Gov. Janet Mills’ administration is rebuilding a public health system decimated under her predecessor, but key positions vital to confronting the coronavirus crisis – such as public health nurses, epidemiologists and lab technicians – remain vacant.

A state law enacted in 2017, when Paul LePage was governor, requires the governor to staff all public health nursing positions approved by the Legislature, which at the time was 59 positions, including 48 front-line nurses. But when LePage left office Jan. 1, 2019, just over 20 nurses were employed.

Today, state officials say 38 people are employed in the public health nursing program, including 24 front-line nurses, which is well below the threshold set in 2017.

A spokesperson for the Maine Department of Health and Human Services said the state has “aggressively recruited” to fill the positions and is committed to restoring public health nurses throughout the state. Despite the vacancies, the state Center for Disease Control and Prevention says it is prepared to handle COVID-19, the disease caused by the novel coronavirus.

“In the event that Maine CDC encounters any issues, it will deploy contingency plans, which are a core function of public health preparedness, to ensure appropriate staffing and allocation of resources,” DHHS spokeswoman Jackie Farwell said in an email.

Those contingency plans, she said, include “identifying, monitoring and mitigating risks, such as supply chain interruptions or staffing challenges. Actions resulting from these plans are designed to reduce the likelihood and severity of these risks to lessen their impact.”

As of Tuesday, 32 people in Maine had tested positive for COVID-19, including at least 17 in Cumberland County and three hospitalizations, according to the CDC. Another 1,303 people have tested negative.

Over the weekend, the health emergency entered a new phase, as new cases were detected in people who had not traveled out of state state or to a country with a documented outbreak, or had close contact with someone who had tested positive. This is known as a community transmission.

During public health emergencies, public health nurses are tasked with providing important information to communities and health care providers that can stop the spread of infectious diseases. Public health nurses partnered with other providers, including school nurses, to provide vaccinations during the H1N1 flu outbreak in 2009.

Over the summer, public health nurses were deployed to the Portland Expo in Portland to vaccinate and conduct health checks on hundreds of migrant families who had arrived unexpectedly. During the ice storm of 1998, nurses went door-to-door to check on people.

Public health nurses are currently providing guidance about which patients should be tested for coronavirus through a state CDC hotline and in-home visits. As of Tuesday, public nurses had fielded more than 2,000 calls on the CDC’s hotline from physicians with questions about testing patients for COVID-19.

Dr. Nirav Shah, director of the Maine CDC, said his agency is seeing evidence of community transmission but only in Cumberland County. A school nurse said a 12-year-old boy at Cape Elizabeth Middle School who tested positive for COVID-19 likely contracted the illness through community transmission.

“At this time, we have evidence of community transmission only in Cumberland County,” Shah told reporters Tuesday. “We expect there to be evidence of community transmission detected in other areas of Maine as we have seen across the northeast and certainly in New England.”

The emergency has prompted unprecedented action, including the closures of many public schools, a planned early adjournment of the Legislature and other government offices closing to the public. Portland officials declared an emergency, forcing bars, restaurants and other gathering places to be closed on St. Patrick’s Day, and requiring those businesses to be closed from 8 p.m. to 2 a.m. daily.

Mills has declared a civil emergency and ordered insurers to cover the cost of coronavirus testing, as well as tapping the Small Business Association for loans to support struggling businesses. She’s also recommended the cancellation of gatherings of 50 or more people, among other actions.

As the health emergency enters a new phase of community transmission, questions are being raised about whether the state has enough public health staffing to keep up.

Unlike other states, Maine does not have county public health programs, and only two municipalities – Bangor and Portland – have public health departments. That leaves the lion’s share of public health duties – which include disease prevention, education, investigation and response – to state government.

During his two terms, LePage failed to fill a variety of public health positions. He eliminated 111 positions within the Maine CDC, while refusing to hire for vacant positions, Farwell said.

Public health nurses, who typically earn between $46,000 and $61,000, work under the Maine CDC, which is an office within the state DHHS.

In fiscal 2020, the CDC had a $113 million budget, with $18.2 million coming from the state’s general fund, $65.3 million from the federal government, and the rest from other sources. The level of state funding increased by nearly $2.2 million over the previous year.

