It wasn't yet clear if the patient – who has not made his identity public – had the coronavirus. Nasal swabs taken at the clinic were in transit to the Centers for Disease Control and Prevention in Atlanta. But health district staff weren't taking any chances, and Curtis was tasked with the first of a now mundane practice: contactless delivery.

[ Katie Curtis, prevention services director at Snohomish Health District : LinkedIN = [HL007E][GDrive]  ]

• Katie Curtis, prevention services director at Snohomish Health District, was manning the after-hours phone line that Sunday when a local clinic called to report a man with flu-like symptoms and a history of travel to Wuhan.

• [....]

• On Monday, [Katie Curtis] pulled up outside the patient's home and dropped off a thermometer, some paper face masks and other supplies. She knocked on the door and left. "This was right before" it was confirmed, she said. "We were thinking, there’s something going on, things are not right."

History appears to be repeating itself.  Almost 20 years ago, a virus appeared in wildlife markets in southern China, and it was unlike any the world had seen. It was winter 2003, and sufferers complained of fever, chills, headache, and dry coughs—all symptoms you might expect during cold and flu season.

But this condition would progress into a lethal form of pneumonia, one that left honeycomb-shaped holes in people’s lungs and generated severe respiratory failure in a quarter of patients. While most infections only spread to three additional people, some of the afflicted became “superspreaders”—patients who unwittingly transmitted the disease to dozens at a time. By the time the epidemic of severe acute respiratory syndrome (SARS) ended seven months later, more than 8,000 cases and 800 deaths stretched across 32 countries.

That’s why international officials are now concerned over a new, SARS-related virus that has emerged in central China. The disease has spread to major cities like Beijing, Shanghai, and Shenzhen—as well as to neighboring Taiwan, Thailand, Japan, and South Korea—in just three weeks. On Tuesday [which would be Tuesday January 21 - the very same day that this article is published], the Centers for Disease Control and Prevention (CDC) reported the first U.S. based case in Washington State.

“Human-to-human spread has been confirmed [but] how easily or sustainably this virus is spreading remains unknown,” [Dr. Nancy Messonnier (born 1965)], director of the National Center for Immunization and Respiratory Diseases at the CDC, said in a press conference where she announced the development of a rapid genetic test for the Wuhan virus. “Right now we are testing for this virus at CDC, but in the coming weeks we anticipate sharing these tests with domestic and international partners.”

As of Wednesday [this would be January 15 of 2020], nearly 450 cases have been reported globally along with nine deaths, and the World Health Organization plans to hold an emergency meeting on Wednesday to decide if the outbreak represents a public health emergency of international concern. Epidemiologists suspect thousands of cases likely exist. Last Friday [this would be January 17 of 2020], the CDC announced that screening for the new virus would begin at three major U.S. airports, but the first U.S. patient arrived before this surveillance had even begun.

As with SARS, all of this fuss appears to have emerged due to wildlife trade, and virologists aren’t surprised.

“If we were to shut the wildlife markets, a lot of these outbreaks would be a thing of the past,” says [Dr. Walter Ian Lipkin (born 1952], director of Columbia University’s Center for Infection and Immunity, whose lab worked with Chinese officials to develop early diagnostic tests for SARS.

That’s because both SARS and the new outbreak are zoonotic, meaning these diseases started in animals before spreading to humans. Zoonotic diseases rank among the world’s most infamous. HIV, Ebola, and H5N1 influenza, for example, all percolated in wildlife before close interactions with humans spawned international outbreaks. With SARS, food preparers and people who handled, killed, and sold wild animals made up nearly 40 percent of the first cases. The earliest episodes were also among people who were more likely to live within walking distance of wildlife markets.

Reservoir bats

Health officials first reported the new outbreak on December 31, citing a flush of pneumonia-like cases connected to a seafood market in Wuhan City, a transit hub in central China with more than 11 million inhabitants. But CNN reported that the “South China Seafood City” market in Wuhan peddled more than seafood, obtaining video that allegedly shows racoon dogs and deer housed here inside small cages.

But why might such conditions create a breeding ground for zoonotic diseases?

“When you bring animals together in these unnatural situations, you have the risk of human diseases emerging,” says [Kevin James Olival (born 1975)], a disease ecologist and conservationist at the EcoHealth Alliance. “If the animals are housed in bad conditions under a lot of stress, it might create a better opportunity for them to shed virus and to be sick.”

This interplay between virus and animal can also help trace the source of an epidemic. Viruses mutate as they spread and multiply, a trait that virologists and wildlife biologists can use to trace the evolution of a disease, even if it hops between animals.

SARS and the new virus behind the Wuhan outbreak are highly related, both belonging to a family called coronaviruses. Coronaviruses are a large family of viruses, some of which cause illness in people, while others circulate among animals, including camels, cats, and bats.

Four months after the SARS outbreak started in early 2003, research teams in Hong Kong tested racoon dogs, palm civets, and badgers and discovered close relatives of the SARS coronavirus—the first evidence that the disease existed outside of humans.

The discovery kicked off a rush of viral sleuthing in wildlife, which would ultimately point to Rhinolophus horseshoe bats in China as the likely source of SARS. Global surveys would ultimately reveal that the ancestors and relatives of SARS had been circulating in bats across Asia, Africa, and Europe for years. Bats are now considered the original source of all major coronaviruses.

“The genetic sequence of the virus itself can lead you back to the source,” Olival says. “In Wuhan’s case, the closest match is other SARS-related coronaviruses that are found in bats.”

Wildlife surveys conducted by EcoHealth Alliance in China and elsewhere in Asia show the highest prevalence of coronaviruses tend to be extruded by animals through feces, or guano in the case of bats. Coronaviruses not only spread via the air and the respiratory tract, but also if fecal matter comes in contact with another creature’s mouth. Bats aren’t exactly clean, so if one nibbles on a fruit, the food may get contaminated with fecal matter. If the fruit drops to the ground, then it can serve as a viral crossover point for farmed animals like civets.

Camels, mammals, and vaccines

So far, it appears that animal-based coronaviruses leap into humans and cause severe illness only on rare occasions. SARS represented the first documented occurrence of a coronavirus spillover, and it was followed by Middle East Respiratory Syndrome, a similar but distinct virus that sprouted in Saudi Arabia in 2012 and also spread internationally.

The MERS saga reinforced the animal story told by SARS. The MERS coronavirus hailed from bats but used domesticated mammals—in this case, camels—as a bridge for reaching humans. The initial case of MERS involved a 60-year-old man who owned four companion camels, which slept in a paddock adjacent to his house.

Cutting back the wildlife trade has a win-win effect of both protecting species that are harvested from the wild and of reducing spillover of new viruses.

A 2014 study by Lipkin’s lab and zoologist Abdulaziz Alagaili at King Saud University found antibodies against MERS—a telltale sign of infection—in camel blood samples dating back to 1993. The MERS virus had circulated for more than 20 years without anyone noticing.

“We did work in two slaughterhouses in Saudi Arabia, where people were slaughtering camels,” says Lipkin. “In some instances, they were washing the meat with high pressure hoses before packing it into shrink wrap. You could find MERS coronavirus on meat that was destined for supermarkets.”

Saudi Arabia imports thousands of camels each year from African nations, much of which serves as a food source, especially during the Muslim pilgramige. Biologists found signs of MERS infection in camels hailing from African countries like Ethiopia, Kenya, Tunisia, Egypt, and Nigeria.

Unlike SARS, which emerged and flamed out within a year, MERS became somewhat entrenched in human communities, with cases reported in Saudi Arabia through 2017. But this persistence raised the possibility of developing a vaccine, given there was a consistent population in which to test the effectiveness of such a treatment.

“You could vaccinate the people who have the most common contact with camels, like the bedouins and the people who work in the slaughterhouses,” Lipkin says.

However, a MERS vaccine never materialized despite widespread efforts. As of today, no specific treatment exists for SARS or MERS.

In the absence of a medical remedy, infection control strategies—like washing hands, quarantines, and hygiene—become the sole tools for keeping SARS, MERS, and now the Wuhan coronavirus in check.

The Wuhan outlook

It’s hard to say what people should expect from the Wuhan coronavirus. In the spectrum of epidemics, SARS fell toward the side of worst-case scenarios, while MERS was lethal but much milder in scope.

Most pneumonia-like conditions reserve the worst of their harm for older populations, but SARS was just as likely to punch a hole in the lungs of a young adult as an elderly person; the median age of SARS victims hovered around 40. MERS, by contrast, was mostly severe in patients above 50 years of age, and typically in people with preexisting conditions.

