I’ll start with the easier questions and kind of move to some of  the bigger scope of this question. So first of all clarifying whether an autopsy was done or not  I’d refer that question to the Coroner’s Office. They would have answers or choose to release  information at their discretion about a lot of the things that are asked at the end of  this question about cause of death contributory, etc.

So I can tell you that the state reporting  system, if someone tests positive at the time of death, it is reported to the state system as  a death in someone who also tested positive.  The system is not designed to attribute cause  of death. Now you might ask, well what if the cause of death clearly had nothing to do with COVID-19, say they’re asymptomatic from COVID-19 and so we’ve actually reached out to the  state to clarify how that would be handled.  Now getting to the bigger question here about COVID deaths and the number now being north of 220,000 across the country.  

Leading public health experts, now I won’t say 100 percent of them because, you know, certainly if you have a lot of different minds thinking about the same thing, you’re never gonna get a hundred percent consensus, right, but the vast majority of them believe that this number is actually an under counting of all COVID-related deaths and there are a few reasons to think that. So you can look at the number of excess deaths over a certain time period and compare that number to those that are definitively related to COVID-19, or tallied as related to COVID-19, and there has been a clear excess.  Now, some of those may have  been due to deferred health care or people being afraid to seek care for their non-COVID related things such as a heart attack or a stroke, there are ways to adjust for that. And so again after adjusting for those things, looking at and comparing those numbers, the vast majority think that we’re under counting deaths, if we’re off one way or the other. Now I will speak also to another item here that some people attribute these deaths as being inflated because people had other pre-existing conditions and whatnot.  

There have been some really misleading statements out there talking specifically about comorbidities and you  know deaths being falsely attributed to COVID-19.  Now in many of these cases, these are very common things that many, many people that you and I know,  

have which aren’t in the vast majority of cases a really big deal. It might be high blood pressure that’s very well controlled with a single medication, it might be diabetes that’s well controlled with a single medication.   These might be seemingly very minor things that sure, they are technically a comorbidity, but they would be listed on a death certificate.  And so it’d be really inappropriate to look at all death certificates that carry COVID-19 and say that you know most of them are not due to COVID-19 because there is a comorbidity such as high blood pressure or diabetes listed.  

The reality is though that when a death occurs it’s not as simple as putting your finger on the one thing that caused it. There can be many different things that cause it and one disease process can play off of another and so sometimes it might be a combination of these two or three things that all come together in the perfect storm and cause death. And so we can be left in scenarios, as a provider who’s worked in the acute care setting, sometimes you don’t know and you just cannot put your finger on the one thing that caused the death and there are lots of shades of gray in between. And so, it’s not so simple but the general consensus is if anything, this is an underestimate and any statements that say this number is falsely inflated as a result of the comorbidities are simply not true and maybe just have a misunderstanding or a flat out disregard for how complex it can be to attribute death sometimes in the face of other comorbidities.  

14 mins 5 sec in:   

Question by Redheaded Blackbelt:  In regard to the COVID deaths locally, will you be adding any data to the county dashboard which would reflect demographics of the COVID deaths, similar to what the state is making public, and if not, please explain the reasoning?  (See image below.)

Answer by Dr. Ennis: 

So, first of all, any data that’s available through the California COVID website, when we were first building out our own local dashboard we thought hard about how much value it brings to present more or less the same data that the state already has. And after a lot of deliberation over this, we felt that it would be best to put our energy elsewhere to information and data that supplements what’s available through the state, rather than recreating the wheel of sorts.  And so that was the reason that we chose to not  put the exact same or nearly identical information directly on our local dashboard, because it’s  already available through the state website.

Now the first part of this question asks about demographics of the COVID deaths, and there’s already a fair amount of demographic data available on the state website. I would maybe ask the question, you know, what other additional demographic data would be helpful to know about that is actionable? And I would say that if you look at where the cases are occurring, if you look at those demographics, you look at the occupational settings, it’s the same  

trends and same groups and same themes that are occurring, whether that’s higher case rates, whether that’s deaths, and so it doesn’t add a whole lot of value, in our opinion, to go digging and sorting that information at this point with the deaths in Humboldt County. Additionally the numbers are so small that it’s very likely to misrepresent what’s really going on. 

16 mins 20 sec in:  

Question by Reporter Daniel Mintz:  At Tuesday’s Board of Supervisors meeting, it was reported that the county is addressing a cluster of COVID-19 cases related to a place of worship. How many cases are in this cluster and what are the circumstances of transmission — how large was the gathering or gatherings at the place of worship, were people indoors or outdoors, wearing masks, distanced, etc. 

Answer by Dr. Ennis: 

So again if we feel information is in the interest of the general public needing to know we release that information.  I will speak generally about place of worship guidance that the state has and you know the guidance that’s out there is a reiteration of the things I talked about at the very beginning. It’s that you structure things to try and keep your distance, you encourage mask use, discourage high-output activities such as forceful singing, you also exercise hand hygiene.  These are things that we know really slow and limit transmission. Naturally when you bring people together into a place of worship that assumes more risk and we know that. Our experience is  that if the appropriate measures are put in place it’s not going to prevent 100 percent  transmission but it does perform fairly well.  

Now with the specifics of this case, you know I’m not at liberty to say what happens at this particular place of worship, I’ll tell you though that it being referred to a cluster means that it’s more than a handful of cases and it has spread beyond just the place of worship and has resulted in hospitalizations as well.  So this is something of great concern.  

