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Let’s Find Out

This afternoon the Governor issued an executive order stating the Arizonans “shall limit their time away from their place of residence or property” with some exceptions. Let’s explore what those exceptions are, ok?

One exception category is for what’s called “essential activities”. Another category is “essential functions”. A third exemption category is for what’s called “essential business services”. So, the stay at home order covers everything but those exceptions.

Let’s unpack what those words essential activities, essential functions, and essential business services mean under the Order (the exceptions). As you explore the list of exceptions try to find something that’s not on the list. At the end, you can answer this question for yourself, “does this make any real changes to what was happening before the Order? “

Let’s dig into the exemptions:

• Essential Infrastructure Operations: includes but is not limited to: food production, distributions, and sale; construction (including, but not limited to, construction required in response to this public health emergency, hospital construction, construction of long-term care facilities, public works construction, and housing construction); building management and maintenance; landscape management; airport operations; operation and maintenance of utilities, including water, sewer and gas; electrical (including power generations, distribution, and production of raw materials); distribution centers; oil and biofuel refining; roads, highways, railroads and public transportation; ports; cybersecurity operations; flood control; solid waste and recycling collection and removal; internet, video and telecommunications systems (including the provision of essential global, national, and local infrastructure for computing services, business infrastructure communications and web-based services). Essential Infrastructure shall be construed broadly to avoid any impacts to essential infrastructure, broadly defined.

• Essential Businesses and Operations: includes but is not limited to Healthcare and Public Health Operations, Human Services Operations, Essential Governmental Functions and Essential Infrastructure Operations as well as the following:

  • Stores that sell groceries and medicine: Grocery stores, pharmacies, certified farmers’ markets, farm and produce stands, supermarkets, convenience stores, and other establishments engaged in the retail sale of groceries, canned food, dry goods, frozen foods, fresh fruits and vegetables, pet supplies, fresh meats, fish and poultry, alcoholic and non-alcoholic beverages, and any other household stores that sell groceries, medicine, including medication not requiring a medical prescription, and also that sell other non-grocery products, and products necessary to maintaining the safety, sanitation and essential operation of residences and Essential Businesses and Operations.

  • Food, beverage and agriculture: Food and beverage manufacturing, production, processing, and cultivation, including farming, livestock, fishing, baking; and other production of agriculture, including cultivation, marketing, production, and distribution of animals and goods for consumption and businesses that provide food, shelter and other necessities for life for animals, including animal shelters, rescues, shelters, kennels and adoption facilities.

  • Outdoor recreation activities: any outdoor recreation area, park, site or trail that provides opportunities for outdoor recreation with social distancing such as walking, hiking and biking. This includes golf courses if restrictions on food and beverage service under Executive Order 2020-09 are followed.

  • Organizations that provide charitable and social services: Businesses and religious and secular nonprofit organizations, including food banks, when providing food, shelter and social services and other necessities of life for economically disadvantaged or otherwise vulnerable individuals who need assistance as a result of this emergency and people with disabilities.

  • Media: Newspapers, television, radio and other media services.

  • Gas stations and businesses needed for transportation: Gas stations and auto-supply, auto-repair and related facilities including (including vehicle sales), truck stops, and bicycle shops and related facilities.

  • Financial institutions: Banks, currency exchanges, consumer lenders, including but not limited to payday lenders, pawnbrokers, consumer installment lenders and sales finance lenders, credit unions, appraisers, title companies, financial markets, trading and futures exchanges, affiliates of financial institutions, entities that issue bonds, related financial institutions and institutions selling financial products.

  • Hardware and supply stores: Hardware stores and businesses that sell electrical, plumbing and heating materials.

  • Critical trades: Building and Construction Tradesmen and Tradeswomen and other trades including but not limited to plumbers, electricians, exterminators, cleaning and janitorial staff for commercial and governmental properties, security staff, operating engineers, HVAC, painting, moving and relocations services, and other service providers who provide services that are necessary to maintaining the safety, sanitation, and essential operation of residences, essential activities and essential businesses and operations.

  • Mail, post, shipping, logistics, delivery and pick-up services: Post offices and other businesses that provide shipping and delivery services, and businesses that ship or deliver groceries, food, alcoholic and non-alcoholic beverages, goods or services to end users or through commercial channels.

  • Educational institutions: Educational institutions-including public and private pre-K-12 schools, colleges and universities-for purposes of facilitating distance learning, performing critical research, or performing essential functions, provided that social distancing of six-feet per person is maintained to the greatest extent possible. This Executive Order is consistent with and does not amend or supersede any order by the Governor and Superintendent in effect to close schools, except that affected schools are ordered closed through April 10, 2020.

