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Today the AzPHA and the School Nurses Organization of Arizona issued joint recommendations as benchmarks for the safe return of in-person teacher-led classroom instruction as outlined in Executive Order 51. View our Open Letter here and the text below:

July 30, 2020

Governor Douglas A. Ducey

Office of the Governor

1700 West Washington

Phoenix, Arizona 85007

Dr. Cara Christ

Director, Arizona Department of Health Services

150 N. 18th Avenue

Phoenix, Arizona, 85007

Dear Governor Ducey and Dr. Christ,

On behalf of the Arizona Public Health Association and School Nurse Organization of Arizona, we strongly recommend the postponement of in-person public education in Arizona until specific evidence-based measures are in place.

While many school districts have developed quality mitigation plans to lower the risk of spread, community transmission is currently too high to adequately protect children and staff. Testing capacity is inadequate, sample turn-around times are insufficient, contact tracers are receiving tardy data, public health laws are inadequate and unenforced, and testing and infection control in care homes needs improvement. 

All the above issues are fueling community spread and need to be improved before schools open for in-person instruction this fall. There are two categories of criteria we ask you to use when making this decision:

• The quality of school district mitigation plans and their ability to execute those plans with fidelity; and

• Evidence-based criteria that measure community transmission.

Specifically, we recommend that you consider the following community spread measures as benchmarks for the safe return of in-person teacher-led classroom instruction as outlined in Executive Order 51:

• A consistent 30-day reduction in the number of new COVID-19 cases in the county as measured by a 7-day moving average;

• A county percent positive rate of less than 5% for 21 days as measured by a 7-day moving average;

• 90% of samples returned by analytic laboratories within 72 hours of specimen collection with a transparent metric on the ADHS Dashboard; and

• Community hospitals open for elective procedures.

When a community meets all these criteria, the district could be free to set a date for in-person instruction.  If community transmission rebounds and the above criteria are no longer met, then districts should suspend in-person instruction.

Having measurable criteria in place to make that happen can build additional community motivation to achieve and maintain the important mitigation measures that reduce transmission of the virus.

Thank you for your consideration of our recommendation.

Sincerely,

Aimee Sitzler, MSW

President,

Arizona Public Health Association

Board of Directors School Nurses Organization of Arizona

There’s finally some good news from the field this week. Providers are reporting that they see a plateauing – if not an actual downturn  in key hospital-specific metrics.  However, despite these improvements the pressure on hospitals remains significant and variability in patient need and human resource availability continues. To date the AZ Surge Line has supported over 1800 patient transfers.

Providers are increasingly recognizing the importance of using the rapid antigen test as a long-term strategy for optimal transfer decision-making, patient cohorting, and support for under-resourced behavioral health and community service organizations.

St. Luke’s Hospital Alternate Care Site Update

You’ll recall that a couple of months ago there was a high-profile press conference out at the old closed St Luke’s hospital. The governor and health director talked at length about how that would become an acute care surge hospital in the event of a “worst case scenario”. The plans have changed and now St. Luke’s is would become a step-down non-acute care site (if needed). Over $8M in state dollars have been used to prepare the facility. 

Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial

This is the study that you likely heard about early in the week with the promising results from the Astra Zenica Phase II vaccine trial in the UK.  Promising results indeed! Not only did the vaccine tested form antibodies at several doses, it also generated cell mediated immunity (called killer T cells). 

Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020

In this new study published in CDC’s Emerging Infectious Disease South Korean researchers found that kids younger than 10 transmit to others much less often than adults do, but the risk is not zero. And those between the ages of 10 and 19 can spread the virus at least as well as adults do.

Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report

Among hospitalized patients with Covid-19, treatment with dexamethasone resulted in lower 28-day mortality than usual care, according to the level of respiratory support the patients were receiving, indicating a possible correlation between efficacy and the stage of infection.  Read the article.

The AzPHA and many faculty and staff from the University of Arizona sent this open letter to the Governor and ADHS Director this week. It provides our evidence-based recommendations for improving the COVID-response in Arizona.

July 28, 2020

Governor Douglas A. Ducey

Office of the Governor

1700 West Washington

Phoenix, Arizona 85007

Dr. Cara Christ

Director, Arizona Department of Health Services

150 N. 18th Avenue

Phoenix, Arizona, 85007

Dear Governor Ducey and Dr. Christ,

Arizona’s COVID-19 cases have grown exponentially, increasing from 400 cases a day in May to 5000 daily cases in July. The use of evidence-based, proven strategies could curb the spread of the virus, allowing businesses and schools to re-open safely and preventing further harm.

On behalf of the researchers and professors at the University of Arizona’s Mel and Enid Zuckerman College of Public Health and the Arizona Public Health Association, we respectfully request an enhanced government response to Arizona’s COVID-19 pandemic that would include the following: 

Address testing shortages and delays

Inadequate test availability and delays in delivering test results make it harder to identify and treat those currently infected.  Currently, test results may not be received for 7-14 days, making it more difficult to isolate infected individuals and track the people they contacted. Test shortages could be addressed, and we could be kept safer by:

• Committing to achieving laboratory turn-around times of less than 72 hours for 90% of samples and placing this metric on the ADHS COVID dashboard.

