Will Humble State Legislature, Wills Blog

Legislative Update: March 15, 2020

This week at the Legislature was again dominated by floor votes- there wasn’t that much committee action (except in Rules).  Lots of action on the Floor and many of the bills that we support are in good shape.  

Here’s next week’s docket:

Senate HHS Committee – Wednesday 9 am:

HB 2670 Doulas; Voluntary Certification  (AzPHA Supports)

HB 2453  Exemption, Food Code Wineries – (AzPHA Opposes)

HB 2784 Medical Marijuana Research – (AzPHA Supports)

House HHS Committee – Thursday 9 am:

SB 1221 SNAP; benefit match  (AzPHA Supports)

Senate Commerce Committee – Thursday 2 pm:

HB 2739 Liquor Omnibus  (AzPHA Opposes)

Bills that Have Been Passed & Signed

HB 2764 Mental Health Omnibus – AzPHA Supports

Grants the Arizona Department of Insurance the authority to enforce mental health parity, and establishes the Suicide Mortality Review Team and the Children’s Behavioral Health Services Fund (Fund). Appropriates funds to the Department of Education for services to prevent suicide among children.

Bills that We Support that Passed a Full Chamber & Sent to Other Chamber

SB 1086 Long Term Care Surveyors  Passed Senate 28-2

SB 1167 Graduate Medical Education  Passed Senate 30-0

SB 1170 AHCCCS Dental for Pregnant Women Passed Senate 27-2

SB 1221 SNAP; benefit match  Passed Senate 28-1

SB 1493 Pharmacists; Dispensing Contraceptives – Passed Senate 26-0

SB 1571 Newborn Screening Fund – Passed Senate 26-2

HB 2244 Dental; Native Americans Passed House 60-0

HB 2550 ADHS Licensing Surveyors –  Passed 56-0

HB 2608 Overdose Prevention & Harm Reduction Passed 50-10

HB 2670 Doulas; Voluntary Certification  Passed House 48-12

HB 2727 AHCCCS Dental Coverage Pregnancy – Passed House 52-8

HB 2784 Medical Marijuana Research – Passed House 58-2

Bills that We Oppose that Passed a Full Chamber

HB 2453  Exemption, Food Code Wineries – Passed House 60-0

HB 2739 Liquor Omnibus-  Passed House 57-2

Bills that We Support that Still Need a Floor Vote

(but  that are still in good shape)

SB 1028 Public Health Surveillance  Now Dead

HB 2104 Child Care Assistance and Training 

HB 2549 Adult Protective Services Audit

Will Humble Disease Control, Wills Blog

What’s the Real Average Case Fatality Rate for Persons Infected with COVID-19?

This Post was last updated on March 15, 2020.

An important question regarding the etiology of the COVID-19 virus is outstanding… what’s the average case fatality rate?  

The case fatality rate is the number of folks that die from an illness divided by the number infected. The WHO has released a statement suggesting that the case fatality rate is 3.4%. This is inaccurate. Other sources have suggested that it’s 2%. This also is almost certainly a gross over-estimate of the average case fatality rate.

So are there any good data out there to get a better estimate?

Perhaps the best source is the S. Korean CDC, which has done robust testing. S. Korea has done far more testing than we have here in the US and have a much more broad testing protocol than we do.  Up until this week in the US, only severely ill patients with no alternative diagnosis, symptomatic folks with known contact with a case, or symptomatic people with travel history to an epidemic region are in the testing protocol.

As of this morning, S. Korea has 8,162 confirmed cases and 75 deaths (case fatality rate of 0.9%). Bottom line- the best data I can find is from S Korea and it suggests the average case fatality rate is 0.9%.

But the case fatality rate varies a lot with age. Of the deaths in S. Korea, 25 have been over 80 years old, and 28 between 70-79 y/o. Fourteen were between 60-69 and 6 deaths have been among people 50-59 y/o.

Seventy-one percent (71%) of the deaths in S Korea are among people 70 years old and above and 89% are among those over 60. The case fatality rate for those over 80 is about 9%, and for all those over 70 it’s about 6.7%.

However, for people under 40 years it’s just 0.04% or 4 in 10,000. You can see from those data that COVID-19 is far more serious among those over 79 years old, and that for those under 40 it’s really not all that lethal.

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To get a better picture of the percentage of confirmed cases that are asymptomatic let’s take a look at what happened on the Princess Cruise Ship – perhaps the best place to look for which there’s a good denominator (as they were a captive population).

A brand new study from that incident estimated that the delay-adjusted asymptomatic ratio of the positive COVID-19 infections on board the ship was 34.6%. In other words, about 35% of the folks on the Princess ship that were infected with the virus were asymptomatic. That’s an important factor, because it suggests that the S Korean CDC data (perhaps the best that’s out there right now) is an overestimate of the the case fatality rate.