Anytime you bring more people together, there is more risk involved, and so the more we can just move forward with the basic precautions, the more it’s going to help mitigate that risk and allow us to continue doing things we want to continue doing.

18 mins 45 sec in: 

Question by Reporter Daniel Mintz:  At this point how well is the county doing with surveillance testing and getting a broad enough range of residents tested to document the extent of community transmission?

Answer by Dr. Ennis: 

This is the million-dollar question, are you testing enough people?  So I’d say our county, because of the timing  if we look back seven or eight months ago, we’ve generally been doing well.  I can tell you that if you look at a few different  items I think we are still falling short of how much testing we really need to be doing and that’s  largely being limited by capacity at this point.  

We still need more testing, that is that is for certain. And so I can give you a few uh specific items. If you look at the symptoms that our local Humboldt County residents have had, on our dashboard the percentage of those completely  asymptomatic is somewhere around six or seven percent. Now we know from some larger studies,  there was a really large cross-sectional one in the northeast that was done, there’s also some fancy ones that use modeling to look at this, we know that asymptomatic infections are a large part of all those infected. At a bare minimum, I put that number around 20 or 25 percent, there are some modeling studies out there that suggest it’s upwards of 50 percent. That’s a big range, you know I think it’s probably more somewhere in the middle but we don’t know but it is a large percentage of all cases. And so if you compare that, you know, 25 percent number with what we’re actually seeing locally of six or seven percent, it’s clear we’re missing a lot of asymptomatic cases. Now the second part of this is that I mentioned at the beginning that there’s been a very slow and steady uptick in the number of hospitalized cases and you know  early on we could correlate large numbers of cases with hospitalizations two to four weeks later.  That’s been dis-coupled a little bit lately and so the conclusion I believe is that we have a little more disease circulating in the community that is undetected. I don’t want to sound alarmist, you know this is probably low lying level activity, but the trend is clear in hospitalizations, and so there probably is a little bit of pandemic fatigue going on here and people aren’t as inclined to get tested. And so we need to continue building testing capacity, we need to continue to support decentralization of testing capacity, and we need to bring it out  into all pockets of our geographically spread out county and we’re working to support that day in, day out. 

22 mins 5 sec in: Question by North Coast News:  The Humboldt County Sheriff’s Office says it’s begun testing for COVID-19 during autopsies at the request of public health. When did this process begin, and is it possible the death count could be higher in Humboldt if such post mortem tests would have begun sooner?

Answer by Dr. Ennis: 

I’d like to just clarify one item here. This  process didn’t begin recently, it’s been available to the Coroner’s Office throughout  the entirety of the pandemic and I think maybe what this is referring to is  that six, eight weeks ago, we did encourage the use of testing in scenarios  that were felt to be appropriate.  Prior to that communication and encouragement to test in appropriate scenarios, there were specimens submitted from  the Coroner’s Office to Public Health.   Now the reason we decided to encourage its appropriate use is because it’s another way of having some type of system that’s looking for more disease circulating in the community. And as I’ve already said, based on hospitalizations, we suspect that there is a little bit more disease circulating undetected. And so it is certainly possible that we have missed some deaths but again because of the timing of how many cases there were in the Bay Area versus here when the original Shelter in Place order went in place, we were able to get a lot of things in  place, and so I would not suspect that we’ve, if we’ve missed any, it’s not a large number.

24 mins in:   

Question by North Coast News:  Some have been critical about how COVID-related deaths are reported statistically (ex. The most recent death being discovered during an autopsy); do you believe the way data is represented is adequate?

Answer by Dr. Ennis:

I think I’ve spoken a lot about this already. I might just add with the you know post-mortem COVID-19 testing, I’ll just  expand on that a little bit perhaps. When I say encourage appropriate use, you know  I think we can all think of scenarios there it would be appropriate to test. You know if  you had a family member who passed away and it was unexpected and you know that they were talking  about having a little bit of cough recently, seems like an appropriate scenario to testing. You  know what we tried hard to avoid is encouraging inappropriate use and we really left it to the  discretion of the folks in the Coroner’s Office as well as any pathologists that may be involved  with any particular case. And so just hoping to clarify that maybe with this question as well  as the previous one, that you know we’re doing things that and making recommendations that would  seem very reasonable to any common person who’s an outside observer.

25 mins 35 sec in:  

Question by North Coast News:  A California court ordered state corrections officials to cut the population of San Quentin State Prison in half due to COVID. It was the site of one of the nation’s worst coronavirus outbreaks, with 28 inmate deaths and 2,200 infections at its peak — about 75% of the inmate population. Nearly 300 employees were sickened and one died. Do you support early inmate release to minimize the impacts of the virus?

Answer by Dr. Ennis:

So, I’ve never worked within Corrections,  I don’t have a good understanding of the correction system and so I really don’t  know that I could offer up a well-rounded, thoughtful answer to this question. 

Now, from a Public Health perspective,  certainly when you have a lot of people in closer quarters, those are conditions where we  know that a disease such as COVID-19 will spread quickly and rapidly. Now whether you  know whoever’s making that decision about early inmate release, you know…  I don’t understand that system enough to be able to weigh in here. 

Community members with questions or concerns are encouraged to call 441-5000 for additional information.  

For the most recent state and national COVID-19 information, visit cdc.gov or cdph.ca.gov. 

Local information is available at the Humboldt County COVID-19 Data Dashboard: humboldtgov.org/dashboard, on Facebook @HumCoCOVID19, Instagram @HumCoCOVID19, Twitter @HumCoCOVID19, and Humboldt Health Alert humboldtgov.org/HumboldtHealthAlert