“It's unclear whether or not this [Wuhan] virus is simply going to die out or whether it's going to evolve into something that's more pathogenic,” Lipkin says. “We don’t have any evidence yet of superspreaders, and hopefully we never will. But we also don’t know how long this new coronavirus lasts on surfaces, or how long people will continue to shed virus after being infected.”

At first, officials claimed all of the Wuhan coronavirus involved crossover events from animals, but now the disease appears to be spreading from human to human. On Monday, Chinese officials confirmed that 14 health care workers had contracted the virus, and the patient in Washington reported that he had travelled through Wuhan.

How the Wuhan coronavirus made the final jump into humans will also remain a mystery until China releases more details about what was housed in the now infamous seafood market. Officials closed and cut off access to the market on New Year’s Day. But those clues could help investigators identify which animals might be capable of carrying and spreading the virus both in China and abroad.

The Wuhan outbreak also raises the question of whether wildlife trade needs better oversight, or ought to be shuttered for good.

“One intervention, which is fairly simple, is just reducing the wildlife trade and cleaning up the wildlife markets,” Olival says. “Cutting back the wildlife trade has a win-win effect of both protecting species that are harvested from the wild and of reducing spillover of new viruses.”

Public Health – Seattle & King County, Washington State Department of Health and the Centers for Disease Control and Prevention (CDC) are reporting three presumptive positive cases of novel coronavirus (COVID-19), including one person who died. This brings the total of presumptive positive cases in King County to four.

• Two of the confirmed cases are associated with LifeCare nursing facility in Kirkland, King County, Washington: 

  • • One is a health care worker from LifeCare. She is a woman in her 40s, is currently in satisfactory condition at Overlake Hospital, and she has no known travel outside the United States. 

    • The second case, a woman in her 70’s, is a resident at LifeCare and is in serious condition at EvergreenHealth Hospital. 

• In addition, over 50 individuals associated with LifeCare are reportedly ill with respiratory symptoms or hospitalized with pneumonia or other respiratory conditions of unknown cause and are being tested for COVID-19. Additional positive cases are expected. 

• The death occurred in a patient at EvergreenHealth Hospital but was not a resident of the long-term care facility.

Public Health – Seattle & King County is current working with LifeCare to provide care for ill patients while protecting uninfected patients. The CDC is sending a team of epidemiologists to King County to support our efforts to identify, isolate and test all of those who may be at risk because of these new cases.

Public Health is at the very beginning stages of this investigation and new details and information will emerge over the next days and weeks.

EVERETT, Wash. — On Jan. 20, 2020, a man who had just traveled from Wuhan, China was transferred to Providence Medical Center in Everett with flu-like symptoms.

The next day — one year ago today — it was confirmed that he had the coronavirus, the first case in the United States.

“It’s been a rollercoaster. When the first case was here, we had all naively hoped it was going to be a pretty limited event’” said Providence Everett Chief Medical Officer Dr. Jay Cook.

The Snohomish County man in his 30s had traveled through Sea-Tac Airport on Jan. 15, 2020, and later developed symptoms. 

While the case prompted health officials to screen travelers for the virus, at the time, health officials said there was a low risk to the public. Gov. Jay Inslee said it was “not a moment of high anxiety.”

It would be another month until Washington’s second coronavirus case and the U.S.’s first COVID-19 death were confirmed. But officials later said they believed the virus was already circulating in the United States before the Snohomish County case was identified.

Receiving the first call that a patient at his hospital had COVID-19 was a shock to the system, Cook said.

“When I received the call I was a little apprehensive, but I knew that our teams had been practicing and drilling for managing successfully a highly contagious infection outbreak, as a result of the Ebola event that happened a few years previously,” he said.

Nurse Robin Addison was at home after a long shift at the hospital when her phone rang with the news.

"I wasn't shocked to see the first patient was in Washington, but I have to say I was a little surprised it was in our little town,” Addison said.

She was one of the first medical professionals in the country to treat a patient with the coronavirus. Addison leads the Biocontainment Evaluation and Specialty Treatment Team at Providence.

“I think that in a lot of ways, having that first patient was a stroke of luck for us here because it twigged everybody to what was going on with this virus long before the rest of the world had figured it out,” she said.

Addison's team specializes in containing highly contagious diseases, like COVID-19. They had just finished a training session on disease containment few weeks prior to the case arriving at the hospital.

“Boy, was it ever lucky that we had just had that training with the larger community and talked through some issues that we sort of anticipated would arise,” she said.

They were able to keep the virus from spreading from that initial case. However, within weeks, unrelated cases of coronavirus were being diagnosed throughout the area, and then around the United States.

“I think just managing the uncertainty was one of the biggest challenges. But our team here showed such great resilience and such great flexibility and such a great ability to change and adapt to all this. I think that was a big part of our success,” Cook said. “I couldn’t be more proud. I try to tell people that as often as I can.”

In February of last year, just weeks after the patient was discharged, Addison spoke to KING 5 about her experience.

"There was a big sigh of relief and then a lot of cleanup,” Addison told KING 5 in 2020.

Now she reflects on all that has changed in the last 365 days.

"We had to change the whole way we deliver healthcare; we had to change the way hospitals work. I walked past the gift shop on my way here, it's still decorated for Easter of last year because it's been closed since last March. So, a lot of that changed. It was just way, way bigger than I ever thought it would be,” she said.

Cook has learned a lot as well.

“I think we’re in a much better place with knowing how to manage these patients. Many of the processes that are now standard procedure were not that when we started. We really didn’t know how best to isolate and manage these patients. Many of these treatment and care flows have actually come from our facility and others in the northwest,” Cook said. “We are much aware more of how all aspects of our medical operation impact all patients. Our environmental service, our dietary, our security. All of these have really at one point of another been sort of at the forefront of our response and it really does take a team and a village to have a successful outcome.”

Now Providence has given nearly 9,000 doses of the COVID-19 vaccine.

"I think that gives a real ray of hope here," he said. “Now that the pool of people who can get vaccinated has increased, we're going to really need more supply to provide those vaccines for an increased number of patients."

Addison hasn’t seen her parents in over a year because of the virus. She just got her second dose of the vaccine, and hopes it'll soon bring her the reunion with her family that's been a year in the making.

"I think if we can get the world vaccinated then we will be able to go back to what is normal life. I would love to be able to go to restaurant again, I would live to be able to drive up to Vancouver and see my family,” she said.

COVID-19 Timeline

On Jan. 21, 2020, a Snohomish County man who had traveled to Wuhan, China became the first confirmed case of coronavirus in the United States. At that time, the only cases were in China, where a reported 17 people had died and over 540 have been infected.

At the end of February, a COVID-19 case was identified in a teen in Mill Creek – the second case in Washington state – and one day later the first U.S. coronavirus death was reported, also in Washington state.

A man in his 50s who was living at the Life Care Center in Kirkland died Feb. 26, 2020, two days after he was admitted to the hospital.

The virus quickly spread through the long-term care facility, becoming the epicenter of COVID-19 cases at the beginning of the pandemic. There were eventually 101 confirmed cases among residents and 55 confirmed cases among staff, reports King County Public Health.

RELATED: 'Ready for this to be over': Staff at Kirkland's Life Care Center, site of 1st US outbreak, receive second shots

By March, health officials had sounded the alarm on the virus. Inslee ordered public schools to close and a ban on large gatherings before issuing a stay-at-home order.

Since the start of the pandemic, there have been 294,017 total cases of COVID-19 in Washington state and 3,940 deaths, according to data from the Washington State Department of Health, as of Jan. 18, 2021.

Case Report

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.

[Image here ...   ] 

Apart from a history of hypertriglyceridemia, the patient was an otherwise healthy nonsmoker. The physical examination revealed a body temperature of 37.2°C, blood pressure of 134/87 mm Hg, pulse of 110 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 96% while the patient was breathing ambient air. Lung auscultation revealed rhonchi, and chest radiography was performed, which was reported as showing no abnormalities (Fig. 1). A rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. A nasopharyngeal swab specimen was obtained and sent for detection of viral respiratory pathogens by NAAT; this was reported back within 48 hours as negative for all pathogens tested, including influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and four common coronavirus strains known to cause illness in humans (HKU1, NL63, 229E, and OC43).

Given the patient’s travel history, the local and state health departments were immediately notified. Together with the urgent care clinician, the Washington Department of Health notified the CDC Emergency Operations Center. Although the patient reported that he had not spent time at the Huanan seafood market and reported no known contact with ill persons during his travel to China, CDC staff concurred with the need to test the patient for 2019-nCoV on the basis of current CDC “persons under investigation” case definitions.8 Specimens were collected in accordance with CDC guidance and included serum and nasopharyngeal and oropharyngeal swab specimens. After specimen collection, the patient was discharged to home isolation with active monitoring by the local health department.