We’ll get a better picture of how lethal the COVID-19 virus is in the coming weeks- but I felt compelled to include this data from S Korea and the cruise ship this week because there are a lot of people out there that are hanging their hat on the 3.4% and 2% case fatality rate numbers- and those are overestimates.

Also, remember that this discussion is about the average case fatality rate.  The fatality rate for certain sub-populations like the elderly and people with pre-existing conditions that put them at more risk will have a much higher case fatality rate than the average case fatality rate.

Will Humble Disease Control, Early Childhood, Public Health Law, Wills Blog

What’s the Evidence Base for School Dismissal as a Public Health Intervention?

One of the non-pharmaceutical interventions that jurisdictions around the US and in Arizona will be considering in the coming weeks in response to the COVID-19 virus are coordinated school closures. It’s important for decision-makers to be informed about the costs and benefits of such a policy before making a decision.

The best published resource that I found was from  The Community Guide’s Evidence Review on School Dismissals to Reduce Transmission of Pandemic Influenza. The Systematic Review is based on evidence from a systematic review of 67 papers.

The supporting materials, analytical framework and the evidence tables are in the Review. It also includes Actual School Dismissals Historical Studies and Modeling Studies.  Their review also includes a detailed Rationale Statement.

 

Results for “Moderate” Pandemics

The Task Force found insufficient evidence to determine the balance of benefits and harms for coordinated (widespread) school dismissals during moderate or less severe pandemics because few studies provided enough information to assess the potential benefits and costs of school dismissals for pandemics.

They also state that the level of public concern in moderate pandemics would be unlikely to support and sustain the extended school dismissals (weeks to months) and that the  “social and economic costs of community-wide dismissals would likely exceed potential benefits, especially for some segments of the population, such as families in which both parents work and no other child care is available”.

Results for “Severe” or 1918-Like Pandemics

The Task Force found sufficient evidence that the benefits of coordinated (widespread) school dismissals outweigh the societal and economic costs during a severe influenza pandemic (a pandemic with high rates of severe illness like in 1918).  However, the potential benefits are limited to slowing transmission of infection and reducing peak burden of illness on health care resources.

Those conclusions were based on the effectiveness of reducing or delaying the spread of infection and illness within communities from retrospective assessments of public health actions taken during the 1918 pandemic and modeled simulations.

Research Example from the 2009 H1N1 Pandemic

A simulation of costs and benefits for school closures in Pennsylvania during the 2009 H1N1 outbreak found that closure-related costs were greater than savings resulting from reductions in disease. Researchers found that each day of school closure may have cost an estimated average of $120,000 and that the costs of school closure may have been approximately 5 to 40 times higher than the total costs from influenza without school closure mitigation.

Will Humble Disease Control, Early Childhood, Public Health Law, Wills Blog

CDC Guidance on School Closures

Last week the CDC issued “Interim Guidance for Administrators of Childcare and Schools to Prepare for and Respond to the Coronavirus“.  The CDC stops short of recommending school closures and makes it clear that those decisions are up to local authorities.

Information about the evidence base for each NPI and considerations for their implementation is available in: Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017.

Will Humble Disease Control, Federal Public Health Bud, Wills Blog

About $19M Headed to AZ Public Health for the COVID-19 Response

State and County Governments to Receive Funds

Last week congress passed and the president signed HR 6074 which is an emergency supplemental funding bill providing $8.3B to address the coronavirus response.  About $1B of that ($950M) is earmarked for county, state and tribal public health response efforts.  Arizona is about 2% of the US, so our cut should be about $19M, which is a lot of money. 

It’ll be important for state and county public health officials to have an open and informed dialog about the most effective use of those funds- both distribution and priority-wise. The narrative of the bill says that the state and county public health portion should be for surveillance, epidemiology, laboratory capacity, infection control, mitigation, and communications.

Will Humble Affordable Care Act, Wills Blog

Senate Proposes Watered-Down Plan to Address Prescription Drug Costs

Last December the US House of Representatives passed a bipartisan bill known as H.R.3 (called the Lower Drug Costs Now Act) – a policy intervention that would allow Medicare to negotiate with pharmaceutical companies on drug prices. 

H.R. 3 would not only lower the cost of drugs for Medicare and Medicare beneficiaries, but it would help everyone because manufacturers would be required to offer the lower negotiated prices to group and individual health insurance plans too.  According to the nonpartisan Congressional Budget Office, H.R. 3 would lower drug prices by an average of 55% and save Medicare $456 billion over 10 years.

