In late July, at one of his weekly COVID press conferences, Gov. Steve Bullock said young people have been driving the spread of COVID-19 throughout Montana.

“We’re seeing more and more that the younger age groups are contributing to our increase in cases,” Bullock said.

At the press conference, Caty Gondeiro, a 23-year-old Helena resident, shared her personal COVID-19 story. Gondeiro didn’t know where she contracted it, but said she hadn’t been taking the virus too seriously. She developed moderate symptoms, and more than three weeks after testing positive she still struggled to take walks. But she said she was less concerned about herself than about the people in her life who might not recover if she passed the virus on to them.

“We’re driving the spread of this. While we may recover from this, we have people in our lives that won’t,” Gondeiro said.

The message was aimed at people under the age of 40, who have accounted for 54.4% of all cases across Montana through mid-September, and a much higher number in some areas.

The World Health Organization has noted a similar trend worldwide. While young people who contract COVID-19 often don’t get as sick as members of more vulnerable populations do, they are amplifying the spread of the virus through their interactions with a larger number of people.

In recent weeks, Montana has experienced its largest outbreak since the beginning of the pandemic. Since that July press conference, the state’s death toll from COVID-19 has more than tripled to 165 deaths as of Sept. 24. The total number of recorded cases statewide has increased from 3,676 to 11,242 in that same span.

The outbreak has been significantly driven by students returning to school and by young people in their 20s and 30s.

Over the past two weeks, there has been a 50% increase in cases afflicting people from age 20 to 39, said Stacey Anderson, lead epidemiologist for the Montana Department of Public Health and Human Services. They have mostly been infected during attendance at social events, including parties, family gatherings and going to bars, Anderson said.

Aware that young people are a significant vector of COVID’s spread, health departments across Montana have implemented a variety of strategies to help reach young people with information about the virus’ spread, from social media marketing to distribution of masks and sanitizing equipment on college campuses to placing ubiquitous public health messages at bars. The operative theory, based on successful past public health campaigns, is that public health officials have to reach their target audience where they are. Examples include distributing free condoms on college campuses, helping hairstylists recognize signs of domestic violence and teaching barbers how to educate customers about colon cancer and sexually transmitted infections.

In general, though, reaching young people — especially those who aren’t gathered in institutions like colleges or the military — is difficult. A 2015 review by the National Academy of Sciences found that “there is limited evidence on these difficult-to-reach populations and on what strategies may be most effective in engaging them so they are better able to recognize and care about the potential risks they create or encounter.”

Additionally, the review found that public health campaigns can be less likely to benefit people who are economically or educationally disadvantaged.

Younger people are “the ones who attend weddings. We’ve had several outbreaks associated with weddings. Or they’re service workers. We found they hang out together after work, and go out and socialize at bars and have parties,” Flathead City-County Health Officer Tamalee St. James Robinson said.

She later added: “I’m not sure how you reach them. Social media has been our best attempt. Facebook, stuff like that. I don’t know, they’re a hard group to reach.”

SOCIAL MEDIA

One of the most effective ways to reach younger people, the National Academy of Sciences review found, is social media. Public health officials in both Gallatin and Flathead counties said social media has been a target of their outreach efforts.

Whitney Bermes, a spokeswoman for Gallatin County, said the department has used age-targeted Spotify and YouTube ads to get its messages across. Flathead County is focusing on Facebook, Robinson said.

Barbara Schneeman, a spokeswoman for RiverStone Health in Yellowstone County, said the county is also developing a social media plan aimed at young adults. In Missoula, the health department has created YouTube videos to provide updates on the virus as it spreads, with the videos racking up hundreds of views.

Recruiting celebrity spokespeople has also been a focus for outreach campaigns across the state. Football coaches at Montana State and the University of Montana participated in a public service announcement for the state’s Mask Up Montana campaign. Actor and part-time Montana resident Jeff Bridges delivered a 30-second digital public service announcement for the Montana Hospital Association. At the national level, National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci went on the popular Barstool Sports podcast aimed at young people and was interviewed for a cover story in InStyle Magazine.

BAR OUTREACH AND THE SERVICE INDUSTRY

Bars are also increasingly considered hotspots for transmission of COVID-19. With both service workers and bar clientele tending to be younger, such public gathering spaces are likely contributing to the spread of COVID-19 among people in their 20s and 30s, said Park County Health Officer Dr. Laurel Desnick.