  • Laundry services: Laundromats, dry cleaners, industrial laundry services and laundry service providers.

  • Restaurants for consumption off-premises: Restaurants and other facilities that prepare and serve food, but only for consumption off-premises, through such means as in-house delivery, third-party delivery, drive-through, curbside pick-up and carryout. Schools and other entities that typically provide food services to students or members of the public may continue to do so on the condition that the food is provided to students or members of the public on a pick-up and take away basis only. Schools and other entities that provide food services under this exemption shall not permit the food to be eaten at the site where it is provided or at any other gathering site. This order is consistent with and does not supersede Executive Order 2020-09.

  • Supplies to work from home: Businesses that sell, manufacture, or supply products needed for people to work from home or conduct distance learning.

  • Supplies for Essential Businesses and Operations: Businesses that sell, manufacture, or supply other Essential Businesses and Operations with the support or materials necessary to operate, including computers, audio and video electronics, household appliances; IT and telecommunication equipment; hardware, paint, flat glass; electrical, plumbing and heating material; sanitary equipment; personal hygiene and products; food, food additives, ingredients and components; medical and orthopedic equipment; optics and photography equipment; diagnostics, food and beverages, chemicals, soaps and detergent; firearm and ammunition suppliers and retailers for purposes of safety and security.

  • Transportation: Airlines, taxis, transportation network providers (such as Uber and Lyft), vehicle rental services, paratransit, and other private, public and commercial transportation and logistics providers necessary for all categories of “Essential Operations” as defined in this order.

  • Home-based care and services: Home-based care for adults, seniors, children, and/or people with developmental disabilities, intellectual disabilities, substance use disorders, and/or mental illness, including caregivers such as nannies who may travel to the child’s home to provide care and other in-home services including meal delivery.

  • Residential facilities and shelters: Residential facilities and shelters for adults, seniors, children and/or people with developmental disabilities, intellectual disabilities and substance use disorders and/or mental illness.

  • Professional and personal services: Professional services, such as legal services, accounting services, insurance services, personal hygiene services (including barber shops and salons) with additional sanitization precautions as recommended for businesses by the Arizona Department of Health Services and real estate services (including appraisal and title services).

  • Day care centers for employees exempted by this Executive Order: Day care centers providing care for individuals serving in any essential services category.

  • Manufacture, distribution and supply chain for critical products and industries: Manufacturing companies, distributors and supply chain companies producing and supplying essential products and services in and for industries such as pharmaceutical, technology, biotechnology, healthcare, chemicals and sanitizations, waste pickup and disposal, agriculture, food and beverage, transportations, energy, steel and steel products, petroleum and fuel, mining, construction, national defense, communications as well as products used by other Essential Businesses and Operations.

  • Hotels and motels: Hotels and motels, to the extent used for lodging and delivery or carryout food services.

  • Funeral services: Funeral, mortuary, cremation, burial, cemetery and related services.

• Essential Governmental Functions: includes but is not limited to: park personnel that provide admission, maintenance and operation of park facilities that provide outdoor recreation; all first responders, emergency management personnel, emergency dispatchers and those supporting 911 services; court personnel, law enforcement and corrections personnel; hazardous materials responders; child protection and child welfare personnel; housing and shelter personnel; military and other governmental employees working for or to support Essential Businesses and Operations. Essential Government Functions means all services provided by the State or any county, city, town or political subdivision thereof and needed to ensure the continuing operation of the government agencies or to provide for or support the health, safety and welfare of the public. Essential Government Functions also includes contractors performing or supporting such functions. Each government body shall determine its Essential Governmental Functions and ensure a plan is in place for the performance of these functions. This order does not apply to the United States government or to a tribal entity, however, any employee, official or contractor of the United States government shall not be restricted from performing their functions under law.

• Healthcare and Public Health Operations: includes but is not limited to: hospitals; clinics; dental offices; pharmacies; public health entities, including those that compile, model, analyze and communicate public health information;  pharmaceutical, pharmacy, medical device and equipment, and biotechnology companies (including operations, research and development, manufacture and supply chain); organizations collecting blood, platelets, plasma, and other necessary materials; eye care centers, including those that sell glasses and contact lenses; home healthcare services providers; mental health and substance use providers; other healthcare facilities and suppliers; providers of any related and/or ancillary healthcare services; entities that transport and dispose of medical materials and remains; manufacturers, technicians, logistics and warehouse operators, and distributors of medical equipment, personal protective equipment (PPE), medical gases, pharmaceuticals, blood, platelets and plasma products, vaccines, testing materials, laboratory supplies, cleaning, sanitizing, disinfecting or sterilization supplies, and tissue and paper towel products; veterinary care and all healthcare services provided to animals. This includes doctors, nurses and any other classification of medical personnel necessary to operate those functions in this category. This category of essential services shall be construed broadly to avoid any impacts to the delivery of healthcare, broadly defined. Healthcare and Public Health Operations does not include fitness and exercise gyms.