On January 20, 2020, the CDC confirmed that the patient’s nasopharyngeal and oropharyngeal swabs tested positive for 2019-nCoV by real-time reverse-transcriptase–polymerase-chain-reaction (rRT-PCR) assay. In coordination with CDC subject-matter experts, state and local health officials, emergency medical services, and hospital leadership and staff, the patient was admitted to an airborne-isolation unit at Providence Regional Medical Center for clinical observation, with health care workers following CDC recommendations for contact, droplet, and airborne precautions with eye protection.9

On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

On days 2 through 5 of hospitalization (days 6 through 9 of illness), the patient’s vital signs remained largely stable, apart from the development of intermittent fevers accompanied by periods of tachycardia (Fig. 2). The patient continued to report a nonproductive cough and appeared fatigued. On the afternoon of hospital day 2, the patient passed a loose bowel movement and reported abdominal discomfort. A second episode of loose stool was reported overnight; a sample of this stool was collected for rRT-PCR testing, along with additional respiratory specimens (nasopharyngeal and oropharyngeal) and serum. The stool and both respiratory specimens later tested positive by rRT-PCR for 2019-nCoV, whereas the serum remained negative.

Treatment during this time was largely supportive. For symptom management, the patient received, as needed, antipyretic therapy consisting of 650 mg of acetaminophen every 4 hours and 600 mg of ibuprofen every 6 hours. He also received 600 mg of guaifenesin for his continued cough and approximately 6 liters of normal saline over the first 6 days of hospitalization.

The nature of the patient isolation unit permitted only point-of-care laboratory testing initially; complete blood counts and serum chemical studies were available starting on hospital day 3. Laboratory results on hospital days 3 and 5 (illness days 7 and 9) reflected leukopenia, mild thrombocytopenia, and elevated levels of creatine kinase (Table 1). In addition, there were alterations in hepatic function measures: levels of alkaline phosphatase (68 U per liter), alanine aminotransferase (105 U per liter), aspartate aminotransferase (77 U per liter), and lactate dehydrogenase (465 U per liter) were all elevated on day 5 of hospitalization. Given the patient’s recurrent fevers, blood cultures were obtained on day 4; these have shown no growth to date.

A chest radiograph taken on hospital day 3 (illness day 7) was reported as showing no evidence of infiltrates or abnormalities (Fig. 3). However, a second chest radiograph from the night of hospital day 5 (illness day 9) showed evidence of pneumonia in the lower lobe of the left lung (Fig. 4). These radiographic findings coincided with a change in respiratory status starting on the evening of hospital day 5, when the patient’s oxygen saturation values as measured by pulse oximetry dropped to as low as 90% while he was breathing ambient air. On day 6, the patient was started on supplemental oxygen, delivered by nasal cannula at 2 liters per minute. Given the changing clinical presentation and concern about hospital-acquired pneumonia, treatment with vancomycin (a 1750-mg loading dose followed by 1 g administered intravenously every 8 hours) and cefepime (administered intravenously every 8 hours) was initiated.

On hospital day 6 (illness day 10), a fourth chest radiograph showed basilar streaky opacities in both lungs, a finding consistent with atypical pneumonia (Fig. 5), and rales were noted in both lungs on auscultation. Given the radiographic findings, the decision to administer oxygen supplementation, the patient’s ongoing fevers, the persistent positive 2019-nCoV RNA at multiple sites, and published reports of the development of severe pneumonia3,4 at a period consistent with the development of radiographic pneumonia in this patient, clinicians pursued compassionate use of an investigational antiviral therapy. Treatment with intravenous remdesivir (a novel nucleotide analogue prodrug in development10,11) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion. Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved

with the exception of his cough, which is decreasing in severity.

Methods 

• Specimen Collection : Clinical specimens for 2019-nCoV diagnostic testing were obtained in accordance with CDC guidelines.12 Nasopharyngeal and oropharyngeal swab specimens were collected with synthetic fiber swabs; each swab was inserted into a separate sterile tube containing 2 to 3 ml of viral transport medium. Serum was collected in a serum separator tube and then centrifuged in accordance with CDC guidelines. The urine and stool specimens were each collected in sterile specimen containers. Specimens were stored between 2°C and 8°C until ready for shipment to the CDC. Specimens for repeat 2019-nCoV testing were collected on illness days 7, 11, and 12 and included nasopharyngeal and oropharyngeal swabs, serum, and urine and stool samples.

• Diagnostic Testing for 2019-nCoV : Clinical specimens were tested with an rRT-PCR assay that was developed from the publicly released virus sequence. Similar to previous diagnostic assays for severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), it has three nucleocapsid gene targets and a positive control target. A description of this assay13 and sequence information for the rRT-PCR panel primers and probes14 are available on the CDC Laboratory Information website for 2019-nCoV.15

• Genetic Sequencing : On January 7, 2020, Chinese researchers shared the full genetic sequence of 2019-nCoV through the National Institutes of Health GenBank database16 and the Global Initiative on Sharing All Influenza Data (GISAID)17 database; a report about the isolation of 2019-nCoV was later published.18 Nucleic acid was extracted from rRT-PCR–positive specimens (oropharyngeal and nasopharyngeal) and used for whole-genome sequencing on both Sanger and next-generation sequencing platforms (Illumina and MinIon). Sequence assembly was completed with the use of Sequencher software, version 5.4.6 (Sanger); minimap software, version 2.17 (MinIon); and freebayes software, version 1.3.1 (MiSeq). Complete genomes were compared with the available 2019-nCoV reference sequence (GenBank accession number NC_045512.2).

Results

Specimen Testing for 2019-nCoV

The initial respiratory specimens (nasopharyngeal

and oropharyngeal swabs) obtained from this

patient on day 4 of his illness were positive for

2019-nCoV (Table 2). The low cycle threshold

(Ct) values (18 to 20 in nasopharyngeal specimens

and 21 to 22 in oropharyngeal specimens)

on illness day 4 suggest high levels of virus in

these specimens, despite the patient’s initial mild

symptom presentation. Both upper respiratory

specimens obtained on illness day 7 remained

positive for 2019-nCoV, including persistent high

levels in a nasopharyngeal swab specimen (Ct values,

23 to 24). Stool obtained on illness day 7

was also positive for 2019-nCoV (Ct values, 36 to

38). Serum specimens for both collection dates

were negative for 2019-nCoV. Nasopharyngeal

and oropharyngeal specimens obtained on illness

days 11 and 12 showed a trend toward de-

EVERETT, Wash. — It started with a stubborn cough. A visit to an urgent care facility. A test being sent off to the Centers for Disease Control and Prevention. And then a 35-year-old resident of Snohomish County, Wash., being named the first confirmed case of the coronavirus in the United States.

[After the patient has been re-admitted for urgent care, ]Hollianne Bruce, the lone epidemiologist assigned to the control of communicable diseases in the county’s public health office, jumped into action. Declining to wait for a C.D.C. team to arrive from Atlanta, she dialed up the patient, who had been taken to an isolation unit at a hospital.

Seeking to establish a rapport, Ms. Bruce told him she knew he was not feeling well. She apologized for the disturbance. But she impressed on him how he might help save lives by sharing where he had been in recent days and with whom he had come into contact.

“We don’t know a lot about this virus,” she told him. “We’d like to ask you some questions.”

The man, who had been taken to the hospital the night before in a covered gurney intended for Ebola patients, agreed to help. It would be the first of several conversations he would have with Ms. Bruce, some by phone, others over a walkie-talkie as she stood outside his sealed room. Once, at his request, she bought him lunch at a nearby Panda Express.

In their conversations, she took him back six days, when he had returned from visiting family in Wuhan, China, the epicenter of the outbreak.

Could he tell her the dates of his travel? His flight number? His seat number?   [ Shouldn't this be accessible? ] 

How had he returned home from the airport? When did his symptoms start? Where did he work? Did he stop anywhere on the way to work? Did he stop on the way home? Had he gone out for any meals?

For Ms. Bruce, it was a relief to learn that the patient lived alone, that he took the stairs rather than the elevator to his office, and that he did not work in an open cubicle.

