Bars Open Across Arizona

Bars have now opened across almost all of Arizona. There are just a few counties that haven’t yet met the moderate spread metrics- and over 90% of Arizonans now live in counties where bars are open. In order to open, bars are supposed to go to the ADHS website and attest that they will follow mitigation measures.

Following mitigation measures is critical in these businesses. As we saw between May 15 and June 26 bars and nightclubs create super-spreading environments without mitigation.

Over the last couple of weeks there has been some strong administrative advocacy urging the state to develop a meaningful compliance program to ensure that bars and nightclubs follow the required mitigation measures upon opening. ADHS had already been requiring bars and nightclubs to sign attestations that they’ll follow mitigation measures, but until late last week there wasn’t an organized active compliance system.

The advocacy worked and late last week the department announced that they would be sponsoring a COVID-19 Compliance Hotline at 1-844-410-2157.  They committed to investigating complaints by referring them to the county health departments or in some cases investigating the complaints themselves.

Editorial Note: Let’s hope that the plan is well organized and works. If the compliance program isn’t effective, we can expect broad non-compliance with mitigation as we say earlier this summer, creating an increase in cases. If that happens, students in the K-12 system will suffer if that happens because counties would no longer meet in person instruction benchmarks in short order. That lost opportunity would be directly attributable the lack of an effective compliance system for bars and nightclubs.

National Academies of Medicine Releasing Draft Vaccine Allocation Report Tuesday

Comment Period Ends Next Friday: We Need to Focus Next Week & Get Comments in to Ensure Health Equity is Included

With the Phase II vaccination clinical trials showing promising results and Phase III trials well underway, it’s time to develop a comprehensive state plan for the equitable prioritization and deployment of COVID-19 vaccine in Arizona. That plan will need to set priorities for the early doses as well as outline the logistical details of its distribution. 

Fortunately, the National Academies of Medicine is working on an objective plan for the equitable allocation of those early doses. Beginning Sept. 1, the National Academies of Medicine will provide opportunities for discussion of their draft Preliminary Framework for Equitable Allocation of COVID-19 Vaccine.

A public listening session will be held Sept. 2 from 9 a.m – 2 p.m. AZ Time. The listening session requires registration. More information about the public comment period is available here.

The initial written comment period will ONLY be open from Sept. 1-4 so we will need to work quickly next week to get our comments in. Hopefully many of our members can listen in and develop thoughts about the initial plan- with a lens to ensuring it includes health equity. Let’s post those comments on our policy committee Basecamp this upcoming week so we can get comments in by Friday.

Arizona Center for Rural Health Annual Report

The AzCRH Annual Report  summarizes activities from 07/01/19 to 06/30/20 related to its mission to improve the health & wellness of Arizona’s rural & vulnerable populations.  The Center houses a record $4.5 million/year in federal and state funded rural programs, and provides subawards, services, webinars, conferences, continuing education, technical assistance, data, analyses, evaluations, and reports to inform and support Arizonans, providers and policymakers on rural best practices, legislation and regulation. Enjoy their Annual Report.

FDA Issues Emergency Use Authorization to Yale School of Public Health for SalivaDirect

Last week the FDA issued an emergency use authorization to Yale School of Public Health for its SalivaDirect COVID-19 diagnostic test, which uses a new method of processing saliva samples when testing for COVID-19 infection. SalivaDirect does not require any special type of swab or collection device; a saliva sample can be collected in any sterile container.

Pandemic Policymaking: Assessing Legal Responses to COVID-19

As the nation continues to grapple with the ongoing COVID-19 pandemic, the Network has joined with public health law partners to produce a report that includes critical analyses and recommendations from 50 national experts convened to assess the U.S. policy response to the crisis to date.

This new report offers policy recommendations on 35 wide-ranging topics, including pandemic preparedness, access to health care, voter health and safety, protections for essential workers, food insecurity and immigration policy. Designed to advise leaders at the federal, state and local level, the report presents a timely examination of policy challenges and opportunities in light of the pandemic.

Read the full report here

Preliminary Framework for Equitable Allocation of COVID-19 Vaccine

Having a vaccine prioritization plan that is fair, equitable, and evidence-based will be a key element in the national and Arizona response to the COVID-19 Pandemic. The National Academies has been working on a Preliminary Framework for Equitable Allocation of COVID-19 Vaccine. It will be released on September 1. 

Starting September 1, the National Academies will invite public comments on a Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine, part of a study commissioned by NIH and CDC. The report will be released on September 1.

The study will recommend priorities to inform allocation of a limited initial supply of COVID-19 vaccine, taking into account factors such as racial/ethnic inequities and groups at higher risk due to health status, occupation, or living conditions.