Park County recently conducted an analysis of contact tracing data that shows how and where cases are spreading in the county. The results were unsurprising, Desnick said. Bars were one of the main locations where COVID is being spread.

“Developmentally, this is the age group that is more social. It makes sense they are the ones that are free to be out. This is the way this society works,” Desnick said.

Nick Chinman, a salesman at Bronken’s Distributing in Bozeman, has worked with bars in Gallatin County to create universal signage encouraging people to take measures to protect themselves, such as wearing masks and maintaining social distancing. Chinman, who works in both Bozeman and Big Sky, said many Bozeman bars told him they were serving very few locals. He said he took the signage idea from the Chamber of Commerce in Big Sky, where his clients were reporting more local business.

Together with people including Mike Hope, owner of the Rocking R Bar in Bozeman, they created consistent signage, including handouts to put on tables encouraging people to keep six feet apart and a banner over Main Street.

Hope said the bar had to shut down for two weeks in July after an outbreak among staff. He said he sees his workers, as well as workers from other bars in downtown Bozeman, spending time together hanging out after work.

“Sometimes they’re the customer too, when they’re not working,” Hope said.

Hope said he is taking precautions to try to make the bar safer during the pandemic. The Rocking R’s occupancy level is normally 312 people, but the bar is now limiting its capacity to 75. The business today works like this: Wait at the door to be seated. Wear your mask until you get to your seat or table. If you’re sitting at the bar, you must be at least two barstools away from the next party.

EFFECTS ON YOUNG PEOPLE

One part of the message that should be stressed is that COVID-19 can be a serious disease even for young people, Schneeman said.

Yellowstone County has seen at least one death of a person in their 30s. Statewide, three people in their 30s have died of COVID-19.

“This is a disease that younger people can also die from,” Schneeman said.

Robinson said one of the main difficulties in reaching younger people is that they think they won’t get sick.

“It’s just a really hard population. They see themselves as invincible,” Robinson said.

But young adults are not immune to the effects of COVID-19, studies have increasingly shown. About one-third of young adults age 18 to 25 are medically vulnerable to COVID-19, with pre-existing conditions like obesity and hypertension leading to adverse effects, according to a July study from the University of California San Francisco.

More than half of people who are infected with COVID-19 develop lung deformities, and up to 20% of people who become sick with the disease develop long-term heart damage. Once they are in hospital, young adults age 18 to 34 are twice as likely to die from COVID-19 as from a heart attack, according to a recent Harvard study.

‘DEFINITELY SEEING WORKPLACE SPREAD’

Yellowstone County has had the largest outbreak of COVID-19 in Montana, with 2,990 recorded cases as of Sept. 24. An analysis of August positive test results by RiverStone Health found that about 44% of Yellowstone County residents who were infected during that month did not report a known contact who tested positive for COVID-19, Schneeman said.

Of that 44%, the most common shared characteristic is that 64% had been to work outside the home. A little more than half had been shopping, while only 27% had patronized a restaurant or bar.

“We’re definitely seeing workplace spread,” Schneeman said.

Among the most vulnerable are front-line workers who interact with the public. That includes bartenders, who serve unmasked customers sitting at a bar and facing them for long periods of time, Robinson said.

In Park County, the health department surveyed people at a community-wide testing event in June about their COVID-19 circumstances in order to get a read on community attitudes. Nearly a third of respondents said they continue to work even though they don’t feel safe at their jobs, Desnick said.

That attitude has been especially pronounced in the service industry, Desnick said. Park County set up surveillance testing of tourist-facing businesses near Yellowstone’s northern entrance. During that ongoing testing, many workers have reported that they don’t feel safe interacting with tourists from across the country hour after hour, day after day, she said.

At the same time, it’s common for young service workers at restaurants and bars to socialize over drinks after work or visit co-workers’ homes to wind down after their shifts, increasing the risk of viral spread, Desnick said.

“It’s just a very hard needle to thread,” Desnick said. “We’re asking them to go to work in very vulnerable places, and we’re blaming them for being vulnerable in the rest of their lives.”

Robinson said it’s just part of being young.

“They’re just a social entity of society, and they’re going to find a way to be social,” Robinson said.

Desnick said she doesn’t blame the workers, who have little choice but to continue working during the pandemic.

“It’s hard to maintain good judgment in a pressure cooker,” she said.