State and county health officials, as well as the leadership of a Bremerton hospital, knew Aug. 13 that at least three employees and two patients there had COVID-19. An outbreak was declared the following day.

But the public wasn’t told for another week. And some hospital employees say they found out at the same time the public did.

The state Department of Health (DOH) says it’s up to local health departments to decide when to notify the public of an outbreak. A spokesperson for the Kitsap Public Health District said the outbreak was small, contained to one unit of the hospital, and cited federal laws governing the privacy of health information.

“We are very careful with the level of public information we release regarding cases at specific facilities, especially when a small number of cases is involved,” health district spokesperson Tad Sooter of the health district wrote in an email.

When the public was notified, it was via a joint news release from the health district and the DOH, sent out on a late Friday afternoon, Aug. 21, a day after the health district notified the state and a full week after the outbreak was declared.

At least three patients who were admitted in that intervening week now have coronavirus infections that are linked to the outbreak.

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As of Sept. 2, the hospital has confirmed 65 cases: 44 staff members and 21 patients.

St. Michael Medical Center, part of the Tacoma-based CHI Franciscan system, is the largest hospital and main health care option for many residents of Kitsap County.

Local health departments can declare an outbreak when a hospital has two or more confirmed cases, or one probable case and one confirmed case; at least two of the cases began within 14 days of each other; and there’s a plausible link between the cases with no other known connection outside the workplace.

But the guidance is less clear for when to notify the public about an outbreak. Local health districts are responsible for those decisions, said state Secretary of Health John Wiesman.

“What we really encourage is the hospital to communicate with their employees and their staff transparently and timely,” he said. “And that’s the expectation we hold them to.”

The hospital contacted patients and staff in the affected unit when it became aware of the first five cases, said Dr. Michael H. Anderson, CHI Franciscan’s chief medical officer.

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But some other employees at St. Michael said hospital leadership didn’t tell them about the outbreak, and they instead learned of it through news reports and a visit from the federal Centers for Disease Control and Prevention — which had also been notified Aug. 21.

“Workers realized there was a problem when people with the ‘CDC’ across their chest showed up,” Cindy Franck, a nurse at St. Michael’s, said during a news conference held last week by UFCW 21, the union representing health care workers at the hospital. “We should have been notified about that.”

Kitsap Public Health registered the outbreak in the Washington Disease Reporting System on Aug. 14. The health district formally notified DOH on Aug. 20, as cases were discovered in three more units of the hospital.

That spread beyond one unit was what prompted the health district to make a public declaration, Sooter said.

It isn’t uncommon for public health districts and hospitals to cite the federal health information privacy law known as HIPAA — the Health Insurance Portability and Accountability Act — when making decisions about publicizing a disease outbreak, said Tanya Karwaki, a Health Law Fellow at West Virginia University’s College of Law.

“Sometimes this is true, and sometimes it is just a shield that makes folks back down because of our cultural preference for privacy and a federal law one can hide behind,” she said, noting she doesn’t know which was the case with the St. Michael outbreak.

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But, generally, information about infected people can be anonymized to avoid breaking federal laws about health information, Karwaki said.

Since announcing the outbreak publicly, the health district has recommended the hospital screen staff before work, continue testing employees and patients, restrict visitors and limit movement between departments.

Since Aug. 21, St. Michael has tested at least 2,000 of its 2,100 employees and screens them before they enter the building, according to the hospital’s website. This has resulted in 137 employees being quarantined while awaiting test results; nonemergency procedures have been limited while these quarantines affect staffing levels.

The hospital also says it tests all patients when they’re admitted, before procedures and upon discharge, and isolates patients who are confirmed or suspected to have the virus.

The state is leading an investigation into the outbreak, which appears to be the largest at any hospital in the Puget Sound region. No hospital outbreaks have been reported in Pierce County. Snohomish County had a small one at the end of March. By press time, Public Health – Seattle & King County didn’t have information on King County hospital outbreaks.

The state’s largest psychiatric hospital, Western State Hospital in Lakewood, Pierce County, had an outbreak earlier this summer in which one patient died. Seventy-three employees and 23 patients had COVID-19 at Western State; three patients and three staffers are still sick.