Register Now! Public Listening Session

Wednesday, September 2 | 9:00 to 2:00 pm AZ Time

Please join the National Academies for an open session in which members of the public will be invited to address the study committee. You can sign up now to make a comment.

Because time at the session will be limited, they can’t guarantee that everyone will have the opportunity to make an oral comment. Please consider submitting a written comment between September 1 and September 4 (more information below).

Register

Written Comment Period: September 1 – 4

Members of the public are encouraged to submit written comments for consideration by the study committee (as individuals or on behalf of an organization). The public comment period will be open for 4 days, from 12:00 p.m. ET on Tuesday, September 1, until 11:59 p.m. ET on Friday, September 4. 

Members of the public will be able to download and review the discussion draft before submitting a comment through a form (uploaded documents accepted). All materials comments received will be placed in the committee’s Public Access File, and may be provided to the public upon request

More Information

The Antibody Drama from Last Week

Back on August 3, the CDC issued new guidance regarding people who are infected with the coronavirus. It flew under the radar until the New Your Times wrote a story about that change.  Following the NYT article, other media outlets improperly interpreted the new CDC guidance and wrote stories suggesting that immunity wanes after 3 months. That is not what the CDC guidance said.

What the CDC actually said was that “People who have tested positive for COVID-19 do not need to quarantine or get tested again for up to three months as long as they do not develop symptoms again. People who develop symptoms again within three months of their first bout of Covid-19 may need to be tested again if there is no other cause identified for their symptoms.”

Last Friday the CDC issued a clarifying statement saying, “Contrary to media reporting today…  the latest data simply suggests that retesting someone in the 3 months following initial infection is not necessary unless that person is exhibiting the symptoms of COVID-19 and the symptoms cannot be associated with another illness.”

Some scientists have speculated that immunity from the virus might only last 3 months based on a study published in Nature back in June that showed many patients began to show decreasing levels of immunity 2–3 months after infection and that antibodies may not last very long among asymptomatic mildly ill persons.

But remember, antibodies are just one part of the immune system and it’s normal for antibodies to decrease once an infection recedes.  It also doesn’t mean that waning antibody titers mean waning immunity.  The memory B cells that first produced those antibodies are still around and stand ready to make more antibodies on demand. There is also good evidence that people infected with the SARS virus also generate a robust T-cell response- providing a longer lasting type of immunity.

Next week I’ll do a have a piece on the immune system and how it works with an eye toward the pandemic.

US Supreme Court Sets ACA Court Date

The ACA is in more jeopardy than you might realize.  Here’s a blog post from last summer that explains why.

The Supreme Court will hear oral arguments on the future of the Affordable Care Act on November 10, exactly one week after the presidential election, it announced Wednesday.  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.

Several Counties Almost Meeting the Bar & Nightclub Benchmark Criteria Allowing them to Open

Will There be a Compliance System this Time?

As you recall from last week’s blog post, the ADHS has proposed benchmarks for when bars, nightclubs and gyms can re-open.  When a county reaches numeric benchmarks like a defined percent positivity rate the paused businesses are free to re-open if they implement safety protocols and guidelines and turn in an attestation form committing to stay in compliance.

The benchmarks for each county are posed on the ADHS’ Dashboard.  That dashboard shows whether the county meets the benchmarks. There’s a drop-down box that let’s you see each individual county’s metrics. The default is the statewide numbers.

Editorial Note: Several counties are coming close to meeting the metrics that will allow bars and nightclubs to open again. And while each business will be required to attest that they are implementing the mitigation guidelines, there is still no defined compliance and enforcement system to ensure that the businesses stay in compliance.

Without a rigorous and compliance system that is enforceable it’s highly likely that large numbers of bars and nightclubs will ignore the mitigation guidelines and behave exactly like they did from May 15 all the way until late June when the governor finally “paused” these businesses. If that happens we will again see a dramatic growth in cases and percent positives which will jeopardize the opportunity for in-person instruction in our K-12 system.

Such a compliance system isn’t rocket science. The state could require each of these businesses to post a number to a complaint hotline (perhaps even the smoke free Arizona hotline). Complaints could be distributed to the county health departments who could send out their Environmental Health Specialists (Sanitarians). Businesses that are out of compliance as determined by the county inspector would have their attestation canceled. Business closes. Compensation for that work could come via CARES Act money. Voila, compliance.

All-Cause Mortality Trends In AZ During the COVID-19 Pandemic

There has been much debate about the magnitude of the public health impact attributable to the SARS CoV2 epidemic in Arizona. We examine total mortality during 2020 as a measure of this impact. Our full report has the narrative along with the Figures and Tables. Below you can read the narrative of our report.

