Nonresident COVID-19 cases significant part of Pitkin County, Aspen virus footprint

As summer tourism spiked in the Aspen area last month, so did the number of visitors and residents of neighboring counties who tested positive in Pitkin County for COVID-19.

From July 11 through Aug. 5, Pitkin County reported a total of 63 new COVID-19 infections. But during that 26-day stretch — notable for an influx of visitors as much of the nation grappled with a coronavirus surge — a total of 100 people tested positive here. Of those additional 37 cases, 22 were visitors from outside the region and 15 were residents of neighboring Eagle County or Garfield County, according to data obtained by Aspen Journalism through an open records request.

As of Aug. 27, Pitkin County had reported a total of 192 COVID-19 cases, including six new cases since Aug. 18. There were three additional new cases in that time frame tied to nonresidents, according to county public health officials.

Throughout Colorado, COVID-19 case numbers reported by county health departments include only respective county residents. When a resident from another county tests positive outside their home jurisdiction, that case is added to the total cases from the patient’s county of origin, according to Pitkin County and state officials.

However, in Pitkin County and other resort areas of the state, counting county residents alone may not provide a complete picture of the virus’ footprint in a community, given the hospitality-driven nature of an economy that relies both on workers who live away from the resort center in another county and visitors who sustain local businesses.

Anyone who had been in Pitkin County for at least 30 days at the time of their positive test — even if their listed home address is in another county — is counted as a Pitkin County resident.

Pitkin County began tracking nonresidents who tested positive here in mid-July, after numerous inquiries on the topic from news media and community groups; Aspen Journalism on July 13 filed a Colorado Open Records Act request for data on nonresident COVID-19 cases. County officials shared data Aug. 5 tallying nonresident cases from July 11 through Aug. 5. That information was compared with data available on Pitkin County’s COVID-19 statistics dashboard to determine the proportion of nonresidents to residents testing positive for the novel coronavirus over that span.

The fact that visitors from outside the region made up 22% of total positive tests in a given time frame, with residents of neighboring counties accounting for 15%, is significant but not unexpected, according to Pitkin County epidemiologist Josh Vance, who added that public health officials are now closely watching the number of “travel-related,” or nonresident, cases that are discovered locally.

“We recognize that because we are a tourist town, we are going to see people who come here who have been exposed elsewhere and they are going to be here and they are going to test positive,” Vance said in an interview Aug. 7. “So, I think to some extent, we are expecting a significant amount of individuals anyway, and that’s just going to happen regardless of what policy we put in.”

But if the number of nonresident cases approaches that of resident cases, the county will need to consider new mitigation strategies, Vance said.

On Aug. 20, staff from Pitkin County Public Health presented six policy options for reducing travel-related COVID-19 spread to the county’s Board of Health, which is made up of elected officials and medical experts, and advises on public health orders. County staff believes that most visitor-restriction policies would be more effective if they were implemented at the state level, as opposed to locally.

The options, which the county might advocate be implemented at the statewide level, included requiring visitors to sign a declaration stating they are not experiencing any symptoms, requiring visitors to certify they have tested negative for COVID-19 within 72 hours of arrival, screening incoming travelers at the airport for symptoms, and/or mandating a 14-day self-quarantine for visitors arriving from areas with elevated case counts.

“Research is showing that probably the most effective strategy is the (14-day self-quarantine) strategy,” Pitkin County Public Health Director Karen Koenemann told the board. That is based on an internal review of the various strategies conducted by public health department staff, she told the board.

At their next meeting Thursday, Board of Health members are expected to discuss which strategies, if any, they would support advocating at the statewide level.

The best policy may involve a combination of strategies.

“In my mind, this is like chasing a fugitive and you use as many strategies as you can to corner them,” said Pitkin County Commissioner Greg Poschman, who also is a member of the Board of Health, of the effort required to contain the virus.

Riding a rising wave

The first COVID-19 case in Colorado was discovered March 5 in an out-of-state visitor in Summit County. Shortly thereafter, more cases began turning up in the Denver area and at the state’s ski resorts. Aspen’s first cluster of cases, confirmed March 11, was diagnosed in a group of visiting Australians.

