Five days before Indiana's first coronavirus victim was hospitalized with symptoms that proved fatal, she attended a meeting with 11 other senior citizens at a Moose Lodge on the south side.

Two days earlier she was at a bar in Beech Grove where her partner, who has not tested positive for the virus but remains in quarantine, was playing in a band.

And just three days before she went to the emergency room at Community Hospital East on March 7, she was working at her part-time job shuttling cars and employees for Enterprise Rent-A-Car.

State and local public health officials say they track the movements of patients diagnosed with COVID-19 to warn people who might have been exposed so they can self-quarantine. Such social tracking, or contact tracing, is a valuable tool in the early days of an epidemic, when the numbers of victims are still low and outbreaks can be thwarted.

'God heard her weary cry': Remembering 'Birdie,' Indiana's first coronavirus death

But in the case of Roberta "Birdie" Shelton, Indiana's first-known COVID-19 victim, there were significant gaps in that effort. Representatives of the company where Shelton worked, the lodge she frequented and the bar she visited a week before entering the hospital all told IndyStar they were not contacted by public health officials.

"No one has talked to me," said Dee Watkins, the 74-year-old secretary at the Loyal Order of Moose Lodge 1883 in Beech Grove. She kept minutes at the March 2 meeting Shelton attended and has a list of all 12 participants."I would have thought they would have."

The mayor of Beech Grove also didn't get an official notice. “If she sought medical attention for an illness I would have expected at that point a phone call from them so we can take safety measures,” Mayor Dennis Buckley told IndyStar.

Exactly why such holes existed in Marion County's response is unclear. Citing health care privacy restrictions, state and local health officials did not respond to questions about actions they took to notify people in close contact with Shelton.

But health experts told IndyStar gaps like those seen in Shelton's case could represent a critical missed opportunity to identify potential clusters and head them off early.

"It is most efficient early," said Dr. Arnold Monto, a professor of epidemiology at the University of Michigan School of Public Health. "If you can do some of the contact tracing and quarantining, you should do it. But that only works when you have small numbers."

As the disease spreads, tracking patient contacts becomes impossible. And Indiana may have already passed that point. At the time Shelton's family notified her employer on March 14 that she had tested positive for the virus there were only 3 confirmed cases in Marion County. A week later, there were 46, and the total now stands at more than 110.

The numbers are expected to continue growing, forcing health professionals to shift into a triage, rather than prevention, mode.

Tracing one deadly case

As Shelton was getting sick, Indiana was just beginning to reckon with the pandemic that has killed thousands around the world.

Gov. Eric Holcomb announced the first presumptive positive on March 6, the same day he declared a public health emergency. That was the day before Shelton was hospitalized.

By the time officials announced Shelton’s death on March 16, another 23 cases had been confirmed across 13 counties in Indiana.

Cities and states around the country had begun taking drastic steps that eventually led to cancellations of sporting events, closures of schools, bars, restaurants, health clubs, churches and other gathering places. Officials encouraged employees to work from home to avoid getting within six feet of others. President Donald Trump said people should limit all gatherings to 10 people.

COVID-19: 5 things to know about Indiana's first victim

The disease is highly contiguous, health officials warned, and those in contact with people infected should self-quarantine for 14 days. The virus can be transmitted before a carrier exhibits symptoms.

Facebook posts from Shelton provided her friends with information about her health.

“We knew she wasn’t feeling good,” said Watkins, the Moose secretary at the March 2 meeting with Shelton. “She said she wasn’t feeling perky.”

Three days later, Shelton posted, "Damn I'm so sick. Eyes hurt to be open. Top of head feels like it can blow off. Coughing. Been doing breathing treatments and at Dr. Office now.”

But it wasn't until March 7 that she went to the emergency room at Community East.

It is not clear when Shelton was diagnosed as positive for COVID-19. She didn't specifically mention it on Facebook, but in response to questions from friends she posted that she had been tested and did not have the virus. One of those responses came at least two days after she was hospitalized.

State Health Commissioner Kris Box said during a news conference last week that testing isn't perfect and negative results can create a false sense of security. That's one reason officials initially limited tests to those hospitalized with suspected symptoms, she said.

"The reality is you could have minimal symptoms today and be tested and be negative and two days from now be positive for COVID-19, so that gives you a false sense of security," Box said during the briefing where the state's first death was announced.

Media representatives from both state and Marion County health departments said they could not comment on Shelton's case or even confirm that she was a coronavirus victim.