But he had attended a group lunch the day he developed a cough, and all eight of his lunch partners would be tracked down. Once he developed a cough, he had walked into a crowded health clinic. Thirty-eight other people who were in the clinic that day would need to be monitored.   [ So he checked into the health clinic AFTER his lunch, meaning 1PM-2PM PST, or 4PM-5PM EST on Sunday January 19]

The coronavirus, which has killed hundreds of people in China and sickened more than 20,000 in countries across the world, has been declared a global health emergency. To slow its spread, the Trump administration has invoked a rarely used constitutional power to impose a quarantine on Americans returning from the area around Wuhan.

But within the United States, containing the virus is a local responsibility. Across the country, where at least 11 more cases have since been confirmed, it is health officials at the county and municipal level who are scrambling to isolate the sick, learn where they have been and monitor those who have come into contact with them. Health workers are also debunking rumors, calming fears and bracing for the expected emergence of new cases.

At the Snohomish Health District, the staff of 113 has poured 1,000 hours into coronavirus control since the patient’s test was sent to the C.D.C. over the Martin Luther King’s Birthday weekend. Food inspectors, human resource managers and opioid outreach specialists have pitched in.

“All responses are local,” said Dr. Satish Pillai, an infectious disease specialist who headed an eight-person team that was dispatched from C.D.C. headquarters in Atlanta to monitor the case. “What happened in Snohomish is emblematic of what we need to evolve and improve our ability to respond to a virus we are seeing for the very first time in the United States.”

[ NOTE - interesting interview of here for  Dr. Satish Pillai :  https://globalhealthchronicles.org/items/show/7912  ] 

An account of the last two weeks at the Snohomish Health District — whose offices are festooned with messages like “Immunizations: They’re your best defense!” and “Save A Life: Give Your Blood” — offers a look at what may be in store for more of the nation’s 3,000 local health jurisdictions in the weeks to come.

Delivering a Thermometer

The Wuhan coronavirus still seemed far away on the evening of Jan. 19 when Dr. Chris Spitters, the district’s interim health officer, was alerted that a local clinic had sent specimens to the C.D.C. from a resident who had recently returned from Wuhan.

“In the first moments you kind of want to deny that this is happening,” Dr. Spitters recalled.

Dr. Spitters, who was out of town for the holiday weekend, asked Katie Curtis, the district’s assistant director of prevention services, to check on the man, who had agreed to remain isolated at home until the test results came back.

His symptoms were relatively mild. But health officials wanted to monitor him for fever and to make sure he had any supplies he might need so he did not need to leave his house.

He had plenty of food, the man told Ms. Curtis on the phone, but no thermometer.

When Ms. Curtis knocked on his door the next morning after picking up a thermometer at a pharmacy, he answered wearing a face mask. He promised to text her his temperature every few hours

His first text came a few minutes later.

It was no cause for alarm.

But before the next one, Ms. Curtis called him with Dr. Spitters on the line. By then, a team of nurses and emergency medical technicians had been assembled. The simulation they had performed earlier in January on how to transport and quarantine a highly infectious patient was suddenly becoming reality. An isolation unit at Providence Regional Medical Center, meant for Ebola patients and never before used, was in the process of being erected.

“We have your test results,” Ms. Curtis told the patient.

‘Can I Cure It With a Lime?’

The reactions among the dozens of people potentially exposed to the patient ranged from anxiety to irritation. Some expressed gratitude to Ms. Bruce and the other health workers who reached out to them. There were several jokes about Corona beer.

“Can I cure it with a lime?” one wanted to know.

Only one person earned the notation “resistant to public health intervention.”

Everyone on Ms. Bruce’s “close contact” list received two phone calls from a public health worker to impress upon them the seriousness of the situation. They were required to take their temperatures twice a day and report any fevers or coughs. After that, they could opt to receive a text message, carefully worded so as not to raise alarm should another person see it.

“This is the Health District with your daily symptom check for your household,” it read. “Please reply with 1 if you have no symptoms, reply with 2 if someone in your household is ill.”

Across the county line, Ms. Bruce’s counterparts in King County were performing the same task with dozens of others who worked with the patient, were on his flight or rode with him from the airport. At least nine people who were exposed to the patient have developed symptoms that fell within the C.D.C.’s criteria for testing. Results for three of them are still pending; the others were negative.

A ‘Person Under Investigation’ Breaks Quarantine

In many ways, the coronavirus response was familiar ground for the local health workers, who routinely labor to prevent and control outbreaks of gastroenteritis, measles, tuberculosis and H.I.V.

The novel nature of the coronavirus added urgency — and a disquieting uncertainty — to the work. Who is most at risk? How soon do symptoms arise in people who are infected? How, exactly, is the virus transmitted?

During a season when nearly everyone has a sore throat, it was hard to know who among the contacts they were tracing needed to be tested and given the “PUI” designation, for “person under investigation.”

Those who were ordered to stay in their homes were taken care of. The groceries that the Seattle and King County public health department delivered to one prospective patient included hair conditioner, blueberries and 2 percent milk.

Still, when Ms. Bruce could not reach one of the people she was monitoring over the weekend of Jan. 25, she grew alarmed. After leaving a message with the woman’s emergency contact, she received a call at home that night. The woman explained that she had been in the process of moving to Wisconsin, and that she had taken her flight as planned.

“You did what?” Ms. Bruce asked. The woman has subsequently tested negative.

Accusations of a Cover-up

The people of Snohomish County had questions.

Why had local health officials not released the name of the clinic where the patient had received care?

Was this all a government scheme to sell vaccines? Was it safe to take children to the airport? Was the rumor at a local high school that a student had tested positive for the virus true?

There was no reason to believe, health officials told residents, that the patient had posed a risk to people with whom he had not been in reasonably close contact. To disclose the clinic location could create a false sense of panic, officials said.

There was no government scheme, officials made clear. They had tested no minors for the coronavirus, they said of the school rumors. And as for the airport, they said parents should encourage their children to wash their hands.

But it was hard for officials to keep up with the anxiety.

“This is an evolving situation,” reads a post on the health office’s Facebook page.

Seeking a Normal Life Again

Carrie Parker, the outreach and preparedness supervisor for the Snohomish Health District, took on the role of “incident commander” over the last two weeks. On Tuesday, she told her 30-person team that they might soon be returning to their day jobs.

The Snohomish County patient has been discharged from the hospital with instructions from Dr. Spitters to remain in isolation at home for now. Snohomish health officials declined to release his name, and his identity could not be determined.

In a statement, the man said he was continuing to get better and he thanked those who had cared for him. He expressed a desire to return to his normal life and “not to be in the public eye.”

On Tuesday, Ms. Parker told her 30-person team that they might soon be returning to their day jobs.Credit...Chona Kasinger for The New York Times

Amy Harmon is a national correspondent, covering the intersection of science and society. She has won two Pulitzer Prizes, for her series “The DNA Age”, and as part of a team for the series “How Race Is Lived in America.” @amy

EVERETT, Wash. – It's been a full year since the first known U.S. case of COVID-19 was confirmed in Snohomish County in a 35-year-old man returning from Wuhan, China.

He was admitted on Jan. 20, 2020, to Providence Regional Medical Center in Everett

"The world shifted for us, and the world shifted maybe a little bit earlier here, but it shifted for all of us," Mayor Cassie Franklin told USA TODAY last week. "Our city is transformed by this and we still don’t know all the ways because we aren’t through it yet."

A year on, longtime residents, small business owners and medical professionals reflected on how they learned of a first patient in their midst, and how they have been navigating the pandemic.

Sharon Tolbert

• Tennessee native Sharon Tolbert, 55, moved to Everett in March to open a soul food restaurant, Grandma’s In Da Kitchen, just as the pandemic was heating up in Snohomish County.

• "I picked up everything and just put all my eggs in one basket to move here in Everett," Tolbert said. "So the ups and downs have been pretty scary. … Right now, I’m really fighting a storm."

• Tolbert has lost four relatives to COVID-19 and one of her regular customers, a Boeing employee. She has never held her five-month-old grandson, King, who is fighting COVID-19. And she’s still processing the loss of her son, who was fatally shot five years ago. His face illuminates a mural on an outside wall of the restaurant, alongside an image of Breonna Taylor.

• "Everything I do really, I just keep going because I hear his voice telling me to keep going. So I guess that’s how I process things."

Brad Hultman

• Longtime resident Brad Hultman, 72, drives down to the hardware store, buys coffee and cheerios to feed the seagulls, and parks overlooking the harbor marina with his chihuahua, Peanut.

• "I like the activity of the waterfront. I was born and raised in Everett and I’ve lived here pretty much all my life," Hultman said.