Colorado Gov. Jared Polis on the evening of March 14 issued an order closing all the state’s ski areas starting the next day. The order remained in effect through what would have been the end of the ski season.

As case counts grew statewide, Pitkin County on March 23 issued a “stay at home” order closing nonessential businesses and limiting activities outside the home to critical functions such as grocery shopping, health care and exercise.

In addition to the stay-at-home order and closure of ski areas, Pitkin County asked that visitors stay away and that second-home owners quarantine for 14 days if they came to their properties here.

The stay-at-home order was loosened to a “safer at home” order, which allowed local lodges to reopen May 27 at 50% capacity, while dropping the requirement for second homeowners to quarantine. Lodges were allowed to welcome guests at full capacity beginning June 26. The order forbids travel to Pitkin County for any visitors experiencing COVID-19 symptoms within 10 days prior to arrival.

New cases in Pitkin County slowed to a trickle between late April and mid-June, but the curve began tracking up after that, coinciding with increasing economic activity in town.

Metrics documenting the influx of nonresidents in Pitkin County include the volume of wastewater treated by the Aspen Consolidated Sanitation District, which correlates to how many people are in the Aspen area. Daily treatment volumes in March and April were down an average of 20% from the same months in 2019. In June, flows were down 10.2% from June 2019. From July 1 through Aug. 15, wastewater flows were 11% lower than the same time period in 2019.

Traffic coming across Castle Creek Bridge on Colorado 82 into Aspen since spring also has been climbing back toward pre-pandemic levels. Total car counts for June were 13% lower than June 2019, rebounding from a 36% decline for the months of March and April. Traffic levels in July were 6% lower than for July 2019.

On June 15, Pitkin County had reported 67 total COVID-19 cases since March, climbing to 180 cases Aug. 5 — numbers that account only for county residents.

Nonresident cases skew younger, break along racial lines

Of the 37 cases attributed to nonresidents who tested positive in Pitkin County between July 11 and Aug. 5, 22 were from other states, the largest share being from Texas (seven cases), followed by Florida (four) and California (three).

Seven cases were Garfield County residents and five were Eagle County residents. Both counties are home to many who work in Pitkin County.

“Although not residents of Pitkin County, we certainly consider them a part of our community,” Koenemann, Pitkin County’s public health director, wrote in an email.

The places of residence for three people with COVID-19 and on the out-of-county list are categorized as unknown.

The nonresidents who tested positive for COVID-19 in Pitkin County tended to be younger. The median age of Pitkin County residents who tested positive was 38, compared with 31 for visitors and 26 for residents of Eagle County or Garfield County. About one-third of the nonresidents with COVID-19 were in their 20s, compared with less than a quarter of residents.

The Latino population has been disproportionately affected by COVID-19, and the Roaring Fork Valley is no exception.

In Pitkin County, about 24% of the resident cases are Latino, although they account for only 10.5% of the county’s population, according to U.S. Census demographic data.

The numbers are even more skewed in Garfield County, where the Latino demographic makes up nearly 70% of the cases, according to the COVID-19 data dashboard, but only 20.5% of the population. In Eagle County, they represent 38% of the county’s confirmed resident cases, according to the county’s case tracking website, while 29.7% of the population is Latino.

Among the 15 people who tested positive in Pitkin County but live either in Eagle County or Garfield County, 73% are Latino.

On the other hand, 70% of the out-of-state visitors who tested positive in Pitkin County are white or non-Hispanic.

Vance, the county epidemiologist, said there are blind spots in the county’s nonresident data because it does not include someone who came here on vacation and then tested positive after returning home. The number of cases fitting that profile is unknown, he said.

Also missing in Pitkin County’s nonresident numbers are Eagle County or Garfield County residents who work in Pitkin County and who may have contracted the disease here but who were tested in their home counties.

“We work closely with Pitkin County, but we are not currently collecting the data on the number of confirmed cases that are related to Pitkin,” Sara Brainard, who works with Garfield County Public Health, wrote in an email Aug. 9.

Nonresident tracking was slow to start

The number of nonresident COVID-19 infections discovered in Pitkin County prior to July 11 is unclear. Before that day, whenever a nonresident tested positive here, county officials explained that they entered that information into a database maintained by the Colorado Department of Public Health and Environment, which classified the case under the patient’s home jurisdiction. Once the case is counted in the state system as another county’s, local public health staffers cannot run a report linking it to Pitkin County, according to Pitkin County Public Health Department officials.