IndyStar confirmed her identity through her employer and acquaintances, including her partner, Tony Sizemore, and two family members, including one who visited Shelton in the hospital and is handling her funeral arrangements.

Who 'Birdie' saw

Shelton was very active, even in the week before she went to the hospital. Friends described her as an energetic and personable woman who attended events and organized fundraisers at the Moose Lodge, booked gigs for bands at crowded bars and drove people around for a living.

In the week before she was hospitalized on March 7, Shelton had close contact with a lot of people.

On Feb. 29, Shelton was at Nite Owls Saloon and Grill in Beech Grove to see her boyfriend's band play. The show didn't end until the early hours of March 1. A friend said she last saw Shelton briefly in the bar as the band's show ended a little after midnight.

Daman Snider, co-owner of Nite Owls, didn’t want to talk about Shelton, but said the health department had not contacted him. The bar is now closed in response to the governor's emergency order.

The next day, March 2, Shelton was at the lodge for the bi-monthly meeting of the Moose Women. The gathering started at 6:30 p.m. and lasted an hour. The 12 women at the meeting were between the ages of 55 and 75, Watkins said, which is a demographic group at increased risk of adverse effects if infected by the coronavirus.

Four club officers were seated at a table and eight members — including Shelton — sat in folding chairs facing the table as members gave updates on bills that were due and upcoming events. Shelton reported she was planning a steak dinner fundraiser and a celebration of life for someone who had just died.

Roxanne Jacobs, another friend of Shelton, was cooking hamburgers in the lodge's kitchen. A bartender was also working and a couple of other lodge members milled about. As the meeting was winding down a few members of a dart league trickled in for a tournament.

Watkins and three others at the lodge with Shelton that night said they have not been contacted by the health department. But all of the women have since self-quarantined, to one degree or another, Watkins said, though some didn't isolate themselves until after learning of Shelton’s positive diagnosis nearly a week after she went into the hospital.

“I’m pretty healthy, so I’ve been lucky” Watkins said. “The Good Lord takes care of dumb animals and me, I guess. But I’m following the government guidelines.”

Another woman at the meeting was Gwen Mattingly, 62, who is quarantining in her “big house” in Beech Grove with her boyfriend.

“We keep our distance, and I’m not letting any of my family over,” she said. “We have plenty of food here, and I don’t eat too much. And we never went out that much anyway.”

Moose members closed down the building after learning of Shelton's condition and concluding she could have coronavirus. A March 14 post on the lodge's Facebook page describes "sanitizing and sterilization" efforts by members who volunteered to help. It says the work began "even prior to receiving news of the diagnosis about Birdie having the CORONAVIRUS on Thursday March 12th. The last time she was in the lodge was March 1 and 2nd. The lodge is closing down to ensure safety of our members."

Shelton continued working at Enterprise, where she was a part-time driver for the company's Indianapolis hub. Shelton assigned drivers, picked up and dropped off vehicles, and drove a passenger van that shuttled other drivers to sites around the state, spokeswoman Sara Miller said in an email response to questions from IndyStar.

Her last day at Enterprise was March 4. At that time, Miller said, Shelton "was not showing any symptoms ... and her family confirmed she did not develop symptoms until after her last day in the office."

The statement said Enterprise "became aware of her positive diagnoses March 14" from Shelton's family and immediately contacted local health officials for guidance. The company also talked with workers who could have had close contact with Shelton "as defined and guided by the Health Department," Miller said.

Miller said all employees who worked in the same driver pool were, "out of an abundance of caution," instructed to self-quarantine for 14 days. The company has also taken additional steps to sanitize all offices and vehicles, including dashboards, steering wheels, center consoles, cup holders, seats and other interior parts.

Some of Shelton's friends said they suspect she picked up the virus at work but acknowledged that is only speculation. And without tracing, the source may never be known.

What public health agencies say they do

When Indiana State Department of Health officials learn of a positive COVID-19 case they send that information along to the county health department, which can then do a background trace, Megan Wade-Taxter, a spokeswoman for the state health department, wrote in an email

The local agency can then investigate where the patient spends most of their time, as well as special events the person may have attended, said Curt Brantingham, spokesman for Marion County's health department.

“The goal is to find those who were most at risk for being exposed to an infected person,” Brantingham wrote in an email. “Any close contacts, or if a person thinks they may have come into contact with an infected person, should self-quarantine for 14 days and monitor symptoms. They should contact a health care provider if they develop the symptoms.”