• In Hultman’s lifetime, the city, the largest in Snohomish County, has quadrupled in size, bolstered by the arrival of Boeing, the U.S. Navy and, later, Microsoft and Amazon. When the first U.S. case of COVID-19 was confirmed in the area, Hultman didn’t initially think it was a big deal.

• "I belong to the Elks Club, so I went in there one day wearing a mask and a hazmat suit and all this stuff and kind of made a joke about it. Everybody kind of thought it was like the flu or something. But then it just kept getting worse and worse and worse and people realized, 'Oh yeah, we gotta pay attention to this.'"

Holly Lawing

• Snohomish County native Holly Lawing, 34, manages a colorful, eclectic all-day breakfast restaurant, Kate’s, that her mother opened in downtown Everett. But the business has been closed for most of the year.

• "We’re just people who like people—hearing about different kinds of people, different stories," Lawing said. "I don’t remember (COVID-19) being that big of a deal at the very beginning. The first time I noticed that it might actually affect business was within two weeks of the shutdown."

• Lawing has been podded up with her two kids, 8 and 10, and mother, but she hasn’t seen her father, who has a lung disease, in a year. Lawing said her longtime family friend, Vern, who had been in a nursing home, was intubated and passed away from COVID-19 in March. He grew close to the family after he stopped into the restaurant years ago.

• "We’d mostly just talk. He was a veteran of the Korean War and also Vietnam. He just had neat stories and a different life experience than I’ll ever have," Lawing said. "He was just a kind man."

Dr. Jay Cook

• Dr. Jay Cook, chief medical officer at Providence Regional Medical Center, was home in Mukilteo, Washington, when he got the call that his hospital had the first known U.S. coronavirus patient. The next day, he would tell the public there was no immediate danger to them.

• "One thing our experience with the COVID pandemic has taught us is to be humble with our assumptions and funds of knowledge," he said. "This is a novel coronavirus, so we really had no experience with managing patients with this particular infection. So I believe that in retrospect that it would have been better if we had taken a very conservative route."

• Vaccines have been a source of hope for Cook but he urges people to continue taking public health precautions. "It’s important to understand that we really need to keep the masking and the distancing going for at least another year I think, until a critical mass of the population does get immunized."

Lisa Lamping

• Lisa Lamping, 54, a veteran and former Boeing employee, owns a laundry service in downtown Everett, where she’s lived for decades and raised her two daughters. She was sitting on her couch when she saw the news of the first case at Providence Regional Medical Center. The media was overblowing the situation, she thought at the time.

• "It didn’t seem like a big deal. It was just like, 'Oh, it’s here in Everett,'" she said. "Most people didn’t believe it."

• The bread and butter of Lamping’s laundry business, At Your Leisure Services – once bulk orders from the wedding industry – has shifted over the past year.

• "We’ve lost 20 customers, yet I’m making more money than before COVID. The CARES Act created more business … They’re doing a lot for homeless people, so we’re doing the laundry for the showers they opened, for the shelters. For a while, we were even doing the laundry for the hospital when it moved into the arena," Lamping said. "I think I will be affected later, once the CARES Act goes away."

Dale Amundsen

• Dale Amundsen, 68, a chaplain working in King County, hopes to bring comfort, hope and inspiration for families who have lost loved ones amid the pandemic.

• "Of course, with almost any death, the question is why, and with COVID, it’s the same why," Amundsen said. "There’s maybe some anger about it – maybe if we hadn’t done this or hadn’t gone here. And you can’t answer those questions in most cases. We can ask why all we want, but the focus has got to be on the life they lived more than the death they had."

• Amundsen has participated in nearly 5,000 funerals, and for him, the past year has been brutal. "Sometimes we just got to say, that’s the way it is. We may never know."

Sarah Wilkerson

• Sarah Wilkerson, manager of infection prevention, remembers the day she received a call from Providence Regional Medical Center alerting her that they had a patient who'd recently been to Wuhan and tested positive for the novel coronavirus.

• "We decided at that moment that because it was such a unique situation, not something had anybody really seen yet, especially not in the United States, that we would open our bio-containment unit," Wilkerson said.

• "The hardest days are – it’s just ever-changing. It’s been a year. You’d think that all the questions that could possibly come up would have come up by now. But there’s just a new encounter with every single day, and some days are harder than others."

Sean Weaver

• As a child, Sean Weaver was hesitant to want to become a doctor after seeing his mother battle multiple kinds of cancer, including Lymphoma. Now an Emergency Medical Specialist, Weaver was part of the BEST team, which responded to the first confirmed coronavirus case at Providence Regional Medical Center in Everett, Washington.

• Around the same time, Weaver's wife was diagnosed with breast cancer, so he decided to move out of his family's home. "When I wasn’t working I would go in at night and sit in the garage or sit on the deck and have dinner with them, six feet apart. Never hugging my kids or interacting with them besides talking," Weaver said. "And that went on for four-and-a-half months total until mid-July and, at that point, her chemotherapy was done."

• Weaver cared for many of America's first confirmed COVID-19 cases, and moved back in with his wife and two children at the end of July. "It was a hard thing to do. I’m glad we did it. I’m glad I was till able to work and care for the people here."

Elizabeth Baty

• Elizabeth Baty, 58, a funeral director at a family-run funeral home in King County, recalls gathering with a dozen staff members in the company chapel in late February to discuss the coronavirus pandemic.

• "We had a what-if situation," Baty said. What if the virus came to King County? What if we ran out of PPE? Days later, residents at the nearby LifeCare Center of Kirkland nursing home would begin to die from COVID-19.

• She had been busy all year, but her workload increased significantly last month. "Now that we’re a year down, some people are mad," she said. "They’re mad that they’re still in this situation. They’re mad that they have to consider their own death."

Dr. George Diaz

• Dr. George Diaz, an infectious diseases specialist at Providence Regional Medical Center, had just returned home to his wife and five kids from an infectious diseases conference in Florida when he received the news of a positive test.

• "It was very surprising that we were going to have the first patient in the US at our hospital," Diaz said. "When the patient was admitted, there were two of us that were primarily taking care of the first patient to keep continuity. But thereafter once we started seeing a surge, the entire (infectious diseases) department began seeing these patients."

• A year, staff is exhausted, Diaz said.

• "They are fatigued as a whole, as are all healthcare workers in the country. We have been dealing with this for a year, and what we would ask is for people to continue to do the things that prevent admissions –  wearing masks, social distancing, and getting the vaccine when available. Those are the things that are going to help healthcare workers in the long-run."

On Wednesday, January 20, it will be one year since the first person in the United States to be confirmed to have COVID-19 was hospitalized and tested.

The unidentified 35-year-old man had spent three months visiting family in Wuhan, China and returned to the U.S. on January 15. He traveled alone and lived alone. After becoming sick a few days later, he saw his doctor and was admitted to Providence Regional Medical Center in the town of Everett, in Snohomish County, Washington, north of Seattle.

“There had to be the first case somewhere,” Washington epidemiologist Dr. Scott Lindquist told reporters at the time. “It was in Snohomish.”

The hospital, serendipitously, had rehearsed for a possible pathogen attack weeks earlier as part of a practice drill for a potential Ebola patient. They were ready with enclosed gurneys, PPE, and isolation techniques.

The doctor in charge of the unidentified man’s care asked the FDA for approval to treat him with remdesivir, an antiviral drug developed to treat Ebola. He was the first in the nation to receive the treatment.

The man’s coronavirus diagnosis was confirmed by the CDC the next day, on January 21, 2020, and he became the country’s first positively identified case of COVID-19 imported from China, according to the agency. They sent a team to Washington state to help with the investigation and possible contact tracing.

Also on January 20, 2020, the CDC announced three U.S. airports would begin screening for the coronavirus because of flights between them and Wuhan, China: JFK international, San Francisco International and Los Angeles International. The move came after a handful of cases of coronavirus were reported in Thailand and Japan.

The initial patient in Washington state recovered, and on February 3, 2020, he was released from the hospital. Meanwhile, hospitals nearby were beginning to get their first coronavirus patients, and long-term care facilities were starting to see cases.

From that first hospitalized case, to a year later, more than 400,000 Americans have died from the coronavirus and more than 24 million have contracted the disease. There are two vaccines with FDA emergency authorization approval and every state is working to vaccinate as many people as quickly as possible.

Dr. Li-Meng Yan wanted to remain anonymous. It was mid-January, and Dr. Yan, a researcher in Hong Kong, had been hearing rumors about a dangerous new virus in mainland China that the government was playing down. Terrified for her personal safety and career, she reached out to her favorite Chinese YouTube host, known for criticizing the Chinese government.

