Ouch!

Why are county health officials in West Nile Denial?

Photo by Geoff Du Feu/Getty ImagesState officials just added a 16th victim to the list of West Nile Virus deaths, almost all of them in Southern California. But public-health officials in Orange County are claiming that the mosquito-driven epidemic has peaked and shows signs of waning. Now another vector, the Asian tiger mosquito, has captured the front pages and for the moment replaced the West Nile epidemic as the latest peril de jour.

But even as West Nile deaths are relegated to boxed stories on the back pages next to the mattress ads and legal notices, the numbers of West Nile Virus (WNV) cases and deaths continue to rise across Southern California.

So before you hose off the DEET and resume your early-morning power walks, consider the possibility that your preeminent public-health agency—sentinels of public safety—may themselves have little more than a hazy picture of this epidemic still in our midst.

The Orange County Health Care Agency (HCA) is charged with identifying every WNV case that arises in the county. Along with the Orange County Vector Control District, HCA is the first and, in the case of this epidemic, the last line of defense against any vector-borne virus that enters the county.

So it's surprising and, sure, discomforting to talk to Dr. Hildy Meyers and learn HCA's head epidemiologist has no idea how widespread the virus is across the county, can't estimate how many people might be exposed thus far, and won't discuss the cases or how many of them may have been medically predisposed to the virus.

What we do know is this: HCA claims only 27 confirmed cases of WNV in Orange County out of a population of 3 million people. Compare that number with those of Los Angeles County—with more than seven times the number of cases (200) in a population three times Orange County's—and San Bernardino County—with a population slightly smaller than OC's, with 180 cases.

The numbers suggest that neighboring Orange County—with two major lowland marsh and flood plains—has managed to more or less dodge the mosquito bullet.

Has it?

"That's a good question," admits HCA spokesman Howard Sutter. "There should be a commonality of numbers. It's not like we are separated by great distances or natural boundaries."

Sutter says it's possible that early abatement and public-awareness efforts slowed the vector's advance. Yet we know from OC Vector Control data that infected bird counts—a precursor to disease outbreak among humans—were just as high here in Orange County as in Los Angeles, San Bernardino and Riverside counties. The bird deaths indicated a broad distribution of the virus itself, setting off media alarms earlier in the spring, and let us know that yes, there was an epidemic and it was coming our way.

Then Sutter said something that piqued my curiosity: "Our low numbers may also be because we are really not as directly involved in patient care to the degree Los Angeles County is. Without a system of clinics and county hospitals . . . we just don't have the same data."

Could the epidemic's remarkably low profile in Orange County have something to do with the way county health officials identify potential victims?

The answer, it seems, is yes. It's the county Health Care Agency that establishes the criteria based on the severity of symptoms for who gets tested for WNV; the higher the bar—and the county's bar is very high—the fewer who will be tested. It's the HCA that refers patients to clinics or emergency rooms. And it's the HCA—the county's primary surveillance and assessment delivery system—that ultimately decides what information goes up the chain of command, information on which major county health policy is determined.

That delivery system broke down for a time last month when news of the first WNV-related death in the county, a 57-year-old Fullerton man, somehow failed to reach top county health authorities for three weeks. In that critical time, county officials were in the dark about the approaching WNV epidemic and when and where it would first turn up.

The delay troubled state Assemblyman Todd Spitzer (R-Fullerton) and prompted him to call a press conference. "It is time for the county to treat this as a very dangerous virus, and not like it's a common cold," he said. As a member of the Assembly West Nile Virus committee, he demanded that OC hospitals report WNV-related patient information to the Orange County HCA promptly, a practice already in effect in hospitals in Los Angeles and San Bernardino and which became an HCA requirement only after the lapse in reporting came to light.

But that doesn't mean that Spitzer is giving HCA a clean bill of health. He believes the cracks in the official response to WNV run deeper than mere delays in hospital notifications.

"This is not a new disease," he said. "It's a tornado we should have seen coming. And now that it's here, we're still not doing an adequate job of compiling data from all corners of the county. We are clearly underreporting—intentionally or unintentionally—and it is keeping us from getting a clear picture of this epidemic even now."