Indiana State Department of Health officials told IndyStar it can be difficult to find out where patients have been recently, because patients might be too sick to recall or unable to talk because they are on respirators or breathing tubes.

“In those instances, the case investigator has to rely on documentation that may be incomplete or family and friends whose knowledge or memory may be unreliable,” Wade-Taxter wrote in an email.

In such cases, members of the public are essentially asked to protect each other. Those who contract the disease should contact friends. Those who think they may have had contact should consult a doctor.

"Any close contacts, or if a person thinks they may have come into contact with an infected person, should self-quarantine for 14 days and monitor symptoms," Brantingham wrote in an email. "They should contact a health care provider if they develop the symptoms."

Different degrees of secrecy

What specifically Marion County is doing to reach out to those who have potentially had contact with a positive case of COVID-19, however, remains a mystery, because officials refused to detail those efforts.

The federal medical privacy law, known as Health Insurance Portability and Accountability Act, or HIPAA, prevents agencies from publicly releasing the patient's identity, which would be a more expedient and less time-consuming way to contact them.

IndyStar sent a list of detailed questions to the county health department about what residents in close contact with a confirmed COVID-19 patient can expect from the department, what the department does with the information after they’ve collected it from a patient and whether their employees are involved in collecting information.

IndyStar also asked if the department reaches out to churches, restaurants and workplaces the patient might have visited — and whether the health department offers those establishments any guidance.

The spokesman did not answer those questions and instead issued a statement saying, in part, "Marion County Public Health Department always does as much contact tracing as possible based on the information from patients and their families."

A similar list of questions was sent to the state health department but was likewise unanswered.

"When ISDH is notified of a positive test, we notify the local health department, which conducts the case investigation," a spokesperson responded in an unsigned email. "We cannot speak for how a local health department conducts its investigation. However, if ISDH is doing contact tracing, we follow HIPAA in what we disclose."

Johnson County, however, handles HIPAA differently.

In that county, which has 14 cases and one confirmed death as of March 21, health officials have contacted employers, family and friends for all cases and advised them, said Betsy Swearingen, environmental health specialist for the Johnson County Department of Health.

"That includes day cares, schools and churches where they might have been," she said.

She said patients are asked if they want to sign waivers to the federal health privacy law that allows officials to use their name with those contacts so they know specifically who they are talking about. She said officials have not detected any clusters but were able to link the person who died to a coronavirus case in Hendricks County.

Medical secrecy can be an obstacle

While privacy laws make sense in most everyday cases, like hospitalization for drug overdoses or suicide attempts, some experts say an entirely different balance is needed during a public health emergency,when sharing information is a vital weapon against spreading disease.

"When we have something like a hurricane, or a pandemic such as this, you just need to recalibrate that balance slightly," said Nicolas Terry, a professor at the Indiana University Robert H. McKinney School of Law in Indianapolis. "And you take away just a few of the patient's rights and give a little bit of flexibility to the providers.”

Federal medical privacy laws do not inhibit a public health agency from contacting potentially exposed individuals through community tracing, experts told IndyStar.

Even with HIPAA limits, health care workers can still trace possible exposures, said Lawrence Gostin, a Washington, D.C., lawyer and director of the World Health Organization Collaborating Center on National & Global Health Law. "The contact would be informed of the risk, but not the person's name," he said. "The balance is not hard."

Box, the state health commissioner, said at a news conference Thursday it is also incumbent on people who are diagnosed with COVID-19 to inform those with whom they have been in close contact in recent days. She said that the state would continue to do contact tracing, but with more private practitioners ordering tests, state officials are now concentrating on informing people such as health care workers and workers in long-term care facilities that they have had an exposure.

Terry, the IU professor, said it doesn't need to be that complicated.

"The federal government can waive certain provisions," Terry said." We saw this during the Katrina catastrophe in the south. And we already have two waivers that have been issued by the federal government with regard to the COVID-19 outbreak.”

“It is always a balancing question. It's just there are some things during emergencies where the balance kind of shifts the other way."

Call IndyStar reporter John Tuohy at 317-444-6418. Email at john.tuohy@indystar.com and follow on Twitter and Facebook.

Contact IndyStar data reporter Emily Hopkins at 317-444-6409 or emily.hopkins@indystar.com. Follow them on Twitter: @indyemapolis.

Contact Tim Evans at 317-444-6204 or tim.evans@indystar.com. Follow him on Twitter: @starwatchtim.