Within days, the host was telling his 100,000 followers that the coronavirus had been deliberately released by the Chinese Communist Party. He wouldn’t name the whistle-blower, he said, because officials could make the person “disappear.”

By September, Dr. Yan had abandoned caution. She appeared in the United States on Fox News making the unsubstantiated claim to millions that the coronavirus was a bio-weapon manufactured by China.

Overnight, Dr. Yan became a right-wing media sensation, with top advisers to President Trump and conservative pundits hailing her as a hero. Nearly as quickly, her interview was labeled on social media as containing “false information,” while scientists rejected her research as a polemic dressed up in jargon.

Her evolution was the product of a collaboration between two separate but increasingly allied groups that peddle misinformation: a small but active corner of the Chinese diaspora and the highly influential far right in the United States.

ImageDr. Li-Meng Yan’s interview on Tucker Carlson’s show in September racked up at least 8.8 million views online. Facebook and Instagram flagged it as false information.

Dr. Li-Meng Yan’s interview on Tucker Carlson’s show in September racked up at least 8.8 million views online. Facebook and Instagram flagged it as false information.Credit...Fox News

Each saw an opportunity in the pandemic to push its agenda. For the diaspora, Dr. Yan and her unfounded claims provided a cudgel for those intent on bringing down China’s government. For American conservatives, they played to rising anti-Chinese sentiment and distracted from the Trump administration’s bungled handling of the outbreak.

Both sides took advantage of the dearth of information coming out of China, where the government has refused to share samples of the virus and has resisted a transparent, independent investigation. Its initial cover-up of the outbreak has further fueled suspicion about the origins of the virus.

An overwhelming body of evidence shows that the virus almost certainly originated in an animal, most likely a bat, before evolving to make the leap into humans. While U.S. intelligence agencies have not ruled out the possibility of a lab leak, they have not found any proof so far to back up that theory.

Dr. Yan’s trajectory was carefully crafted by Guo Wengui, a fugitive Chinese billionaire, and Stephen K. Bannon, a former adviser to Mr. Trump.

They put Dr. Yan on a plane to the United States, gave her a place to stay, coached her on media appearances and helped her secure interviews with popular conservative television hosts like Tucker Carlson and Lou Dobbs, who have shows on Fox. They nurtured her seemingly deep belief that the virus was genetically engineered, uncritically embracing what she provided as proof.

“I said from Day 1, there’s no conspiracies,” Mr. Bannon said in an interview. “But there are also no coincidences.”

Mr. Bannon noted that unlike Dr. Yan, he did not believe the Chinese government “purposely did this.” But he has pushed the theory about an accidental leak of risky laboratory research and has been intent on creating a debate about the new coronavirus’s origins.

“Dr. Yan is one small voice, but at least she’s a voice,” he said.

The media outlets that cater to the Chinese diaspora — a jumble of independent websites, YouTube channels and Twitter accounts with anti-Beijing leanings — have formed a fast-growing echo chamber for misinformation. With few reliable Chinese-language news sources to fact-check them, rumors can quickly harden into a distorted reality. Increasingly, they are feeding and being fed by far-right American media.

Wang Dinggang, the YouTube host contacted by Dr. Yan and a close associate of Mr. Guo, appears to have been the first to seed rumors related to Hunter Biden, a son of President-elect Joseph R. Biden Jr. A site owned by Mr. Guo amplified the baseless claims about Hunter Biden’s involvement in a child abuse conspiracy. They were picked up by Infowars and other fringe American outlets. Mr. Bannon, Mr. Wang and Mr. Guo are now all promoting the false idea that the presidential election was rigged.

Big technology companies have started to push back, as Facebook and Twitter try to better police content. Twitter permanently banned one of Mr. Bannon’s accounts for violating its rules on glorifying violence after he suggested on his podcast that the heads of the F.B.I. director and Dr. Anthony S. Fauci, the nation’s top infectious disease expert, should be put on pikes.

But such mainstream notoriety has only bolstered their anti-establishment credentials. Mr. Wang’s YouTube following has nearly doubled since January. Traffic for two of Mr. Guo’s websites soared to more than 135 million last month, up from fewer than five million visits last December, according to SimilarWeb, an online data provider. Many conservatives who claim Facebook and Twitter censor right-wing voices are also flocking to new social media platforms such as Parler — and Dr. Yan, Mr. Wang and Mr. Guo have already joined them.

Dr. Yan, through representatives for Mr. Bannon and Mr. Guo, declined multiple requests for an interview. So did Mr. Wang, citing The New York Times’s “reputation for fake news.”

In a statement sent through a lawyer, Mr. Guo said he had only offered “encouragement” for Dr. Yan’s efforts “to stand up against the C.C.P. mafia and tell the world the truth about Covid-19.”

“I would gladly assist others seeking to tell the world the truth,” he said.

Finding a platform

As the new year began, Mr. Wang was doing what he did best: attacking the Chinese Communist Party on YouTube. He railed against China’s crackdown on Muslims and pontificated on the U.S. trade war.

Then on Jan. 19, he suddenly shifted to the emerging outbreak in the central Chinese city of Wuhan. It was early in the crisis, before the lockdown in the city, before China had disclosed that the virus was spreading among humans, before the world was paying attention.

In an 80-minute show devoted to an unnamed whistle-blower, Mr. Wang said that he had heard from “the world’s absolute top coronavirus expert,” who had told him China was not being transparent. “I think this is very believable, and very scary,” he said.

Image

Wang Dinggang, left, a YouTube host and China critic, and his frequent co-host, known as An Hong. In January, Mr. Wang suddenly shifted his attention to the emerging coronavirus outbreak in Wuhan.

Wang Dinggang, left, a YouTube host and China critic, and his frequent co-host, known as An Hong. In January, Mr. Wang suddenly shifted his attention to the emerging coronavirus outbreak in Wuhan.Credit...YouTube

Mr. Wang, who was a businessman in China before moving to the United States for unknown reasons, is part of a growing group of commentators that have emerged on the Chinese-language internet. Their shows, which mix punditry, serious analysis and outright rumor, cater to a diaspora that often does not trust Chinese state media and has few reliable sources of news in its native language.

Since starting his program several years ago, Mr. Wang, who broadcasts under the name Lu De, has emerged as one of the genre’s most popular personalities, in part for his embrace of outlandish theories. He has accused Chinese officials of using “sex and seduction” to entrap enemies, and urged his audience to hoard food in preparation for the Communist Party’s collapse.

His January show on the unnamed whistle-blower combined the same elements of fact and fiction. He called his source, later revealed to be Dr. Yan, an expert, but greatly exaggerated her credentials.

She had studied influenza before the outbreak, but not coronaviruses. She did work at one of the world’s top virology labs, at the University of Hong Kong, but was fairly new to the field and hired for her experience with lab animals, according to two university employees who knew her. She helped investigate the new outbreak, but was not overseeing the effort.

The episode caught the attention of Mr. Bannon, who said he started worrying about the virus when China began locking down. Someone, he didn’t say who, pointed out the show and translated it.

A few months later, Mr. Wang suddenly told Dr. Yan to flee Hong Kong for her safety, he explained in later broadcasts. Mr. Guo, his primary patron, paid for her to fly first class, he added.

On April 28, Dr. Yan quietly left for the airport. Her family and friends panicked but could not reach her, said Jean-Marc Cavaillon, a retired professor of immunology at the Pasteur Institute in Paris who has known Dr. Yan since 2017. A missing persons report was filed in Hong Kong.

Two weeks later, she resurfaced in the United States.

“I’m currently in New York, very safe and relaxed” with the “best bodyguards and lawyers,” Dr. Yan wrote on WeChat, in a screenshot seen by The Times. “What I’m doing now is helping the whole world take control of the pandemic.”

A media makeover

After Dr. Yan arrived in the United States, Mr. Bannon, Mr. Guo and their allies immediately set out to package her as a whistle-blower they could sell to the American public.

They installed her in a “safe house” outside of New York City and hired lawyers, Mr. Bannon said. They found her a media coach, since English is not her first language. Mr. Bannon also asked her to submit multiple papers summarizing her purported evidence, Dr. Yan later said.

“Make sure you can walk people through this logically,” Mr. Bannon recalled telling her.

Mr. Bannon and Mr. Guo have been on a mission for years to, as they put it, bring down the Chinese Communist Party.

Mr. Guo, who also goes by Miles Kwok, was a property magnate in China with ties to senior party officials, until he fled the country about five years ago under the shadow of corruption allegations. He has since styled himself as a freedom fighter, though many are skeptical of his motivations.