• Human Services Operations: includes but is not limited to: long-term care facilities; residential settings and shelters for adults, seniors, children and/or people with developmental disabilities, intellectual disabilities, substance use disorders, and/or mental illness; transitional facilities; home-based settings to provide services to individuals with physical, intellectual, or/or developmental disabilities, seniors, adults, and children; field offices that provide and help to determine eligibility for basic needs including food, cash assistance, medical coverage, child care, vocational services, rehabilitation services; developmental centers; adoption agencies; businesses that provide food, shelter, and social services, and other necessities of life for economically disadvantaged individuals, individuals with physical, intellectual and/or developmental disabilities, or otherwise vulnerable individuals. Human Services Operations shall be construed broadly to avoid any impacts to the delivery of human services, broadly defined.

Whew. So, those are the essential business and other services. Now let’s tackle the exceptions in the essential activities category. Essential activities are exempted even if the activity isn’t associated with an essential business or other service.

• Obtaining necessary supplies and services for family, household members and pets, such as groceries, food and supplies for household consumption and use, supplies and equipment needed to work from home, assignments for completion of distance learning and products necessary to maintain safety, sanitation and essential maintenance of the home, residence. 

• Engaging in activities essential for health and safety, including things such as seeking medical, behavioral health or emergency services and obtaining medical supplies or medication. 

• Caring for a family member, friend, or pet in another household or residence, which includes but is not limited to transportation for essential health and safety activities and to obtain necessary supplies and services for the other household. 

• Engaging in outdoor exercise activities, such as walking, hiking, running, biking or golfing, but only if appropriate physical distancing practices are used.

• Attending work in or conducting essential services which includes but is not limited to transporting children to child care services for attending work in an essential service.

• Engaging in constitutionally protected activities such as speech and religion, the democratic process to include voting any legal or court process provided that such is conducted in a manner that provides appropriate physical distancing to the extent feasible.

Now, perhaps you can name a service or activity that’s not exempted. Can you? There are some but you need to be creative to find them.

Oh, also, if someone is doing something that’s not on the exception list above, the Order says that “no person shall be required to provide documentation or proof of their activities to justify their activities under the (this) Order.”

Now answer the question for yourself: “does this new Order make any real changes to what’s happening right now”?

Provides some relief for the social determinants of health

The Coronavirus Aid, Relief, and Economic Security (CARES) Act, was passed and signed last Friday. It includes important provisions to mitigate the sharp economic decline and threat to the social determinants of health unfolding right now.

It includes an expansion of unemployment benefits, direct payments to low- and middle-income families, funds for states to help address the large budget holes and investments across a range of existing programs that can help respond to the current crisis.

Here are some of the specifics:

• Provides a federally funded $600/week benefit increase through July 31 for people qualifying for unemployment insurance (this is a big deal because Arizona’s existing benefit is the lowest in the country, around $230/week); 

• Extends unemployment insurance coverage by 13 weeks;

• Provides (federally funded) unemployment benefits to people that lose their jobs but are ineligible for the state’s regular unemployment insurance program;

• Provides cash payments of $1,200 per adult ($2,400 for a married couple) and $500 per dependent child age 16 or younger. The rebates phase down gradually for couples with incomes above $150,000 and individuals above $75,000 (and the benefits are limited to people that file tax returns);

• Give states money (a $150B Coronavirus Relief Fund) that they can draw down for virus-related costs; and

• $30B for schools and colleges and universities and $3.5 billion for child care.

Of course, there’s a lot more to it. A good summary is in this Center on Budget and Policy Priorities site. Thanks to AzPHA member Lauraine Hanson for finding this good summary resource so fast.

“Everyone is a Keynesian in a Foxhole”

        – University of Chicago’s Robert Lucas, 2009

The Governor has signed several helpful executive orders in the last few days that are and will continue to be helpful in fighting the COVID-19 epidemic. However, there’s an important gap in Arizona’s response that hasn’t been addressed yet.

We urge the Governor to prioritize conducting real-time scaled trials of potentially useful medications in Arizona. There are promising medications that may provide relief for patients and healthcare providers alike. A few are already approved by the FDA and have a good safety record. We urge the Governor to order state government and Arizona’s university system to immediately conduct scaled studies of these medications among COVID-19 patients in Arizona. 

