In a pair of cases of systemic failure in the California public health system, passengers on two flights into LAX in March — and the airlines themselves — were not alerted to the fact that someone on board a long-haul flight had tested positive for COVID-19 after landing.

The Los Angeles Times has uncovered two instances in which the LA County public health department traced an early case of COVID-19 in the county back to a recent airline flight, but did nothing to alert passengers and crew on the flight to their potential exposure. On one flight, a retired surgeon from New York City flew to LA on March 19 in order to move into a dementia care facility, and within 24 hours of his arrival he had a fever and productive cough, and needed hospitalization. On another flight 11 days earlier, on March 8, a woman from the Philippines traveling through Seoul, South Korea, boarded an 11-hour flight to LAX after complaining of being feverish. Within two days, she had died of cardiac arrest in LA County, becoming the first confirmed COVID-19 death in the county.

In both instances, contact tracers should have been in touch with the airlines in question — American and Asiana, respectively — and efforts should have been made to have all passengers and crew tested for the virus. It remains unclear how many other people either patient might have infected by being on an airplane with them for many hours.

When told about the two cases, UCSF epidemiologist Dr. George Rutherford reportedly said, "Christ. That's a problem."

Rutherford went on to tell the LA Times, "I would notify everyone on the flight that they had been exposed. We would encourage them to get tested, and we would do an investigation of the people who were seated most closely... and make sure they got tested."

The skilled nursing home where the New York man went to stay, the Silverado Beverly Place, went on to have a major outbreak of COVID-19 by late March, likely caused by him. That outbreak went on to infect 90 residents and staff at the facility, leading to 11 deaths — including that of the 32-year-old nurse who was assigned to welcome him on his first day, Brittany Bruner-Ringo. Bruner-Ringo's family has said she reported that the man was symptomatic when he arrived, but the nursing home has denied this, saying he did not show symptoms until the following day.

American Airlines has said that it only heard about this man's case from the LA Times in recent days.

In the case of the Asiana flight, it's not clear how many passengers or crew might have been affected, but the family of the woman who died said they heard that a friend of a relative who drove the woman home from the airport later died of COVID-19.

Now both the county health department and the Centers for Disease Control are blaming each other for the lapses. The health department says in a statement, "In March, whenever Public Health was aware that an individual traveled on an airline while potentially infectious with COVID-19, it notified the CDC."

And the CDC says of the Asiana flight, "This flight is not in our contact investigation database, and CDC did not receive inquiries about this flight." However the woman's daughter says that a contact tracer specifically asked for the woman's flight number and seat assignment.

According to the county, in the case of the New York man, "the contact information provided for the individual was incomplete and the investigator was not able to conduct an interview." The man is reportedly of questionable mental competency, and remains unclear why the investigator would not have sought information about his arrival from the nursing home.

There were 154 people aboard Asiana Airlines Flight 202 from Seoul to LAX on March 8. And there were 49 people on American Airlines flight 341 from JFK to LAX on March 19.

The CDC says that it has conducted contact-tracing investigations pertaining to 392 air travelers since the pandemic began. But the Times' investigation now calls into question how many other flights might have slipped through to the cracks as potentially under-trained contact tracers have gone about investigating such cases.

Also, disturbingly, we learn that regulations only require contact tracers to inform airline passengers in the same row, or within two rows of a confirmed infected patient. And according to studies done by the CDC itself in the last decade, "there are jurisdictional and data-access challenges to tracing and alerting passengers" in these situations, due to the web of international, state, and local laws that must be followed, in addition to regulations by individual airlines.

This lates report is yet another that erodes public confidence in the efficacy of the CDC. As Dr. Peter Lurie, a former associate commissioner at the Food and Drug Administration, said in this June report from the New York Times, "Here is an agency that has been waiting its entire existence for this moment. And then they flub it."

Los Angeles County Department of Public Health Director Dr. Sharon Balter said in the same report that the CDC's system for cataloguing and tracing airline passengers went off-line in mid-February, and the county health department was told just to stop trying to trace those domestic and international passengers after they landed in LA. "It was insane," Balter said.

Related: California's Surge in COVID-19 Cases Linked to Increased Testing, CHHS Secretary Says

Photo: Alev Takil