Mr. Bannon, who patrolled the South China Sea as a young naval officer, has long focused much of his energy on China. During his time in the White House, he counseled Mr. Trump to take a tough approach toward the country, which he has described as “the greatest existential threat ever faced by the United States.”

Mr. Guo’s deep pockets and Mr. Bannon’s extensive network have given them an influential platform. The two men set up a $100 million fund to investigate corruption in China. They spread conspiracy theories about the accidental death of a Chinese tycoon in France, calling it a fake suicide orchestrated by Beijing.

By late January, they were both acutely focused on the outbreak in China.

Image

Guo Wengui and Steve Bannon at a news conference in 2018. Mr. Bannon and Mr. Guo have been on a mission for years to, as they put it, bring down the Chinese Communist Party.

Guo Wengui and Steve Bannon at a news conference in 2018. Mr. Bannon and Mr. Guo have been on a mission for years to, as they put it, bring down the Chinese Communist Party.Credit...Don Emmert/Agence France-Presse — Getty Images

Mr. Bannon pivoted his podcast to the coronavirus. He was calling it “the C.C.P. virus” long before Mr. Trump started using xenophobic labels for the pandemic. He invited fierce critics of China to the show to discuss how the outbreak exemplified the global threat posed by the Chinese Communist Party.

Mr. Guo began claiming that the virus was an attack ordered by China’s vice president. He circulated the same claims on his media operation, which includes GTV, a video platform, and GNews, a site that features glowing coverage of Mr. Guo and his associates. He released a song called “Take Down the C.C.P.,” which briefly hit No. 1 worldwide on the Apple iTunes chart.

The men have continued to target the Chinese government even as they battle their own legal woes. Mr. Guo is reportedly under investigation by U.S. federal authorities over fund-raising tactics at his media company. Mr. Bannon, who was arrested this summer on Mr. Guo’s yacht, is facing fraud charges for a nonprofit he helped set up to build a wall along the Mexican border.

In Dr. Yan, the two men found an ideal face for their campaign.

On July 10, she revealed her identity for the first time in a 13-minute interview on the Fox News website. She said that the Chinese government had concealed evidence of human-to-human transmission of the virus. She accused, without proof, professors at the University of Hong Kong of assisting in the cover-up. (The university quickly rejected her accusations as “hearsay.”)

“The reason I came to the U.S. is because I deliver the message of the truth of Covid-19,” she said.

She made no mention of Mr. Guo or Mr. Bannon, by design.

“Don’t link yourself to Bannon, don’t link yourself to Guo Wengui,” Mr. Guo on his own show recounted telling Dr. Yan. “Once you mention us, those American extreme leftists will attack and say you have a political agenda.”

After the first Fox interview, Dr. Yan embarked on a whirlwind tour of right-wing media, echoing conservative talking points. She said that she took hydroxychloroquine to ward off the virus, even though the F.D.A. had warned that it was not effective. She suggested that the World Health Organization helped cover up the outbreak.

Those interviews were amplified by social media accounts proclaiming allegiance to Mr. Guo. They translated her appearances into Chinese, then posted multiple versions on YouTube and retweeted posts by other pro-Guo accounts.

Some of the accounts have tens of thousands of followers — of a dubious nature. Many have multiple indicators of so-called inauthentic behavior, according to an analysis by First Draft, a nonprofit that studies misinformation. The analysis found that they were created in the past two years, lacked background photos and had user names that were jumbles of letters and numbers.

Collectively, the followers created online momentum for the conservative media world, which in turn re-energized the pro-Guo accounts. “The two are filtering and feeding off of each other,” said Anne Kruger, First Draft’s Asia Pacific director.

Going mainstream

In early September, Dr. Yan met with Dr. Daniel Lucey, an infectious disease expert at Georgetown University who had floated the possibility that the virus was the product of a laboratory experiment. Dr. Lucey said Dr. Yan’s associates, who set up the meeting, wanted to find a credible scientist to endorse her claims. “That was the only reason for bringing me there,” he said.

For more than four hours, Dr. Yan discussed her background and research, while one of her associates, whom Dr. Lucey declined to name, impatiently walked in and out of the room. He said that Dr. Yan appeared to genuinely believe that the virus had been weaponized but struggled to explain why.

At the end, the associate asked Dr. Lucey if he thought Dr. Yan had a “smoking gun.” When Dr. Lucey said no, the meeting quickly ended.

Days later, Dr. Yan released a 26-page research paper that she said proved the virus was manufactured. It spread rapidly online.

The paper, which was not peer-reviewed or published in a scientific journal, was posted on an online open-access repository. It was backed by two nonprofits funded by Mr. Guo. The three other co-authors on the paper were pseudonyms for safety reasons, according to Mr. Bannon.

The Wuhan Institute of Virology in China. Among the unsubstantiated claims that have circulated about the coronavirus is that it originated in a Chinese laboratory.Credit...Hector Retamal/Agence France-Presse — Getty Images

Virologists quickly dismissed the paper as “pseudoscience” and “based on conjecture.” Some worried that the paper — laden with charts and scientific jargon, such as “unique furin cleavage site” and “RBM-hACE2 binding” — would lend her claims a veneer of credibility.

“It’s full of science-y sorts of terms that are jumbled together to sound impressive but aren’t supported,” said Gigi Kwik Gronvall, an immunologist at Johns Hopkins University who was among several authors of a rebuttal to Dr. Yan’s report

Other misinformation about the pandemic has also emphasized supposed expertise. In the spring, a 26-minute video that went viral featured a discredited American scientist accusing hospitals of inflating virus-related deaths. A July video showed people in white coats, calling themselves “America’s doctors” and suggesting that masks were ineffective; the video was removed by social media platforms for sharing false information.

On Sept. 15, a day after her report was published, Dr. Yan secured her biggest stage yet: an appearance with Tucker Carlson on Fox News. Mr. Carlson’s popular show has frequently served as an influential megaphone for the right.

Mr. Carlson asked if Dr. Yan believed Chinese officials had released the virus intentionally or by accident. Dr. Yan did not hesitate

“Of course intentionally,” she said.

The clip went viral.

Footage of their interview racked up at least 8.8 million views online, even though Facebook and Instagram flagged it as false information. High-profile conservatives, including Senator Marsha Blackburn of Tennessee, shared it on Twitter. When the Rev. Franklin Graham, the evangelist supporter of Mr. Trump, posted about Dr. Yan on Facebook, it became the most-shared link posted by a U.S.-based Facebook account that day

Lou Dobbs, another Fox host, tweeted a video of himself and a guest discussing Dr. Yan’s “great case.” Mr. Trump retweeted it.

Dr. Yan was welcomed by an audience already primed to hear her claims. A March poll found that nearly 30 percent of Americans believed the virus was most likely made in a lab.

“Once Tucker Carlson picks it up, it’s not fringe anymore,” said Yotam Ophir, a professor at the University at Buffalo who studies disinformation. “It’s now mainstream.”   Fox News declined to comment.

Weeks later, Mr. Carlson said on his show that he could not endorse Dr. Yan’s theories. Regardless, he welcomed her back as a guest to detail her latest claim: Her mother, she told him, had been arrested by the Chinese government.

The Chinese government often punishes critics by harassing their families. But when The Times reached Dr. Yan’s mother on her cellphone in October, she said that she had never been arrested and was desperate to connect with her daughter, whom she had not spoken to in months.

She declined to say more and asked not to be named, citing fears that Dr. Yan was being manipulated by her new allies.

“They are blocking our daughter from talking to us,” her mother said, referring to Mr. Guo and Mr. Wang. “We want our daughter to know that she can video-chat with us at any time.

• Namita Seth Mohta:    This is Namita Seth Mohta for NEJM Catalyst. I am speaking today with Dr. George Diaz, part of the leadership team at the Providence St. Joseph Health System in Washington, who is helping to lead the response to the Covid-19 pandemic.  Dr. Diaz and I will talk today about his experience with the Covid-19 pandemic. Our objective is to discuss care delivery — the very mission of NEJM Catalyst — during a unique and defining moment. Thank you for joining us today.

• George Diaz:   Thanks for having me.

• Mohta:   Share with us some background. Tell us a little bit about Providence St. Joseph as a system, how it’s organized, and how it provides care for patients.

