State and county health officials struggled in the early weeks of Oregon’s coronavirus outbreak to identify, contact and monitor everyone in close proximity to known COVID-19 patients, top public health officials acknowledged this week in interviews with The Oregonian/OregonLive.

The weeks before Gov. Kate Brown issued a stay-home order March 23 marked a crucial opportunity to slow the spread by identifying people potentially exposed to a confirmed infection and telling them to stay home.

But the health officials in charge did not communicate with all Oregonians who had a positive test let alone all of their close connections, the newsroom found.

And after publicly touting the monitoring system as a way to keep tabs on the spread of coronavirus and help protect people, state officials abruptly stopped reporting a key set of tracking numbers without explanation.

State health officials now refuse to say how many people were ultimately traced and placed under monitoring or how many of those people from early weeks were asked to isolate at home.

Shannon Liedtke, for example, still has not heard from public health officials.

Liedtke said she tested positive for COVID-19 last month but never received a phone call from state or county officials asking for a list of people she could have unknowingly infected, who in turn could have spread the virus to others.

Liedtke is a registered nurse. She provides hospice care to dying Oregonians.

“Maybe I fell through the cracks,” she said. “I don’t know. I was surprised no one followed up.”

That Oregon’s tracking system became overwhelmed so quickly foreshadows the need for an even more robust effort when coronavirus cases eventually start falling, giving the state and nation a second chance to control the highly communicable virus before it can rebound.

Dr. Paul Cieslak, Oregon’s medical director for communicable diseases, acknowledged that many counties lacked the resources to keep up their monitoring as cases grew. State officials privately dialed back expectations for county health departments sometime in March and this week said monitoring is generally no longer required.

“It’s sort of been an accumulating consensus as we would hear from more county health departments that they’re getting overwhelmed, they’re not able to follow up on cases,” Cieslak said. “Washington County, for example, was hit very hard.”

In many ways, Oregon is no different than other states overtaken by rising infections and the stark reality that the coronavirus was too widespread to contain through traditional public health defenses.

At some point, Cieslak said, aggressively identifying people for monitoring is no longer worthwhile given how many people are becoming infected from unknown sources.

“If there’s a much larger number of undiagnosed patients out there, then what are we really accomplishing by following up on the handful that we tend to hear about?” Cieslak said.

It is unclear what impact Oregon’s tracing efforts and associated challenges ultimately had on efforts to suppress the coronavirus.

Dr. Dean Sidelinger, Oregon’s state health officer and epidemiologist, said it is entirely possible state and county health officials missed some tracing cases, leaving people to spread the virus and infect others.

No public health investigation of this magnitude identifies everyone, he said.

But Sidelinger said Oregon’s tracking efforts were strong and, coupled with more aggressive social-distancing and stay-home directives since, have hopefully blunted the growth rate of new infections as recent statistical models appear to show. Oregon joined California and Washington as some of the earliest states to adopt stay-home orders nationally.

“I don’t think it’s contradictory to say that I’m proud and confident about what our public health response was early on,” Sidelinger said. “And that, yes, there was a point where the cases did kind of overwhelm us and that some prioritization had to take place.

“That’s part of the evaluation of our response to the outbreak.”

Monitoring numbers disappear

The Oregon Health Authority initially expressed confidence in its ability to keep the virus in check after identifying the state’s first case Feb. 28.

An elementary school janitor who worked in Lake Oswego but lived in Hillsboro had been hospitalized with COVID-19 despite not having ties to anyone who had been infected or who returned from China, where the outbreak originally began.

That meant coronavirus was already circulating in Oregon undetected.

Rather than immediately responding with long-term school or business closures, state officials directed county health departments to identify all close contacts of COVID-19 patients through a time-tested but time-consuming epidemiological process called contact tracing.

After identifying an infection, health workers are supposed to find that person’s close contacts. Officials then need to reach out to them within 72 hours with information about their potential exposure, guidance about whether isolation is necessary, and keep tabs on those people in case they develop symptoms.

State health officials had announced their plan to keep Oregonians informed about coronavirus just four days before they discovered the first infection. They launched a website and promised figures to help instill public confidence.

