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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.

HHS announced significant changes to the process for hospitals to fulfill the agency’s request for daily data reporting on bed capacity, utilization, personal protective equipment, and in-house laboratory testing data.

The CDC National Healthcare Safety Network COVID-19 module is no longer being used. Hospitals now have to either: 

• report data to their state health departments (if their state promises to then report the data to HHS; or

• report directly to the HHS TeleTracking portal.

HHS has made significant updates to the data fields it is asking for in daily reporting. For example, HHS is asking for information on both pediatric and adult patients and is asking hospitals for information about their inventory of remdesivir.

Editorial Note: This is a controversial decision in the public health and academic world. The CDC has built a trusted brand for decades and public health and academics alike trust that the CDC behaves on the up and up, makes data available and is committed to data integrity. There’s less confidence in HHS because there are far more political appointees there- whereas CDC is dominated by career folks. There is concern that the data will become less transparent and questions about whether HHS will edit the data.

COVID-19 testing plans from states, territories, and localities for the months of May and June were posted on the HHS website last week.  CDC awarded $10B in funding to states, territories, and localities to assist with the implementation of these plans. Here is the testing plan that AZ turned in.

An mRNA Vaccine against SARS-CoV-2

Moderna has completed their Phase I Trial in the U.S. of their mRNA-1273 vaccine. The results are promising. It induced anti–SARS-CoV-2 immune responses in all participants, and no trial-limiting safety concerns were identified. These findings support further development of this vaccine.  The Phase II trial is underway with results expected by late August. At that point, it will move to a Phase III Trial which will test safety and efficacy in much larger populations. NCT04283461.  

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EDITORIAL

Covid-19 Vaccine-Development Multiverse

• Penny M. Heaton, M.D.

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Characteristics of Persons Who Died with COVID-19

An early release MMWR outlines characteristics of people who died with laboratory-confirmed COVID-19 and was obtained through CDC’s case-based surveillance data and supplemental surveillance data from 16 public health jurisdictions.

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MMWR: Factors Associated with Cloth Face Covering Use Among Adults During the COVID-19 Pandemic 

Another early release MMWR discusses the findings of two internet surveys that assessed a sample of adults’ use of cloth face coverings and the behavioral and sociodemographic factors that might influence wearing a cloth face-covering out in public.

Within days of the release of the first national recommendation for use of cloth face coverings, most people who reported leaving their home in the previous week reported using a cloth face covering.