So far, the US Senate has refused to bring H.R. 3 to the floor.  In other words, Senators haven’t even had the opportunity to consider the law- and as a result- Medicare is still forbidden from negotiating drug prices on our behalf.

This week, Senator McSally proposed an alternative prescription drug bill.  There are a few big differences between the bills.  The new Senate bill would prohibit Medicare from negotiating drug prices that have existing patents. This is an important difference because the most expensive drugs that are costing Medicare and patients the most are those that are under patent, so the new plan wouldn’t help with the meds that matter the most.

H.R. 3 requires drug companies to offer the prices negotiated with Medicare to extend to group and individual health insurance plans too. McSally’s new bill doesn’t include this important provision, and the 44% percent of Arizonans that are covered by private and employer based insurance wouldn’t benefit from any new negotiated prices on non patent drugs.

Chances are that H.R. 3 will remain in McConnell’s in box and McSally’s new Bill may or may not get debated and go to the floor.  We’ll probably need to wait until the outcome of the election to see whether the American people will finally get meaningful prescription drug cost relief.

Will Humble Affordable Care Act, Wills Blog

US Supreme Court to Hear Lawsuit Challenging the ACA (again)

The Supreme Court said this week that they’ll hear an appeal of the latest challenge to the constitutionality of the Affordable Care Act. 

The case, formerly called Texas v. Azar is now called California v. Texas. The case was originally filed in 2018 by Arizona and 19 other states. It revolves around a provision in the ACA known as the “individual mandate,” which required people to buy health insurance or pay a financial penalty. Congress eliminated that penalty in 2017.

The 5th U.S. Circuit Court of Appeals ruled last December that the individual mandate was invalid after the tax penalty for not having insurance went to zero, effectively ending the mandate. The 5th Circuit panel remanded back to the Texas District Court (where it came from) and asked for clarifications from the lower court judge, who struck down the law in its entirety in 2018 because the penalty is now zero. It’ll now go straight to the Supreme’s.

If the Supreme Court didn’t hear the case now, it would have been sent back to the District court first- delaying the hearing for a year or more. If the case follows a normal pattern from here, arguments would happen this Fall with a decision in mid-2021.

Will Humble State Legislature, Wills Blog

Legislative Update: March 8, 2020

This week at the Legislature was again dominated by floor votes- there wasn’t that much committee action (except in Rules).  Lots of action on the Floor and many of the bills that we support are in good shape.  Below is the summary of where at Legislative Half-Time and here’s our weekly tracking spreadsheet from our policy interns.

Bills that Have Been Passed & Signed

HB 2764 Mental Health Omnibus – AzPHA Supports

Grants the Arizona Department of Insurance the authority to enforce mental health parity, and establishes the Suicide Mortality Review Team and the Children’s Behavioral Health Services Fund (Fund). Appropriates funds to the Department of Education for services to prevent suicide among children.

Bills that We Support that Passed a Full Chamber & Sent to Other Chamber

SB 1086 Long Term Care Surveyors  Passed Senate 28-2

SB 1167 Graduate Medical Education  Passed Senate 30-0

SB 1170 AHCCCS Dental for Pregnant Women Passed Senate 27-2

SB 1221 SNAP; benefit match  Passed Senate 28-1

SB 1493 Pharmacists; Dispensing Contraceptives – Passed Senate 26-0

SB 1571 Newborn Screening Fund – Passed Senate 26-2

HB 2244 Dental; Native Americans Passed House 60-0

HB 2550  ADHS Licensing Surveyors –  Passed 56-0

HB 2608 Overdose Prevention & Harm Reduction Passed 50-10

HB 2670 Doulas; Voluntary Certification  Passed House 48-12

HB 2727 AHCCCS Dental Coverage Pregnancy – Passed House 52-8

HB 2784 Medical Marijuana Research – Passed House 58-2

Bills that We Oppose that Passed a Full Chamber

HB 2453  Exemption, Food Code Wineries – Passed House 60-0

Being heard in Senate Health this Week

HB 2739 Liquor Omnibus-  Passed House 57-2

Bills that We Support that Still Need a Floor Vote (but  that are still in good shape)

SB 1028 Public Health Surveillance  Now Dead

HB 2104 Child Care Assistance and Training 

HB 2549 Adult Protective Services Audit

Will Humble Disease Control, Wills Blog

What are the Priorities for Responding to the COVID-19 Epidemic

All the evidence suggests that the COVID-19 Pandemic will eventually result in community spread in Arizona. The question is when. When it arrives, the response measures should change significantly from things like travel restrictions to activities like laboratory testing and capacity, hospital preparedness and other mitigation strategies.