The Oregon Health Authority pledged to report numbers in two categories: persons under monitoring (PUM) and persons under investigation (PUI).

Persons under monitoring were Oregonians without symptoms who had been to mainland China or had close contact with a person known to have coronavirus. Close contact was considered within 6 feet of someone for a prolonged period or being coughed or sneezed on.

Persons under investigation met the same criteria – only they had symptoms of a fever, cough or shortness of breath – and would be tested for the virus.

“People need to understand their real risks and feel confident the state and their local health departments are working hard to protect their health,” Lillian Shirley, Oregon’s public health director, said in a statement Feb. 24. “We hope sharing these PUM and PUI data will help do that.”

Oregon stopped sharing its monitoring data three weeks later.

The last publicly available tally, from March 16, showed Oregon had identified 51 coronavirus infections that needed tracing and 733 Oregonians who were under monitoring. Of those, more than half had cleared their two-week watch periods without developing symptoms, while 352 were still being actively monitored.

State health officials explained the removal in a brief statement posted online, noting that Oregonians were becoming infected from unknown sources and the governor had closed restaurants and banned gatherings larger than 25 people.

When The Oregonian/OregonLive pressed for a more thorough explanation, Jonathan Modie, a spokesman for the health authority, acknowledged in an email that “state and county public health epidemiologists don’t have the resources to track every person as a PUM who may have been exposed to a case.”

Labor intensive

The cases were rising too high, too fast, said Cieslak, the state director of communicable diseases.

Each infection generates an undisclosed number of new persons to monitor, requiring more work and identification. Cieslak said public health officials ultimately started making phone calls on behalf of some desperate counties.

“When a county calls us up and says they’re overwhelmed, and we’re not able to fill in the gap for them, I’ve basically told them over the phone, do what you can, and focus on the high-risk people,” he said.

In 2019, the most common disease requiring intensive tracing was salmonella, with 549 cases, he said. COVID-19 eclipsed that in one month.

“It’s fairly labor intensive,” he said, “and so it’s difficult to do.”

The Oregon Health Authority officially revised its written guidelines March 23, telling counties to focus on household contacts of people with known infections or other high-priority populations. The state further scaled back expectations for monitoring this week.

Determining the precise impact of Oregon’s early tracing efforts and associated challenges is difficult.

Inadequate testing nationwide makes comparisons problematic, but Oregon now appears to be doing reasonably well. Oregon has documented fewer COVID-19 cases and deaths per capita than many states despite identifying its first case earlier than most.

The true number of coronavirus infections statewide remains unknown, however.

New modeling suggests total infections – both identified and unidentified – grew five-fold, from about 250 to 1,250, in the roughly three weeks between Oregon’s first known case and the governor’s stay-home order.

The tally could reach 4,000 infected Oregonians by early May, according to the projections by the Institute for Disease Modeling in Washington. As it stands, Oregon through Friday has identified 899 infections and 22 people have died.

Washington County, Oregon’s current epicenter, reported more than a quarter of all known infections.

No phone call

Registered nurse Shannon Liedtke, 44, said she tested positive for coronavirus March 20. But two weeks later, Liedtke (pictured with her family) said no one from public health had asked her to identify her close contacts.

COVID-19 hit Shannon Liedtke fast.

The registered nurse had been out for lunch March 11 when she noticed a tickle in the back of her throat and started to feel stuffy. By the next morning, Liedtke said she had shortness of breath. She got tested for coronavirus a day later.

Liedtke said a physician’s assistant from a Providence facility gave her the positive result March 20. Liedtke said she was told to expect a call from public health officials in Washington County, where she lives, to find out who she had been in contact with.

It never came.

Liedtke said she decided to call the county health department the next day but could not speak to anyone because it was a Saturday. She said she followed up that Monday and Tuesday, leaving her number both times.

Someone from Washington County finally returned the call Tuesday, she said, but only to see what questions Liedtke had.

Liedtke said she was told Washington County did not have her positive test result and someone would follow-up to ask about her close contacts after it arrived.

“But no one has ever done so,” she said.

Liedtke, 44, does not know how she got infected.