West Nile Virus was carried around the Nile River valleys of East Africa in the bellies of mosquitoes, first appearing in the U.S. in New York in the summer of 1999 and in Washington, D.C., shortly after. The Centers for Disease Control has tracked the epidemic's westward migration every year since. It's a killer disease, but early reports suggested that only the elderly and the immune-compromised were at risk of serious illness. Now there's a different story. The average age of a confirmed WNV case in California is just over 50, and some have been as young as 18. Even here in Orange County, where the only statistical picture we can get is from an extremely small pool of confirmed cases, more than half of all victims are under the age of 55.

Unfortunately, public knowledge in Orange County stops there. The HCA does not make public specific or even general descriptions of patients' medical conditions. Nor does it state the health of the infected before exposure—preconditions that may have contributed to the illness that could shed some light for all of us on who gets sick and who doesn't.

There's disturbing evidence gleaned from Los Angeles and San Bernardino county records indicating that not only do confirmed cases appear to be getting younger, but that many of the confirmed WNV cases also had no particularly compromising preconditions before contracting WNV.

Why is that valuable public information not available to the public from our own county public-health agency? HCA officials cite privacy issues and say the agency has yet to sift through and "assess" all the cases to date.

All 27? San Bernardino County, with a smaller population, has nearly 10 times as many confirmed cases, yet it doesn't seem to have a problem assessing its caseload. And as for privacy, no one's asking for names.

Worse is that if you think you may have WNV—with the attendant headache, stiff neck, swollen glands or rash—you can't just call the HCA and expect them to test you. Dr. Meyers says her agency conducts no walk-in testing of its own.

"We are set up to test," Dr. Meyers confirmed, "but we basically work through physician referrals. There is no systematic testing of humans going on. . . . We just don't have those data sources."

Los Angeles County does. With 13 public hospitals and a well-established safety net of county-run, publicly funded, low-cost walk-in clinics accessible to all, Los Angeles County Health Services is able to take advantage of a broad sampling of WNV data from the general population, allowing officials there to connect the dots to form a picture of this newly arrived epidemic.

"Of course, we don't have a complete picture yet," said LA communicable-disease specialist Dr. Rachel Civen, "but we have acquired a lot of information, and we are beginning to see the scope of this epidemic more clearly."

For example, Civen says, there's preliminary evidence to show that the epidemic became more quickly and broadly dispersed geographically than expected. There's statistical evidence the virus has hit younger and healthier victims to a greater degree than documented elsewhere. Plus, Los Angeles County makes public the type and degree of WNV-related illness, revealing that nearly half of its confirmed cases developed acute meningitis or encephalitis (swelling of the brain).

Los Angeles County officials are also looking outside their own system of services to complete the picture. Recently, blood-donation banks were tested for WNV contamination, and health officials found that the percentage of WNV-infected donors was one in 1,000 in Los Angeles County and approximately one in 400 in San Bernardino County. That's consistent with the general assessment of Los Angeles County Director of Public Health Jonathan Fielding: "For every person with WNV, there are many, many more who are never reported. We estimate there are thousands of such cases in Los Angeles County."

Orange County HCA has yet to take a similar assist from the Red Cross in Orange County to help determine the extent of the WNV presence here. With technically no county hospital or publicly run clinics of its own, Orange County relies on a hit-and-miss system of physician referrals, overburdened and increasingly understaffed private ERs, and a reluctant string of private health-care clinics to piece together a picture of the current WNV epidemic.

If you, an Orange County resident, should be so unfortunate as to find yourself with a fever, headache, stiff neck, rash or swollen lymph glands, you can call the Orange County HCA. They won't test you, of course. They won't even see you. They will, however, in an engagingly professional manner, refer you to your nearest emergency room, where the chances are fair to poor they will test you—unless, of course, your symptoms are advanced enough with an acute meningeal infection or brain-swelling encephalitis.