This pandemic is progressing very quickly, and Arizona should be making it an immediate priority to quickly identify and deploy medications that can flatten the ICU bed curve here in Arizona.

Maybe.

Researchers from the MIT examined the effect of temperature and humidity on the epidemiology of COVID-19 infections and published their work this week. It’s not peer-reviewed yet. They explored whether the lower number of cases in tropical countries might be due to warm humid conditions. Viruses often prefer cooler drier weather.  High temperatures combined with high absolute humidity often slow the spread of many viruses.

The researchers found that 90% of the COVID-19 illnesses occurred between 38 and 63F with dew points between 32 and 50F (which mostly occur above 30 degrees North Latitude).  They posited that the large difference in the number of cases between the Equator & 30N latitude and between 30N & 50N latitude might mean that 2019-nCoV isn’t as communicable in warmer humid climates (Phoenix’s latitude is at about 33N).

Their preliminary results suggest that both higher temperature and higher humidity (in combination) slows down the spread of the virus. The combination of both high temperatures along with higher humidity may be working together (Note: warmer air can hold a lot more water). 

Arizona typically has temperatures and humidity in the range that may slow transmission during the monsoon season. During late May and June our temps are high in the deserts, but the humidity doesn’t usually pick up until the 4th of July. We should be past peak transmission of the virus by then – but perhaps the monsoon will bring welcome additional relief.

I’ve noticed that many people including journalists are often using the words “isolation” and “quarantine” interchangeably.  They are words that are referring to different things and they refer to different kinds of recommended actions.

Isolation refers to separating sick people with a contagious disease from people who aren’t sick.  So, for example, if you have been diagnosed with COVID-19 disease, then you should isolate yourself from other people until you’re no longer infectious. When a person is in Isolation they separate themselves from people who aren’t infected to prevent spread of the communicable disease. Isolation for public health purposes may be voluntary or compelled by federal, state, or local public health order.

Quarantine refers to separating and restricting the movement of people who were exposed to a contagious disease to see if they become sick.  So, this is the word that you would use if you have been exposed to someone with COVID-19 disease but you yourself aren’t sick. When a person is in quarantine they separate themselves from people who haven’t been exposed to prevent the possible spread of the communicable disease.

For example, my daughter and niece came back to Arizona after having been living in NYC. They have been exposed to people in the last couple of weeks that have tested positive for the virus but my daughter and niece aren’t sick. They are quarantining together, but neither of them are in isolation, because they aren’t sick. If one of them comes down with symptoms, that person will go into isolation. If neither get sick in the next 14 days then they can come home with our family.

The governor signed a new series of Executive Orders late last week to mitigate the spread of COVID-19.  One says that “all licensed healthcare facilities and providers halt all non-essential or elective surgeries, including elective dental surgeries, that utilize personal protective equipment or ventilators.”

This order is consistent with best-practices for preparing for a surge in demand for hospital care which we may see in the coming weeks. Hospitals all have preparedness plans to implement procedures like this – but it does take a lot of execution to make it happen. One of the judgment calls is determining what’s elective and what’s not. The Order started last Saturday.

Additional Executive Orders signed late last week require the closure of all bars, movie theaters and gyms in counties with confirmed COVID-19 cases. Restaurants can still provide take out.  The National Guard has been activated to help grocery stores and food banks. 

Yesterday CMS approved AHCCCS’ waiver request asking for flexibility in responding to the COVID-19 outbreak. The approved waiver does these things:

1. Waive cost-sharing and premiums for ALL participants during the state of emergency, including KidsCare premiums and premium balances

2. Extend KidsCare renewal deadlines so kids can stay enrolled beyond their certification period

3. Delay renewal processing and delay action on circumstance changes to eligibility (though we do not have specifics at this time, this will include KidsCare renewals)

4. Provide 6 months of temporary housing support for participants who test positive for COVID-19 and who are homeless or at risk of homelessness.

5. Allow for payment for home and community-based services provided by family members or other legally responsible parties.

Testing finally became more available early this week with testing now available through LabCorp  and Quest Diagnostics, but a new problem has arisen and testing continues to be a big barrier to an effective response.

Many doctors and hospitals are unable to get their hands on the actual COVID-19 testing kits (swabs and transport medium). So even though commercial testing is available, if clinicians don’t have the swabs and transport media to get the specimens to the lab then they can’t get the testing done. Some hospitals, clinics and clinicians do still have swabs and transport media- but many don’t.