Mills announced Tuesday that her revised, $73 million supplemental budget includes including $1 million for the CDC to supplement federal funds to expand capacity at the state lab, and to hire and retain critical health care personnel including epidemiologists and public health nurses to respond to the pandemic. She has requested 14 additional positions, Farwell said.

Rebuilding public health has been a priority for both Mills and DHHS Commissioner Jeanne Lambrew, Farwell said.

The CDC had 249 positions – of which 73 were vacant – as of January 2019, shortly after Mills took office, Farwell said. But, as of March 13, the CDC had 276 employees, including 46 vacancies. Much of the progress, Farwell said, has come in the public health nursing and chronic disease prevention programs.

Dr. Rebecca Boulos, the director of the Maine Public Health Association, which represents public health and nonprofit nurses, said public health nurses are fixtures in their communities, who often know people who are particularly vulnerable to outbreaks, especially home-bound seniors and other residents in rural areas that lack internet and cell service.

The Association of State and Territorial Health Officials recommended one nurse per 5,000 residents, not considering a state’s geography, rural nature, health disparities, poverty or other measures. By that measure, Boulos said, Maine should have 263 public health nurses – more than 10 times the 24 nurses Maine now has.

“In times like this, when it’s all hands on deck, that local connection and the trusted health care professional is so important to helping people realize if they have symptoms and making sure they have the resources to get tested,” Boulos said.

State Sen. Brownie Carson, D-Harpswell, has been advocating for more public health resources since LePage was governor and public health nurse staffing dropped from 59 in 2011 to the low 20s when he left.

The Legislature in 2017 overrode LePage’s veto of Carson’s bill requiring the state to fill all of the public health nursing positions approved by the Legislature, which at the time was 59, including 48 field nurses.

After his law passed, Carson sued the administration for refusing to hire two qualified nurses for two of those positions. A superior court judge ended the lawsuit last July, after finding the Mills administration was substantially complying with the 2017 law.

Carson said the current emergency shows the importance of public health nurses in responding to disease outbreaks. He’s calling on Mills and the CDC to ramp up recruitment efforts for public health nurses, who are on the front lines in their communities and know who is vulnerable, especially in rural areas.

“They need to do more and they need to do more now, because the lives of Mainers depend on it,” Carson said. “I believe and I hope this administration gets it.”

Farwell, the DHHS spokeswoman, said the department has “aggressively recruited” for all vacant positions and said a shortage of nurses is making it difficult to reach full staffing.

Cokie Giles, president of the Maine State Nurses Association, said Maine is not alone when it comes to having an inadequate public health system. She pushes back on the theory that there’s a nursing shortage. She argues that nurses just don’t want to work in a broken system. She pointed to California, which she said saw thousands of nurses fill vacancies after hospitals reduced patient ratios.

“Our country as a whole is woefully behind in public health,” Giles said. “We really don’t have a public health system. It’s been going down for years.”

The New York Times reported that national, state and local public health departments have lost nearly 25 percent of their workforce since 2008, forcing some departments to shift focus from other duties to tackling the coronavirus.

But that’s not a step Maine has had to take, Farwell said.

“Maine CDC has not reassigned staff from one division to another as part of COVID-19 preparedness and response,” she said.

In addition to the 17 vacant public health nurse positions, there are six vacant positions in the state’s testing lab, which is processing coronavirus samples, according to the state. Two epidemiologist positions are also vacant. Shah has described epidemiologists as “disease detectives,” who investigate how an individual may have contracted a disease, where they traveled and to whom they may have spread it.

The state has 14 infectious disease and medical epidemiologists, and has contracted a former epidemiologist to help respond to the coronavirus crisis, Farwell said.

As of Thursday, the state listed job openings on its website for only a handful of public health nursing positions, but none for epidemiologists or lab workers.

Sarah DeCato was a state public health nurse for six years before she left in 2014. During that time, she and other nurses were deployed to vaccinate schoolchildren and other Mainers during the H1N1 flu outbreak in 2009 and later a Hepatitis A outbreak.

She said public health nurses are “essential staff during times of a pandemic.” She and Carson would like the Mills administration to be more transparent about its progress in hiring more nurses and its recruiting efforts.

“This (emergency) is a prime example of why it’s so important to have a strong public health workforce and that has to include a strong public health nursing department,” DeCato said.