• Dramatically improving testing within assisted living and skilled nursing facilities.

• Increasing use of antigen testing, which is more rapid and has a higher negative predictive value than the existing PCR and antibody tests in use in our state.

• Expediting testing for individuals with symptoms and expanding testing for asymptomatic individuals, who may be unaware they are spreading the disease.

• Allowing for testing without a doctor’s order.

• Processing tests more efficiently using sample pooling techniques currently under development.

• Expanding test availability to all communities, mobilizing walk-through testing in communities with limited transportation and renewing targeted “blitz” testing in high prevalence areas.

Expand use of masks

To keep us safe, robust government action is needed to promote mask wearing. Mask wearing also should be required and enforceable statewide, since the failure of individuals to act responsibly ultimately affects us all. Messaging about mask wearing should include education on its proper use (e.g. masks must cover both the nose and mouth, avoid contact with the outside of the mask, and techniques to avoid self-inoculation). Masks should also be made available to those who can least afford it, including those experiencing homelessness.

Develop compliance and enforcement system for CDC mitigation measures

Implementation and compliance with CDC mitigation measures in retail stores, restaurants, bars, and other public places is inconsistent.  We urge you to develop a workable compliance and enforcement system that includes a hotline for community complaints to ensure compliance with CDC mitigation measures. Arizona has a successful model in the Smoke Free Arizona Act.  We urge you to build and implement a similar model to improve mitigation measure compliance.

Curb the spread among those most at risk

This moment makes clear that the health of every person in our state is intertwined. We can’t afford to leave anyone out of efforts to stop the spread of disease.  This includes people in institutional settings that care for older adults or persons with disabilities who are at risk due to their proximity. It also includes those close-quarter settings where farm workers, prisoners, and meat packers work or reside.

Enhance community-level data collection and response

Strategies should be developed to prevent, rapidly identify and swiftly address outbreaks in local communities. For example, to better identify where the virus is spreading, randomized testing could be conducted locally so that communities needing added resources could be identified. Such data and related information should be transparently shared statewide, allowing resources to be better targeted to communities or populations in need. To ensure effective partnership in COVID-19 mitigation efforts with tribes in Arizona, tribal sovereignty must be recognized to protect and promote data rights and interests.

Strategies should also be developed to address emerging the needs of various local communities. For example, community-based teams should be deployed to help local businesses better assess and modify their work environment to minimize infection risk. 

To effectively educate the public about COVID-19 and how we can each play a role is stopping its spread, it is important to engage trusted, local partners using linguistically-appropriate messages and materials.  Culturally-responsive partners such as tribal community health representatives and promotoras can connect with those who are hard to reach.

Increase treatment capacity

Since intensive care units are nearly full currently, elective surgeries should be scaled back to provide hospitals an opportunity to safely serve the community, protect health care personnel, and ensure adequate supply of hospital beds, personal protective equipment (PPE). Additional action is also needed to address continued shortages of PPE and health care workers.

Help people isolate or quarantine

While each of us bears responsibility for stopping the spread of the virus, it is important to recognize that many who become sick may face challenges isolating. This includes those who care for children or elders; individuals lacking or residing in inadequate housing where self-isolation is impossible; those who feel a need to continue to work due to their job or financial situation; and those experiencing mental illness.  Strategies should be developed to ensure everyone has a safe, supportive environment for quarantine, isolation, and recovery. 

Better leverage technology

Technology could play a role in allowing individuals to receive and submit health information. However, limited access to technology and privacy concerns and misperceptions may limit its use.  Existing platforms, such as AZCOVIDTXT, could be expanded and efforts could be made to address privacy concerns and misconceptions. Public-private partnerships could also expand use of technology in addressing public information and information exchange.

Use comprehensive metrics for decisions regarding re-opening our education

Decisions to open K-12 schools and Universities should be data-driven measured, scaled and responsive approaches to resumption of in-person activities. Clear phases should be guided by metrics that include epidemiological indicators of transmission, and public health, testing and medical capacities. Educational institutions should further demonstrate their ability to monitor and respond to adherence to mitigation strategies and changes in internal transmission and broader community impacts of their re-opening. Mitigation strategies should be clear, public and follow public health guidelines. Community health workers could be trained to periodically assess institutional adherence. 

Now is the time for government to act to stop further spread of COVID-19. We’re at a critical juncture, demanding robust government action based on what we know works.

