After the nation’s initial case of a new coronavirus was diagnosed in January in Snohomish County, state health officials knew they would need to establish a hotline for worried callers.

So the state Department of Health (DOH) turned to the Poison Center, the nonprofit organization with a 24-hour emergency line, which successfully sprang into action during a 2015 measles outbreak.

But the coronavirus and COVID-19, the illness it causes, proved to be a very different kind of outbreak. Public interest surged after the first reported death in February, and the volume “quickly outstripped” the capacity of four Poison Center workers, a health department spokeswoman said.

It wasn’t until March 5, after state officials put out a plea for workers across the DOH to pitch in, that staffing increased. Even then, wait times peaked at 38 minutes. On Saturday, the agency switched to a new vendor, hoping to ease the bottleneck.

As the rest of the nation ramps up its coronavirus response, Washington provides some early lessons on public communication. The state and King County both stumbled in setting up public information hotlines, creating confusion and frustration. Too few operators, technical snafus and contradicting messages from health care providers have all hampered the usefulness of the call centers.

While they still provide comfort to many, the hotlines have become another symbol of a bureaucracy unready for the crisis.

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Typically, “call centers clarify doubts or questions the population may have,” said Elena Savoia, an emergency preparedness expert at the Harvard T.H. Chan School of Public Health in Boston. But “inconsistency generates mistrust in the response,” she said, making it less likely that people will follow public health recommendations.

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Oxana Sistla was one of the callers looking for answers. She picked up the phone when her husband’s fever climbed past 101 degrees and he couldn’t stop coughing. The day before, on March 3, his Seattle company announced a worker had tested positive for COVID-19.

Sistla, 33, first called her husband’s doctor. A nurse said he needed to get tested, based on his symptoms, and to contact a local emergency room. Sistla tried calling a nearby hospital, which instructed her to call the state coronavirus hotline — which was closed for the night. Its after-hours message said to call the hotline run by Public Health – Seattle & King County.

Sistla called the county the next morning and waited on hold for more than 15 minutes, then hung up and tried the state hotline again. There she finally talked to someone, who told her to call her primary care doctor.

“That’s when I came full circle, and I said, ‘thanks for nothing,’” Sistla said. “You can only cure fear with information. That’s why I called them, but it didn’t help much.”

Only 10 callers at a time

DOH spokeswoman Amy Reynolds said the department acted quickly, but was caught off guard by the mass of callers. “We were not as quick to respond to the volume as we would like, but we were up and running within three days,” she said.

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Even after DOH added a dozen staffers to the Poison Center’s four-person operator staff in early March, its phone system wasn’t ready for the onslaught of calls. The technology limited the number of people holding at any given time to 10 callers, Reynolds said. With an average call length in excess of five minutes, the phones were easily jammed.

“These aren’t short question-and-answer calls,” said Cory Portner, a DOH operations section chief who was managing calls last week. “A lot of folks have personal stories to tell. They want to have somebody to talk to.”

Staffing a disease crisis hotline is challenging, experts say, because calls can spike after high-profile events such as death announcements or major government actions. Calls surged when Gov. Jay Inslee, for instance, restricted gatherings of more than 250 people in certain counties last week.

“You can have a moderate amount of volume and then something happens in the world you didn’t anticipate and it doubles your calls,” said John Auerbach, president and CEO of Trust for America’s Health, a public health advocacy group.

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DOH officials began searching for a new vendor to manage the hotline weeks ago, but as procurement and operator training dragged on, the number of calls kept climbing. Last Tuesday the call center received more than 900 calls in 16 hours of operation, or about a call a minute. A note on the state coronavirus web page said the hotline was “experiencing high traffic and may be temporarily unavailable.”

The state hotline was run from a computer training room in Tumwater until Saturday, when the state switched to its new vendor, Washington 2-1-1, a nonprofit that provides referrals to local services. It plans to have 26 people working full time, with a system set to handle more than 100 callers at a time, Reynolds said.

A frustrating experience

It wasn’t just the state that was unprepared for the rush of questions. Counties — which are responsible for tracing the spread of infectious diseases locally — have also struggled to handle the volume.

The state hotline is meant to provide information about the virus and the government’s response, while county hotlines are typically geared towards residents who believe they were exposed to COVID-19, the illness caused by the coronavirus.

Kate Macfarlane, 31, has the autoimmune disease lupus, so when she came down with a cough and fever on March 2, she started by calling her doctor’s office at the Polyclinic. She expected to be tested for COVID-19 because of her weakened immune system.

“I was trying to do the right thing and make sure I wasn’t exposing other people,” Macfarlane said.

Her doctor’s office told her to call the Public Health – Seattle & King County hotline because, they told her, the county was in charge of testing.

“It would go through, then I would sit on hold for a while, then it would just disconnect,” Macfarlane said. “It was a frustrating experience.”

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The number they gave her was the longstanding line for reporting hepatitis A, measles, and other communicable diseases. At the time, the county had not yet launched its dedicated coronavirus hotline.

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Public Health – Seattle & King County in early March was instructing doctors to evaluate patients for COVID-19 symptoms, and to call the epidemiology line themselves (not the patient). Some providers, however, gave that number to patients, who called in droves and overwhelmed the system.

“We are working diligently to ensure all staff and providers are updated and trained on the latest screening and testing recommendations for COVID-19,” Karen Johnson, a Polyclinic spokeswoman, said in a statement.

Doctors and other health care providers have been trying to align their messaging with public health officials, said Dr. Nariman Heshmati, the associate medical director of surgery at the Everett Clinic.

“Everyone is really trying to coordinate the response because this really does change moment to moment,” he said.

Calls centers closed at night

On March 3, three days after the first patient died in the county, Public Health – Seattle & King County opened its coronavirus hotline. Agency spokeswoman Hilary Karasz said they started the line as soon as it was ready.

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“Simply having people to answer calls and the technology to facilitate that is not enough,” Karasz said in a statement. “Staff need to be trained, information needs to flow to the people receiving the call … In a very dynamic and fast moving situation – that changes from hour to hour and day to day — this is difficult.”

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Up to 30 people have been available in recent weeks to answer calls, but the county hotline has had its own limitations.

Some have tried reaching the hotline at night, hoping to avoid a daytime rush, only to find the call center closed. The county’s line is open 8 a.m. to 7 p.m. — more limited hours than the 24-hour hotline called for in King County’s own Pandemic Influenza Response Plan.

Volunteers from the Public Health Reserve Corps, made up of local medical professionals and others, have been manning the phones in addition to Public Health staff. The agency is recruiting other volunteers with medical experience; some now are being trained and their backgrounds screened.

Since the county hotline launched, the call volume has subsided and hold times have dropped. On March 4, the county received 1,549 calls, and the average hold time was 37 minutes. Most people hung up before their call was answered. By March 12, there were fewer than 800 callers, with a two-minute average hold time.

Public health officials say the staffing and technology can’t solve the biggest problem that has frustrated both hotline operators and callers: the lack of available COVID-19 tests. About 80% of callers to the state hotline are sick people, wondering what they should do and where they should go, said Tim Schlender, one of the lead operators at the Department of Health.

“They might just demand a test,” he said last week. “But we don’t have a magic pass to get testing because we’re the Department of Health. People get frustrated because they call us and they want definitive answers.”

For information by phone about the coronavirus, call the Washington State Department of Health, 800-525-0127, or Public Health – Seattle & King County, 206-477-3977.