There was a suspicious illness in her daughter’s classroom. She returned home from a trip to Hawaii in early March. She was also in and out of facilities in Washington and Yamhill counties a few days after that, visiting nursing homes and patients.

“Those are the possibilities,” she said.

Liedtke still has not heard back from Washington County and wonders if health officials still have not received her test results through official channels, two weeks later. By her own estimate, Liedtke said she may have been in close contact with about a dozen people, including her immediate family, just before she fell ill.

She worries she spread the virus to two of her in-laws who are now sick.

Wendy Gordon, a spokeswoman for Washington County, said health officials conducted interviews or followed up on every single known COVID-19 case through March 22.

“We do have a person in that timeframe who was unreachable and who we sent a certified letter to,” Gordon wrote in an email. “This may or may not be the person who contacted you. However, regardless, we would like to talk to her about contacts and also to address any possible gaps in our system.”

Liedtke said she never received a letter from the county. After consulting with doctors and her employer, Liedtke said she is symptom-free and plans to return to hospice work this weekend.

“I am trusting that the info I am getting is accurate, that I am no longer a danger,” she said. “I will be wearing a mask during my visits, just in case.”

Army of tracers

It is impossible to know how many times Oregon and county health authorities did not perform full contract tracing when it was still expected.

The numbers are kept inside a state database. The Oregon Health Authority refuses to disclose them.

“I can’t comment on specific cases or the specific investigations,” said Sidelinger, the state epidemiologist.

The health authority also refused to disclose how many people have been under monitoring since the outbreak began. A spokesman said the count is “unreliable” because of changes about how counties investigate cases.

Challenges continue to persist.

Michelle Spencer said health officials from Washington County called her last week after her mother, Barbara Spencer, 77, was hospitalized at Providence St. Vincent Medical Center with COVID-19. The call came four days after her mother tested positive for coronavirus, she said.

Spencer said she went into great detail about her mother’s close contacts and travel.

A Washington County official called back again this week trying to rehash much of the same information, Spencer said. Frustrated with the inefficiency, Spencer said she hung up.

“If you are going to contact families who are going through this, if you have to spend an hour or more on the phone, that’s fine,” she said. “But do it and be done with it because people are dealing with ‘do I take them off a ventilator?’”

Gordon, the Washington County spokeswoman, said she could not immediately respond Friday night as officials were addressing new federal guidance recommending that all Americans wear face masks in public.

In the months ahead, the United States will need to do robust contact tracing and widespread testing as officials eventually loosen social distancing efforts, public health experts say. Those efforts will help determine how America is able to move forward.

Dr. Tom Frieden, the former director of the Centers for Disease Control and Prevention, called contact tracing “enormously important” in a Thursday call with reporters. Frieden cited China’s effort to trace 700,000 contacts.

“We need an army of contact tracers in every community of the U.S. to be ready to find every contact and warn them to care for themselves and stop spreading it to others,” Frieden said.

Some countries, including South Korea, Taiwan and Singapore, have relied on technological solutions, including smartphone tracking apps or websites that warn people if they have come into contact with someone who tested positive. They allow swift notification, while risking personal privacy.

Efforts are underway in the United States to develop similar apps, including one project in Seattle, that aim to maintain privacy and keep health data secure.

Dr. John Townes, medical director for infection disease and control for OHSU Health, said it will take creative thinking to make contact tracing effective. Townes pointed to Taiwan as an example where tracing worked.

If someone showed up sick, the centralized government could quickly determine whether they had been on a flight and contact other travelers. The United States does not have the same system or capabilities and has a far different approach to civil liberties.

“We have a public health system that is not designed to handle this kind of situation,” Townes said. “It will be quite difficult to do the kind of contact tracing that would be needed to bring an end to the outbreak.”

Shane Dixon Kavanaugh contributed to this report.

-- Brad Schmidt; bschmidt@oregonian.com; 503-294-7628; @_brad_schmidt

-- Noelle Crombie; ncrombie@oregonian.com; 503-276-7184; @noellecrombie

-- Rob Davis; rdavis@oregonian.com; 503-294-7657; @robwdavis

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