Sincerely,

Aimee Sitzler, MSW

President,

Arizona Public Health Association

University of Arizona Faculty and Staff:

Kacey C. Ernst, PhD, MPH

Katherine Ellingson, PhD

Kristen Pogreba-Brown PhD, MPH

Leslie V. Farland, ScD

Elizabeth T. Jacobs, PhD, MS

Sydney Pettygrove, PhD

Purnima Madhivanan, MBBS, MPH, PhD

Megan Jehn, PhD, MHS

Pamela Garcia, PhD, MPH

Bonnie LaFleur, PhD, MPH

Paloma I. Beamer, PhD

Joe K. Gerald, MD, PhD

Mark Nichter, PhD, MPH

Saskia Popescu, PhD, MPH, MA

Erika Austhof, MPH

Lindsay Kohler, PhD, MPH

Jill de Zapien, BA

Aminata Kilungo, MPH, PhD

Joshua Hunsaker, BS

Collin Catalfamo, MPH

Kelly M. Heslin, MPH, CHES

Stephanie Carroll, DrPH, MPH

Yann Klimentidis, PhD

Maia Ingram, MPH

Felina Cordova-Marks DrPH, MPH

Elizabeth Hall-Lipsy, JD, MPH

Cecilia Rosales, MD, MS

Kelly A. Reynolds, PhD, MS

At the urging of Superintendent Hoffman, the governor signed Executive Order #51 last Thursday outlining a process to make better decisions about whether and how to set in-person instruction start dates. For the last several days, we, the Superintendent, teachers, and others have been advocating for a more evidence-based process to set school start dates. Our advocacy worked!

Prior to last Thursday, the governor had been setting proposed in-person instruction dates- but there had been no objective evidence-based criteria associated with those dates.

Last Thursday’s Order also requires face coverings for students over 5 years old when in-person services or instruction begins. There are exceptions for some students and during playground time when outside distancing is happening.

The Order requires the ADHS to develop public health benchmarks that school districts may use to inform their in-person instruction dates. The deadline for developing the criteria is August 7.

While the Order itself doesn’t mention how or whether the county health departments will be involved in setting the criteria, Superintendent Hoffman mentioned the importance of involving the county health departments- which is super-important as they are the public health retailers in Arizona.

While we still need to see what the criteria will be- this is certainly a victory for evidence-based public health policy and the students, parents and educators of Arizona.

The governor extended his executive order from 3 weeks ago that ordered the closure of gyms, bars, nightclubs, movie theaters, water parks, and tubing. The order also prohibits some organized events of more than 50 people. Cities and counties can approve them anyway if they believe there is enough mitigation. You can read EO #52 here.

The modeling team from ASU produced a terrific new COVID modeling update for Arizona on Friday. It’s solid work and has lots of analytics about the epidemiological trends and predictions, hospitalization trends and deaths. You’ll be glad you checked it out.  Many of you will probably end up using this work as part of your job or to inform others.

Dr Gerald also distributed his weekly update today. As expected, it shows encouraging results especially related to COVID hospitalizations. The bottleneck of tests and slow turn-around time is complicating our ability to accurately characterize the magnitude of change on the epidemiological curve. Promises have been made that the backlog will be cleared by Friday – so hopefully that’s true and we can get a more clear assessment on the case trends next week.

It’s officially showtime for Arizona’s hospital system. Last week was an extremely busy week for health care systems with near capacity  ICU care across the state.

Reports from the Field

While the rate of increase for some key hospital-specific metrics appears to be leveling out, the total impact of patient need on current health system capacity remains at a record high – especially in the central & southern parts of Arizona.

COVID-19 hospitalizations in Arizona have increased with hospitals reporting nearly 3,500 COVID-19 inpatients and more than 900 patients in their intensive care units. Hospitals have activated additional beds in their facilities and have been hiring more more nursing staff.

In northern Arizona, variability in need and impact continues; some previously busy hospitals have experienced lower inpatient census for COVID-19 care while other facilities are experiencing new highs.

Out-of-State Healthcare Workers Coming to the Rescue

The AZ Surge Line continues to coordinate patient transfers to higher and lower levels of care. Some of the delays in patient placements last week were because of a statewide shortage of available staffed beds. 

Recognizing that Arizona’s hospital systems are at the breaking point staffing-wise, the ADHS contracted with Vizient, Inc. to bring in 600 critical care and medical-surgical nurses from out of state into Arizona to support expanded capacity within Arizona hospitals (here’s the contract).

Staff will be allocated and deployed using the Surge Staffing Initiative. Hospitals received the application forms this week. Here’s an the application questions and attestations. 

Hospitals that need this critical staffing support can get it for free  for up to six weeks up to 20% of their licensed capacity expenses to implement their surge plans to fill staffing gaps. The money to pay the contractor is coming from the Public Health Emergency Fund.  The governor deposited $50M into that fund last week.

Editorial Note: June and July are the 2 months of the year in which patient census is significantly lower than the annual average.  In fact, June typically has 1,700 fewer inpatients than the annual average and July about 1,200. August comes back closer to the annual average.  That means additional staffed bed demand will be increasing in the coming months as normal, non COVID, patients begin returning to hospitals.