PROVINCETOWN — The board of health and select board held their second emergency joint meeting in only seven days on July 25 and imposed an indoor mask mandate, effective immediately.

The cause was the rising case count in the “Provincetown Covid-19 cluster” — which, as of July 23, included 171 Provincetown residents, 223 other people in Massachusettts, and 157 people who live out of state.

The boards also voted to give Town Manager Alex Morse the power to adjust the mask mandate in response to changing rates of positive Covid tests, and the power to impose other restrictions, such as capacity limitations on businesses.

Only six days earlier, on July 19, the same two boards had enacted an indoor mask advisory. That was in response to the first significant data about the “Provincetown cluster,” which had been presented by Barnstable County and the state Dept. of Public Health that morning. In that first presentation, the total confirmed case count was 132, including 38 cases among Provincetown residents.

By Wednesday, July 21, the total count had risen to 256. By Saturday morning, the 24th, the count had risen to 430, and at the Sunday evening presentation it was 551.

Select board member Bobby Anthony proposed requiring universal masking indoors and outdoors throughout the town, but his motion was not seconded. Select board member Leslie Sandberg later asked for required outdoor masking on Commercial Street only, but with only two apparent votes in favor and three declared votes against, she withdrew her motion.

Indoor and outdoor masking were the only significant policy options discussed at length at the emergency meeting. While the boards also gave Town Manager Morse authority to enact “further restrictions” little was said about what that might actually mean.

That and other responses to the crisis were discussed at the regular select board meeting on July 26. Chair David Abramson asked what authority the town might have to order businesses to require vaccination of their customers.

“It gets a little tricky, legally,” said Morse. “I’m consulting with our legal counsel to find out what rights a municipality has, in terms of licensees and businesses in town.

“Businesses have the right to require it,” Morse continued. “Any business owner listening should impose a vaccine requirement. If we have the right incentives, we can send the message: if you’re not vaccinated, you’re not going to be able to do much while you’re here.”

Abramson asked if employers could require employees to be vaccinated. Some have told employees to either get vaccinated or get a negative test on a regular basis, said Morse.

“There are legal ways to do that,” he said. “People want to know they’re going into a business where the employees are vaccinated.”

Sandberg asked about requiring vaccination of town staff. “We are having those conversations with town counsel,” said Morse. “It’s likely a combination of a vaccine requirement, or, if not vaccinated, you have to provide a medically eligible reason for why you cannot get vaccinated.”

Outside Provincetown, positions on mandatory vaccinations shifted over the weekend. Only a handful of large hospital chains had previously announced vaccination requirements, for example, but on Monday, July 26, the American Medical Association, American Nurses Association, and nearly 60 other medical groups endorsed mandatory Covid vaccination for all health care workers.

Also on Monday, New York City and California announced a get-vaccinated-or-get-tested-weekly requirement for all their employees. California’s rules will apply to the entire health-care industry in that state, effective Aug. 23.

Select board member John Golden also asked what the capacity restrictions on businesses might actually look like, and if “there’s any sense of whether we will be going there or not.”

“If we saw the positivity rate go back up, or stay flat and not decline, we would look more closely at capacity guidelines,” said Morse. “The decision last night does a good job protecting many of our people that depend on the economy in the summer, while not forcing businesses to close. The reason we are doing this is to accelerate that decrease [in the positivity rate] and get back to what is gonna be a new normal.”

Daily Positivity Rate

The daily positivity rate, which is the percent of tests on a given day that come back positive for Covid, is now going to be used as a key benchmark for town policy. The joint order on Sunday delegates control over the mask mandate to Town Manager Morse — but it also advises that the mandate remain until the daily positivity rate is below 3 percent for five days in a row.

At that point, the joint order advises, the indoor mask mandate should become a mask advisory, which itself should continue until the daily positivity rate is below 1 percent for five days in a row. Those numbers were 5 percent and 2 percent in the original text of the joint order, but the board of health approved an amendment by vice chair Dr. Susan Troyan to lower the thresholds to 3 and 1.

The daily positivity rate at the Fallon Ambulance mobile testing site in Provincetown has ranged from 15 percent on July 15 to 7 percent on July 23, according to the Barnstable County Health Dept.’s presentation to the joint meeting.

Before the July 4th weekend, nearly every community on Cape Cod, Martha’s Vineyard, and Nantucket were at or near a 1-percent case positivity rate, according to Vaira Harik of the Barnstable County Dept. of Human Services, who presented the data to both boards.

Missing Case Numbers

No data was presented on case positivity rates from July 1 through July 13, even though the “Provincetown Covid-19 cluster” is deemed by the state DPH to have begun on July 1. The Independent has filed a records request for the daily testing and positivity data for those days, when there was a high demand for rapid testing at Outer Cape Health Services’ Provincetown clinic, but hardly any PCR tests were being conducted in town.

Only PCR tests generate “confirmed cases,” and since the beginning of the Provincetown cluster, the state DPH has released data only on “confirmed cases.” As yet, there is no public information on the results of the hundreds of rapid BinaxNOW tests that were performed at OCHS in Provincetown between July 1 and July 14, when the PCR testing at the Fallon Ambulance mobile testing operation began.

Select board member Bobby Anthony asked whether the results of the rapid testing program were being included in the presentation but received contradictory answers from county leaders.

“You’re asking an excellent question,” said Harik. “For a case to be added to the cluster tally, the sample has to be confirmed via PCR testing.”

“So, what Bobby is asking,” said Abramson, “if someone goes to Outer Cape Health, they test positive on a rapid test, that test then goes for a PCR test to confirm the positive, and gets counted in the totals, correct?”

“Yes, it does,” said Sean O’Brien, director of the county health dept. — incorrectly.

“There’s a retest,” admitted Harik. “The BinaxNOW cartridge is not sent for further analysis.  That’s discarded. A new sample from the patient is taken for PCR testing.

“If there are rapid tests that are positive, they are confirmed, is my understanding,” Harik continued. “They go ahead and confirm that by PCR test. If that is in fact still positive, they enter that into the cluster.”

That statement, too, is almost certainly not correct, at least when it comes to the rapid testing program at OCHS.

The state’s guidance to community health centers on the BinaxNOW testing program, issued on Dec. 7, makes it clear that confirmatory PCR tests for positive BinaxNOW testing is not indicated, and is in fact discouraged, when used at community health centers.

Gerry Desautels, communications director at Outer Cape Health Services, also told the Independent in April that confirmatory PCR tests were not taking place at OCHS. “Regarding the BinaxNOW positives, we report them as such without retesting,” wrote Desautels in an email, “following in line with the same reporting protocol by local towns.”