Last week the ADHS offered the following advice and resources:

1. “Fisher Scientific has E-Swab by Copan (Catalogue # 481C and 482C) and Opti-Swab by Puritan (Catalogue # LA-117), available but they are on a 2-week backorder. These are Aimes-based kits instead of VTM, but the FDA medical device website indicates that these can be used for COVID testing.  https://www.fda.gov/medical-devices/emergency-situations-medical-devices/faqs-diagnostic-testing-sars-cov-2”

2. “You can also reach out directly to the FDA hotline (1-888-INFO-FDA) 24 hours a day for labs to call regarding difficulties obtaining supplies for collecting patient specimens for COVID-19 testing, including swabs and transport medium.”

Because of the swab supply chain issues, testing is basically not available in the outpatient setting right now. Often, testing isn’t necessary for individual treatment- but it certainly helps public health monitor the disease, give folks definitive info about their need to isolate, determine how effective our social distancing interventions are working and help guide future interventions.

Not all is lost, because of the lack of testing because public health has other tools like ILI surveillance, mathematical modeling and hospital admissions and capacity data that helps.

Having a negative test can relieve anxiety but the best thing to relieve anxiety will be to reduce the spread of disease. Public health asks everyone to do the following to reduce the spread of disease and to reduce anxiety:

• Stay home and away from others when you have even the slightest cold symptom.  Don’t expose anyone else until 72 hours after your symptoms are gone.

• Most people recover at home with rest and fluids. If you are over 60 or have chronic medical conditions, call your healthcare provider and get guidance. Only go to the emergency room if you are experiencing severe symptoms of COVID-19 like trouble breathing, trouble staying awake, or fever that won’t go away. 

• Avoid groups > 10 people and reach out to older family, friends and neighbors to make sure they have what they need and they are healthy.

• Please, please wash your hands and don’t touch your face.

Hopefully I can report something more encouraging next week on the testing front.

Younger Adults at Higher Risk for Hospitalization than Previously Thought, but with a Caveat

Now that we have community spread of the new Coronavirus, we’re beginning to get some U.S. specific surveillance data. Up until now, we’ve needed to rely on data from China, S. Korea and Italy.  The new US results are summarized in a CDC MMWR this week (MMWR stands for a Morbidity and Mortality Weekly Report).

Previous mortality data from S. Korea were primarily mortality data, so this is our first real view into what percentage of cases are serious enough to require hospitalization or intensive care.  The previous mortality data found that younger adults are at much lower risk for dying from the illness- but these new hospitalization data suggest that younger adults are at risk of serious enough symptoms to be hospitalized.

Among the 508 patients known to have been hospitalized in the US (12% of the cases), 20% were between 20–44 years old, 18% were 45–54, 17% were aged 55–64 years, 26% were aged 65–84 years, and 9% were over 85.  Overall, 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths were among adults aged ≥65 years.

So, in that young adult cohort you can see that 29% of the cases are among folks 20-44 years old and 20% of the hospitalizations were among that group. Slightly under-represented in terms of hospitalization percentage but not by much.

The CDC doesn’t have information about chronic medical conditions and or how many of these younger adults have medical conditions, which we know puts people at higher risk for severe disease, so this is a big limitation in the report.

Among the 121 patients admitted to an ICU so far, 7% of cases were ≥85 years, 46% were 65–84 years, 36% were 45–64 years, and 12% were 20–44 y/o.  Percentages of ICU admissions were lowest among adults aged 20–44 years (2%–4%) and highest among adults aged 75–84 years (11%–31%).

There have been 44 known deaths so far.  80% (35) of them were older than 65 and 20% (9) have been younger adults.

The CDC identifies several limitations in the data used for the report, and it’s also very early in the US epidemic- so as you think about these results take into consideration that these are preliminary data- but still useful in planning for the healthcare system response.

Here’s a link to the Full MMWR Article.

An allotment from the Strategic National Stockpile arrived Saturday (yesterday). State government will be shipping the supplies to the local health departments and the counties will deliver the resources to healthcare facilities and 1st responders (just like we did during H1N1). Last week’s shipment includes:

• 60,900 N95 masks;

• 244,000 surgical face masks;

• 26,208 face shields;

• 22,200 surgical gowns;

• 102 coveralls; and 

• 90,000 sets of gloves.

Don’t celebrate too much though. This shipment isn’t enough to meet the needs out there right now. Counties will likely be prioritizing acute care facilities to protect those who are providing care to patients who are the most sick.

Outpatient providers have the option to use telehealth or refuse patients, which is not ideal but offers some relief. Maricopa County is planning to provide some PPE to long term care facilities who care for the most vulnerable patients and would be impacted the most by an outbreak.

Yesterday’s shipment is 25% of the stockpile that’s earmarked for AZ.