CDPHE was unable to fulfill a request for a count of nonresident cases originating in Pitkin County.

“That data is not something that could be easily extracted and provided at the county level,” CDPHE records and legal-services liaison Monica Wilkerson wrote in an email. “In the middle of COVID-19 response activities, it isn’t something the department is able to offer to create, with limited staff resources available.”

Wilkerson redirected reporters’ inquiries back to the county level.

According to Koenemann, the local public health department was understaffed prior to the COVID-19 pandemic, with five out of eight of the department’s positions filled. It has taken months to scale up to the magnitude of the COVID-19 response, and the department now has 23 full-time positions, all of which are filled. Vance, who joined the department as a full-time epidemiologist June 15, has been “building out data systems due to the fact that the CDPHE disease investigation data system … was never designed for a pandemic and is not robust enough to do the data collection we were needing.”

Changing picture from county to county

Eagle County officials first responded to a request for information on the number of nonresident cases testing positive in the county by explaining why they do not add that information to their published case counts. Confirmed cases dating to the beginning of the pandemic among Eagle County residents totaled 1,172 as of Thursday.

“Adding confirmed cases of visitors tested in our county and reported to our county does not provide the whole picture of visitors either being exposed prior to coming to our community, not getting tested at all, or being exposed in our community but going home and being tested in an outside location,” Eagle County Communications Manager Justin Patrick wrote in an email. “It gets very messy very quickly, so that’s why we contain our reported case counts to full- or part-time residents only.”

The county does track those numbers internally, however. According to the Eagle County Public Health Department, there were six positive cases from nonresidents from July 11 through Aug. 3, during which time 275 residents tested positive.

“As you can see, this is a very small percentage of our overall cases reported in our community,” said a health department statement.

In Summit County, officials at Centura Health, which runs the largest hospital in the area and oversees the majority of testing, said nonresidents made up a “small majority” of positive tests since mid-June, the Summit Daily reported Aug. 5. The county Thursday reported a total of 361 confirmed or probable cases among residents.

San Juan Basin Public Health, which covers La Plata and Archuleta counties, in southwest Colorado, includes the number of nonresident positive cases detected in its jurisdiction on its COVID-19 dashboard. According to that data, nonresidents account for 45% of 82 total cases tested in Archuleta County and 10% of 264 cases in La Plata County.

A complicated patient origin picture

Nonresidents also figure large in the proportion of tests conducted locally.

The majority of COVID-19 testing in Pitkin County happens at Aspen Valley Hospital, which has collected 2,737 tests from March 1 through Aug. 3, according to data provided by the hospital.

Pitkin County residents accounted for 55% of those tests, according to the data provided by AVH, which is based on the billing address provided by patients receiving COVID-19 tests. Residents of other states made up 20% of the total, with Garfield County residents accounting for 13% and Eagle County residents accounting for 11%. Residents from Colorado areas other than the Roaring Fork Valley received 1% of the tests.

The AVH data does not speak to whether tests were positive, only that a test occurred. The data includes all tests — including PCR swabs, rapid tests and serology tests — and may include some repeat tests if a person was tested more than once, according to hospital spokesperson Jennifer Slaughter.

AVH was unable to provide a state-by-state breakdown of the out-of-state residents who were tested there, saying that such an analysis would require “considerable research.”

AVH CEO David Ressler noted that the Aspen area is unique in how complicated the “patient origin” question can be, with a mix of local residents, second-home owners, residents of other counties who work in Pitkin County and tourists whose population numbers are ever-changing.

AVH boosted its testing capacity in early July, after average tests exceeded 16 per day, causing the hospital to raise its COVID-19 alert level from “comfortable” to “cautious.” Testing demand has since dropped below the 16-per-day threshold, and the hospital is again experiencing “comfortable” status.

“Our numbers increased significantly” after the economy reopened in June and lodges began booking rooms at full capacity, Ressler said.

Downward trend since Aug. 5

The local trend in new cases has been heading down since Aug. 5.