• Diaz:   Providence Saint Joseph Health has 51 hospitals, primarily on the West Coast including Alaska, Washington, Montana, Oregon, California, New Mexico, and Texas. We have about 1,000 clinics. It has a central structure for clinical governance. Each of the specialties within the clinical arena has engaged providers that provide decision-making for the health system. Along those lines, we have a unified EMR [electronic medical record]. We are on the Epic platform and infectious diseases content is one of the areas that I work in to build into our EMR. We received the first patient in the U.S. with coronavirus in January, and as soon as the first patient arrived to our hospital, we activated our Special Pathogens Unit and employed our dedicated volunteer staff of nurses and other staff who work with special pathogens. The hospital where I practice infectious diseases is in Everett, Washington, just north of Seattle. We are a 600-bed hospital, the largest hospital in our county, which is one of the areas hardest hit with the current pandemic. We received the first patient in the U.S. with coronavirus in January,1 and as soon as the first patient arrived to our hospital, we activated our Special Pathogens Unit and employed our dedicated volunteer staff of nurses and other staff who work with special pathogens. On arrival of the first patients, I begin coordinating closely with our system leadership to begin a centralized response to what was likely going to be additional patients coming to our health system. Within 24 hours of the first patient arriving, we updated our electronic medical record to begin screening patients for possible coronavirus infection based on travel history, and by 5 p.m. the next day, all of our hospitals, ERs, urgent care clinics, outpatient clinics, any other ancillary clinics, were all screening patients looking for possible additional patients who could be Covid-positive based on their epidemiological risk.

• Mohta:   Let me clarify that I heard correctly that within 24 hours you had a template up in the EMR, and within what sounds like 1 to 2 days pretty much every part of the hospital was up and functioning in terms of being able to screen patients. How did you implement so quickly?

• Diaz:   We have a leadership group led by [Dr. Amy Lee Compton-Phillips (born 1963)] who made a decision the night we had a patient arrive that we needed to be prepared for any patient presenting anywhere in our organization. We already have the framework within our EMR to rapidly upload different contagions for screening. We had done this for things like Ebola, MERS, SARS, etc. The tool that we designed ourselves within Epic allows us to turn on screening at the county level, where outbreaks are often determined. Because this appeared to be a threat that would not be limited to a single county, the senior leadership team within our health system provided guidance to our clinical leadership to implement the screening immediately. In this particular case, because this appeared to be a threat that would not be limited to a single county, the senior leadership team within our health system provided guidance to our clinical leadership to implement the screening immediately. The build team begin working essentially overnight to update the EMR to allow for screening across our entire enterprise.

• Mohta:   And then what happened?

• Diaz:   At that point, we did end up caring for the patient locally. One of the things we noticed was that our team that was prepared to receive a patient with, for example, Ebola, was limited to about 15 nurses. We knew, given what we saw in China, that the volume of patients coming into our health system potentially could grow exponentially. We began operational plans to increase the number of staff within our hospital to be able to have large numbers of nursing staff be adept at managing patients with potentially highly communicable diseases. This not only improved our hospital, but simultaneously occurred across our health system through centralized governance that provided the same work and operational plan for readying staff for taking care of these patients system wide. With our hospital, we also began implementing plans for surge capacity. Thankfully for my hospital, one entire floor was built in a way that could accommodate the entire floor to be on negative air pressure. That particular unit has 64 beds. We made plans for being able to cohort all our patients who were Covid-positive and Covid rule-outs initially on that floor, so that we would have the nursing expertise localized to one part of the hospital at least early on. The other thing that we had to consider was how we are going to manage volume. We began developing algorithms within our health system to triage patients, either for admission or for home; since we knew based on literature coming out of China that there were a substantial number of patients who developed complications from Covid later in their illness, we felt it was important to design a system that could detect changes in the patient’s status if they happen to be discharged from the ED. This not only improved our hospital, but simultaneously occurred across our health system through centralized governance that provided the same work and operational plan for readying staff for taking care of these patients system wide. We also knew that [personal protective equipment] PPE would be potentially limited and so we wanted to devise a way to minimize the use of PPE as much as possible while keeping patients safe. The solution we came up with was to deploy our telehealth system in a way to be able to safely monitor both Covid-positive patients and ED-discharge patients to home using our telehealth system. We modified the EMR in a way that patients could enter data themselves into MyChart — it’s their record — including templates for the telehealth system to enter notes into EMR so that anybody accessing the patient record would have access to the telehealth notes as well. We developed workflows for a warm handoff between both ED discharges to home as well as inpatient-to-home discharges, where the discharging nurse did a warm handoff to telehealth nursing. So far, we have in the range of about 200 patients within our system right now being actively monitored from home. The number of patients returning to the hospital has been relatively small, on the order of less than 10.

• Mohta:   Let me ask a couple of follow-up questions in this part of the journey. The first is where are we in time now? The first patient came in, in January, and now you’re describing algorithms and elegant workflows around warm handoffs and integrating telemedicine and telehealth; that’s one question. The second is, in this time period, how are you managing testing? Because a lot of what you’re talking to me about is dependent on whether the patient is Covid-positive or not. The third is, if you could talk a little bit — in these transitions between ED to home, or inpatient to home — about the algorithms that you use to decide whether somebody was safe to go home, or not. That is a big unknown.

• Diaz:   I’ll answer the last one first, the question about how you decide to send someone home from ED or inpatient. We currently have clinical trials that give us entry criteria for at least what’s defined as severe pneumonia by inclusion criteria to the clinical trial, and we essentially use those as a way to determine if someone should be either actively monitored or admitted to the hospital. So far, we have in the range of about 200 patients within our system right now being actively monitored from home. The number of patients returning to the hospital has been relatively small, on the order of less than 10. An example would be that the current trial looks at oxygen saturation. If it’s below 94%, for the most part those folks will meet entry for clinical trial, and if those patients are close to requiring oxygen or have another reason for admission, the ED docs will then admit them to the hospital for admission. If patients then stabilize, and oxygen levels improve in the hospital, then they can be discharged to telehealth from the inpatient setting. We are primarily using oxidation status as the way that we determine if someone can safely go home from both ED and hospital. For the second question, system. I would say it was roughly 6 weeks from the time the first patient walked in the door to the time that we were employing this alternative [telehealth] care model.

• Mohta:   Because many of these algorithms appropriately depend on whether a patient is Covid-positive or negative, how did you handle the scarcity of testing kits during this time frame?

• Diaz:   That’s a great question. One of the reasons we also thought that we could use telehealth monitoring was because early on when we started to see a surge in volumes, we did not have rapid access to testing and it took as long as 4 or 5 days to get a result. We were discharging in large numbers people under investigation rather than people who were Covid-positive. Once results came back from testing and they were outpatients, as long as they were clinically stable and if they were Covid-negative they would be then discharged from telehealth. If they were Covid-positive after discharge from the ED or inpatient, then they would continue to be monitored until near resolution of symptoms. The lack of testing, it was a big problem, but we mitigated it by being able to discharge many of these folks outside the hospital setting. What we’re learning now is that in areas where we have populations that are growing and perhaps we don’t have the number of beds that will need to be built to support the increases in population, that we’re going to need to rely on telehealth models to be able to provide care.

• Mohta:   And then monitoring them via telehealth.

• Diaz:   Exactly. They would get hooked up with the telenurse and they would download Zoom at home, or if they were an elderly person who didn’t have access to a computer, all the monitoring could be done by phone.

• Mohta:   Given your experiences over the last few months, what will health care delivery look like in the future? How will it be different than what we knew pre-Covid-19?

• Diaz:   What we’re learning now is that in areas where we have populations that are growing and perhaps we don’t have the number of beds that will need to be built to support the increases in population, that we’re going to need to rely on telehealth models to be able to provide care. It may be people who are local can stay home; there certainly are large numbers of people who have difficulty leaving their homes and going to a clinic. Those patients could definitely benefit from telehealth services. Likewise, patients who live a little bit farther away from the hospital, in rural areas where it’s a burden to drive long-distance just to get care, the virtual visits will be a great way to expand care without expanding brick-and-mortar facilities.

• Mohta:   What are some of the challenges that you’ve had with implementing and now sustaining and scaling this model as you’re using telehealth to manage the pandemic? And what are some challenges you see, either same or different, in the future, post-Covid?

• Diaz:   I would say that the largest management issue is finding and being able to scale qualified staff for rapid-scale increases in telehealth volumes. If the health system has time and a plan, they can scale their staff appropriately, but scaling it rapidly as we’ve done requires identification of the resources to create a program like this that can scale into a multistate scenario. The other area that has been difficult has been cross-state licensing. Currently we’ve had difficulty in being able to contract nurses in the state where they reside, and where the patients live, if that particular state does not have cross-state agreements on credentialing. The biggest success story I would say is that using our telehealth model, so far we’ve been successful in having patients be in the right place for the type of care they require.

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