And there's the catch. Each county establishes its own testing guidelines for WNV screening. In Los Angeles County, prolonged fever, swollen glands and a severe neck ache will get you in the door for a blood test at a county facility, hospital or qualified clinic. But to get a WNV blood test in Orange County, you've got to show up with full-blown encephalitis, aseptic meningitis, acute flaccid paralysis or a full seven days of spiking fever. In other words, you're already cooking brain cells, and you probably belong in an ER anyway.

If, on the other hand, you are still standing and relatively coherent, HCA's patient referral "hot line" will provide you with a list of what they're calling either hospital or community-based public health clinics. And you will be given the distinct impression these are county clinics that will in fact screen you for WNV.

Don't count on it.

I contacted every one of the so-called "public health West Nile clinics" on HCA's list and was told by receptionists, nurse practitioners and supervisors that I was misinformed: they provide no WNV services of any kind. The only advice they had for me: "Go find an ER."

The last HCA-referred clinic on the list I called was a family medicine clinic in Westminster. I decided to play the sympathy card and told them I thought my brain was "swelling up fast" and I needed to come in immediately. Their response? "Call 911," where I would end up—you guessed it—at an ER.

Most of these local clinics, it turns out,are part of the privately run Coalition of Orange County Clinics, which managing director Joan Henry describes as a kind of "ad hoc health-care safety net" for the primary-care needs of mostly children and poor families.

"We don't even screen acute or life-threatening diseases like West Nile Virus," Henry explained.

"The Coalition of Clinics serves more than 186,000 walk-in patients per year. We are a funnel for all kinds of primary-care needs, but we were never meant to be urgent-care facilities for acute or even mild West Nile Virus cases. We have no mandate from the county, no memorandum of understanding to screen these cases. It's inappropriate for the county to send these cases to us when all we can do is refer them on to an emergency room for screening."

Which is not to say that Henry and the 31 clinics and 17-group coalition she represents across the county couldn't ramp up to take on the urgent need for WNV screening even if the county asked.

"It wouldn't be the first time we've stepped in to help the county out in a time of public need," she said. "But nobody's asked us."

Between private clinics that don't screen for WNV and ERs that won't test unless you're in the acute stages of illness because the diagnostic criteria is so high, is it any wonder confirmed cases of WNV in Orange County are so low? It's a game of medical musical chairs played out every day, not only for West Nile victims, but also for thousands of the uninsured and the underinsured in the county who, in the end, usually end up in the same place, lying on a gurney for hours in an ER, the health-care provider of last resort.

Henry says Orange County doesn't have what she calls the kind of "collaborative system of care you find in Los Angeles. There is the perception at the higher levels of [Orange County] government that this is such a wealthy county we don't need a publicly run system of full-care clinics, a managed-care approach to low-cost or no-cost [medical] services . . . or even a county hospital, for that matter," Henry said. "So the process of growing one in this county has been very slow."

UC Irvine Medical Center (UCIMC), a University of California-run teaching hospital, is as close as this county gets to a truly public "county" hospital. But taking on that task has proved too fiscally burdensome over the years, and UCIMC's handlers have recently backed away from that dubious title, in the services it provides, and in the fees it collects. The idea of truly public county clinics has also proved politically, if not financially, unworkable over the years. This is still Reagan Country.

If anything, the trend, even for the Orange County HCA itself, has been to cut services. The most recent example of that is the agency's decision to drop tuberculosis-screening programs from its list of public services.

But don't lay all of the county's health-delivery problems at the doorstep of its HCA, HCA administrators or medical personnel. Failure to follow through with an aggressive WNV health-care response begins with a county Board of Supervisors that has consistently failed to adequately fund a shrinking health-care system in this county at a time when increasing public-health demands are being placed on it. There are more than 500,000 uninsured living and working in Orange County according to a 2003 UCLA/California health-insurance-industry study. And that does not take into account the underinsured. How many of these people will have the wherewithal and the tenacity to seek and find WNV testing should they need it in a health-care environment that appears to be more obstructive than inclusive? With almost one-fifth of the county population under the radar of a health-care policy that does not account for them, how can the agency entrusted to monitor emerging health threats across the county develop a picture of this epidemic that is anything but fuzzy and incomplete?

Henry states the obvious—and frightening—when she says, "There's definitely a hole in public health care here in Orange County."

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