After three new cases reported on the county’s dashboard Aug. 6 and four more Aug. 7, the county went 11 days without a new case tied to a Pitkin County resident. In that time frame, however, two nonresident cases were detected, both of whom were Garfield County residents, according to Vance.

Since Aug. 19, there have been five new county cases and three nonresident cases — two of whom are from California and the other from Michigan, Vance said in an email.

Multiple factors potentially influence the drop in cases noted through the middle of the month. On July 28, the city of Aspen implemented a mandatory mask zone — including outdoor areas — in the downtown core, where many visitors gather. Masks were previously required only in indoor public areas such as restaurants and retail stores. Colorado also introduced a statewide mask mandate July 16.

Also, Pitkin County has reduced the allowable size of informal gatherings from 50 people to 10, a decision implemented July 29 in response to an increasing number of cases tracked to informal gatherings.

The county also has seen decreased mobility and travel with the summer season ending and school starting up.

Nationwide, the trend also has been heading down, with a peak of 75,682 new cases July 16, declining to 37,507 new cases Aug. 13, according to data compiled by The New York Times.

Koenemann said in an email that Pitkin County has worked to have a “more conservative” approach in its loosening of the initial suppression strategies that effectively shut down the local economy in March. She added that she is working on an analysis overlaying COVID-19 case data with the timeline of shifting public health guidance, “which might give us some insight with how orders relate to the actual data.”

“What I also know is that other communities of comparable census populations have had higher hospitalization and mortality rates,” Koenemann wrote. “Not sure what to make of that yet, but it would be good to analyze.”

Most-effective policies cross county lines

Kurt Dahl, the Pitkin County environmental health manager who works on the local contact-tracing team, said that regardless of whether a positive case discovered in Pitkin County is among its residents, contact tracers will reach out to that person and instruct them to isolate for 14 days and will contact any other people who may have been exposed to those positive cases.

“We find there isn’t a significant amount of crossover” between visitors who test positive in Pitkin County and county residents, Vance said. Visitors tend to expose the friends and family members with whom they are traveling in their social bubble, he said.

There is more crossover between residents of Pitkin County and residents of either Eagle County or Garfield County, Vance said. Such crossover often occurs in what he termed “higher risk” workplace settings, where the jobs require being in close proximity to colleagues or customers.

The county has identified carpooling as a transmission risk for nonresidents coming to Pitkin County for work, impacting the construction trades particularly. In response, officials recently published guidelines recommending that carpools limit their occupancy to 50% of a vehicle’s capacity, with all riders wearing masks and sitting next to an open window.

The county also is “shifting the focus to make sure we are being equitable in the information we share,” Vance said. That means that all guidelines and notices are published in both English and Spanish.

Another concern impacting the regional workforce is employees worrying they may face punishment if they call in sick.

“How do we support those individuals that are worried about those consequences?” Vance said.

The sharing of information among the three counties of the Roaring Fork Valley region also is critical.

Patrick, the Eagle County communications manager, wrote in an email that its public health team holds “weekly (if not daily) case review discussions with Pitkin and Garfield’s epidemiology teams to discuss cases that live in one county (and) work or attend school in another, in order to provide coordinated response and improved disease surveillance as we know our community lives fluidly across our three counties.”

Eagle County also has “invested significant financial and staff resources in a comprehensive visitor outreach campaign,” Patrick wrote. This includes public health messaging along highways and other highly trafficked thoroughfares; at the airport; in buses; in hotels; in rental properties; and around shops and restaurants where visitors are likely to congregate. The county also has developed a website targeted at visitors — welcometoeaglecounty.com — and social media outreach.

“We are confident that this blanket messaging approach is effectively communicating our public health expectations to visitors,” Patrick wrote, “and in general we are seeing a very high degree of compliance and respect for our local protocols.”

He added that he is working with the communications teams in Pitkin and Garfield counties to try to take as cohesive an approach as possible in reaching both visitors and residents who commute across county lines.

“It is in everyone’s best interest that we follow the same guidelines and adhere to the same expectations where practicable,” Patrick wrote, “and I believe we are getting closer to that point every day.”

Aspen Journalism is a local, nonprofit, investigative journalism organization. For more, go to aspenjournalism.org.