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Our Question:  What has been the magnitude of the increase in all-cause deaths in Arizona during the SARS CoV2 pandemic (January – July 2020)?

Our Method: We reviewed the population health and vital statistics data collected by the Arizona Department of Health Services from 2011 to 2020 and calculated total mortality rates per 100,000 populations.  Because total mortality rates vary by month, with peak rates in December through March, we calculated rates per month for this 10-year period to capture all-cause mortality trends.

For our analysis, we:

  • Pulled death data from ADHS vital statistics by month

  • Pulled population estimates data 2011-2019 from ADHS population health and vital statistics, population denominators

  • Projected estimate for 2020 population based upon the prior 3-year average annual population growth

  • Calculated rates (# of deaths in a month/ estimated population in corresponding year) * 100,000 and Percent change [(new year’s rate – previous year’s rate)/ previous year’s rate] *100

Our Findings:  We found a profound increase in all-cause mortality in Arizona in the first half of 2020 when compared to previous years. Table 1 displays positive percent change February through July.  July had the largest percent change with a 58% increase in July 2020 when compared to 2019.

From 2011-2019, all-cause mortality death data are consistent from year to year with increased total mortality from December through March. All-cause mortality increased significantly in 2020, with an increase in deaths beginning in April 2020 and profound increases in June and July (Figure 1).

Discussion: Arizona has recorded more than 7,100 more deaths in the first 7 months of 2020 when compared to 2019. According to data from the Arizona Department of Health Services data dashboard, about 4,100 of these deaths have been as a direct result of a SARS CoV2 infection. This suggests that an additional 3,000 deaths during this period may be indirectly attributable to the pandemic.

For example, persons with chronic obstructive pulmonary disease may have developed a mild SARS CoV2 infection that worsened their underlying medical condition. Only a more detailed review of the medical record and death certificate would reveal that the coronavirus was a core cause of the death. In addition, during much of 2020, elective procedures were not available for many Arizonans unless the procedure was urgent.  This causes delays in care that may be responsible for many of the additional 3,000 deaths. 

There is also ample evidence that delayed care during the late spring and early summer because of fears of coronavirus infections in healthcare facilities. These decisions may have also resulted in deaths indirectly related to the novel coronavirus because of the social disruption caused by the rapid increase in cases Arizona experienced in June and July.

Some have suggested that a substantial portion of the increase in all-cause mortality in June and July is attributable to heat-related deaths, unintentional poisonings with opioids or suicides. Our review revealed no evidence that this is the case.

For example, an August 11, 2020 report from Dr. Gregory Hess, Chief Medical Examiner for Pima County concluded that: “Suicide deaths in Pima County have not increased in 2020. There was a thought that Stay at Home Orders and the social isolation caused by it could have increased the number of suicide deaths in Pima County. These deaths have not increased in 2020.”  The same report could find no link to accidental poisonings and the increases in total mortality in 2020.

Our Conclusions: The COVID-19 pandemic is having a profound impact on public health in Arizona. We found clear and convincing evidence that total mortality has substantially increased during 2020, particularly in June and July.  Indeed, the total mortality rate per 100,000 during July 2020 was nearly 58% higher than July 2019. These findings are consistent with the exponential growth in the number of persons infected with COVID-19 during June and July 2020 in Arizona. We find that the increase in deaths are due to the direct and indirect effects of the pandemic. We could find no evidence that suicides or accidental poisonings are responsible for this increase.

Editorial Note: Over the course of the pandemic we have seen that the SARS CoV2 virus responds to policy decisions and the administrative effectiveness of the public health response. Ill-advised decisions to emerge from the Stay at Home Order rapidly without requiring community mitigation measures resulted in an exponential spread of the virus. In addition, testing capacity was inadequate, sample turn-around times were insufficient, contact tracers were receiving tardy data, public health orders were inadequate/unenforced, and testing/infection control in care homes were insufficient. These factors also contributed to exponential community spread of the virus.

This report documents that the exponential growth in cases in June and July resulted in large increases in deaths that are directly and indirectly attributable to COVID-19 infections. Indeed, the total mortality rate per 100,000 during July 2020 was nearly 58% higher than July 2019.

We urge the governor and state health director to consider the impacts caused by the policy decisions made in May and June as they evaluate opening bars and nightclubs. In particular, we urge them to ensure that compliance and enforcement systems are in place when bars and nightclubs are allowed to reopen and when in-person school instruction begins. If community spread begins to rapidly increase (as was the case in very early June) we urge swift action to mitigate spread.

As we have learned, the public health burden of policy errors are profound.

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