Here’s a quick summary of some of the top priorities as I see it:

Laboratory Testing

Having the ability to test patient specimens in-state at the ADHS’ State Laboratory should be a top priority right now. Right now, specimens need to be sent to Atlanta at CDC which creates an unacceptable turn around time. Clinicians will need to know the results of tests quickly so they can make treatment and patient isolation decisions.

I saw an email from the ADHS suggesting that at least some testing capability will be available this week (Monday it says). Let’s hope it’s substantial and the capacity is adequate to meet the coming demand for tests.  

Partner and Public Communications

Communicating with partners and stakeholders should be a top priority in response to any epidemic.  Community partners like hospitals, primary care physicians, EMS, schools, health plans and businesses are starved for information at the beginning of an epidemic- and good information is needed in order for them to do proper planning.

PPE Inventory, Distribution and Conservation

There will be increased demand for personal protective equipment (PPE) for heathcare workers when community spread begins. Healthcare workers at every level will need to know what kinds of PPE are needed under what circumstances.  Institutions of all types will need access to appropriate PPE and there should be an inventory tracking system that allows the sharing and bartering of PPE resources. PPE inventory tracking and resource allocation should  also be a priority so there’s good information when PPE from the Strategic National Stockpile becomes available. 

Discuss Mitigation Strategies

Discussions should be happening within the public health and health care communities about alternate standards of care and potential waivers of targeted regulations in case they’re needed. Additional discussions about which non-pharmaceutical interventions are likely already happening among health officials.

This week the CDC issued Interim Guidance for Administrators of Childcare and Schools to Prepare for and Respond to the Coronavirus“.  Thankfully, it stops short of recommending school closures per-se, and makes it clear that those decisions are up to local authorities. We urge any school or pre-school to talk with your county health officials before even considering closing your school or pre-school as a result of a COVID-19 case.

Information about the evidence base for each NPI and considerations for their implementation is available in:  Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017.

I’ll have more on the evidence base for school dismissal interventions in next week’s update.

Funding

There will be significant federal funds coming from the US government (via CDC) to assist with the response. Officials at the state and county levels are probably already discussing how to most effectively use those funds so that decisions aren’t being made at the last minute.

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Will Humble Disease Control, Public Health Law, Wills Blog

What Kind of Enhanced Health Policy Authority Exists in AZ Law During a Public Health Emergency?

County Health Officers have existing authority that allows them to institute isolation and quarantine for an emerging and dangerous infectious disease in certain circumstances even without a declared emergency, but there are also additional powers that can kick in when a governor declares a “public health emergency dangerous to public health”.

About 15 years ago the state legislature passed a series of laws designed to provide health officers with enhanced powers during a public health emergency.  The law outlines additional authorities that kick in when the Governor declares a public health emergency that’s “dangerous to public health”.  The statute has 3 parts: let’s explore each of them here.

ARS 36-787: Public Health Authority During a State of Emergency

This is the law that provides over-arching enhanced authority to the ADHS during a governor declared emergency.  It provides additional authority for:

Planning and executing public health emergency assessment, mitigation, preparedness response; Coordinating public health emergency response among state, local and tribal authorities; Collaborating with relevant federal government authorities, elected officials of other states, private organizations and private sector companies; Establishing a process for temporary waiver of the professional licensing requirements; and Granting temporary waivers of health care institution licensing requirements.

More specific and aggressive authority exists for the ADHS to mandate medical examinations for exposed persons, Ration medicine and vaccines, and to buy medicines and vaccines.  Under more narrow circumstances, the Director can mandate treatment or vaccination of people and even order the isolation and quarantine of folks.

ARS 36-788 Isolation and Quarantine

This one kicks in only under an executive order from the governor as well.  It allows the ADHS director and county health officers to order “persons who have contracted the disease or who have been exposed to the disease may be subject to isolation and quarantine if the director determines that quarantine is the least restrictive means by which the public can be protected from transmission of the disease“.

Fortunately, it requires that isolation or quarantine be done by the least restrictive means necessary to protect the public health and orders that the isolation be done in a hygenic manner.

ARS 36-789 Due Process for Isolation and Quarantine

This is the law in the series that outlines the due process that’s required.  It’s a good thing they thought to include this.  It says that the ADHS or the local health departments can isolate or quarantine a person or group of persons without getting an order from the court if a delay would pose an immediate and serious threat to the public health. But…

Within 10 days after that directive, the department or local health authority needs to file a petition for a court order authorizing the initial isolation or quarantine.  After that, there is judicial review and hearings etc.

– I’m not saying that this authority will be needed or exercised when the COVID-19 virus arrives- but I thought I’d include it this week to highlight that the authority is there if the circumstances call for it (in the mind of the governor).

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