We published the above opinion piece in the Arizona Republic this week that urges public policy changes to improve access to testing and treatment of undocumented persons. Congress has left millions of immigrants, many of them essential workers, without access to necessary COVID-19 care, threatening all of our health.
You can read our opinion piece in the July 8 Arizona Republic.
Dr. Gerald updated his analysis of COVID epidemiology and hospital admission/capacity trends over the weekend. Here’s a link to the 6-page analysis. Below are a few of the take-aways:
Given the reporting lag, it is unclear how PCR testing capacity changed this past week; however, the percent of patients testing positive continues to increase from a low of 4.9% in mid-May to a new high of 23.4% this past week
From a May 22 plateau, total Covid-19 hospitalization has increased 301% from 1093 to 4384 occupied beds. Increases in general ward occupancy have outpaced ICU occupancy, 345% versus 191%, respectively. Continued increases in new cases are expected to drive additional hospitalizations for the near future.
899 (52%) of Arizona’s 1730 ICU beds were occupied for Covid-19 care, a 13% increase from last week. An additional 174 (10%) beds remain available which is about the same as the 171 beds available last week. About 50 ICU beds were added to Arizona’s total capacity on July 10th.
Most ICUs are at or over their capacity limits with regard to an adequate supply of health care workers; some hospitals are near or at capacity for ICU beds. Widespread personnel shortages are already being reported in critical care settings. Local conditions will provide a better indicator of critical capacity than state-wide trends.
With 204 deaths reported to date, the week ending June 28th is now the week with the largest number of Covid-19 deaths eclipsing the 202 deaths the week ending June 21st. This increase is consistent with the recent increases in new cases. Given that case counts are still increasing, a larger number of deaths in the coming weeks is expected.
The shift towards younger, working-age adults has abated; therefore, future case increases will be more directly tied to hospital utilization and deaths.
June typically marks the nadir of Arizona hospital admission Arizona. From now until January, non-Covid hospitalizations are expected to increase putting additional strain on hospital capacity.
For the last several weeks our public health response system has been impaired because of the slow turn around times for the diagnostic PCR tests. Much of the public discourse has focused on the shortage of testing that’s available but there’s been less discussion of the poor turn-around times (between 6-8 days and often more).
Slow turn-around times impair the public health response because folks that get tested don’t know their status for several days. When they don’t know their status- it’s less likely that they’ll make the behavioral changes needed to prevent the spread of the virus (e.g. they’re unlikely to isolate).
Also, contact tracing effectiveness is nullified because the folks at the county health departments get the case report several days too late. By the time they’re able to do the case investigation the person is likely no longer infectious- and the opportunity to intervene has passed. Contacts may already be symptomatic and in some cases may have even recovered.
Those are reasons why we really need to improve turn-around times.
We got word this week that there is now a goal to improve those turn around times. The ADHS has publicly committed to increasing diagnostic capacity to 35,000 units per day by the end of July. To accomplish that, they’ve earmarked $2M to Sonora Quest to buy instruments/reagents etc.
Hopefully they’ll also be looking at: 1) the specimen courier services; 2) the instruments needed for the analysis; 3) staffing to make it happen; and 4) report out logistics.
We also need a new metric in the ADHS dashboard that tracks turn-around time. Public metrics are essential to accountability and performance improvement. Without a public metric I’m afraid that this super-important performance measure won’t be a priority for leadership.
The 2020 regular session will stand out as one of the most unpredictable, unforgettable years ever. Session lasted 135 days but was suspended for more than 40% of that time because of the pandemic. The year began with loud, crowded committee meetings and ended with near-empty buildings and remote voting.
Legislators introduced 1,734 bills this year (more than any session on record) but had the fewest number of bills signed into law in recorded history. Only 5% of those bills made it to the Governor’s desk. Nearly 90% were bipartisan.
Just before the session was suspended, they approved a “baseline” budget which was basically a continuation of last year’s spending, adjusted to pay for projected growth in health care and education enrollment. It also included an additional $105M to address the COVID-19 pandemic.
Here are some of the bills that passed:
A bill requiring AHCCCS to ask for federal authorization to reimburse the Indian Health Services and tribal facilities to cover the costs of adult dental care.
A bill that increases federal funding for hospitals that provide care for AHCCCS patients by requiring the facilities to contribute the matching funds needed to bring more federal dollars to Arizona.
Increasing suicide prevention training for school counselors and social workers, and by providing more information about mental health resources to students and mandating all public and charter schools include information on school ID’s (grades 9-12) like the phone number for a national and local suicide prevention hotline and the number for a network of local crisis centers.
A Mental health parity bill that expands access to mental health resources and creates committees responsible for identifying new ways to ensure students and other Arizonans have access to mental health care.
Most of our policy priorities were not achieved. Bills to provide dental services for pregnant women enrolled in Medicaid and encouraging women to complete post-partum visits didn’t pass.
We were also unable to get bills through that would classify electronic cigarettes as tobacco products so they would be covered by the Smoke Free Arizona Act. We also weren’t able to get a Tobacco 21 passed this year either.
A bill that would have decriminalized evidence-based syringe service programs also didn’t make it. Likewise, no progress was made to improve access to care through additional graduate medical education enhancements nor the state loan repayment program.
There had been support for some limited criminal justice reform but the bills that would have improved sentencing standards including second chances didn’t pass in the end. Bills that would have made it harder for law enforcement to take a suspect’s assets, and require state agencies to give most occupational licenses to individuals who have been convicted of a drug offenses also didn’t get over the line.
As a refresher, here was our set of 2020 Legislative Session Priorities (ppt).
Visualizing the effectiveness of face masks in obstructing respiratory jets
Physics of Fluids 32, 061708 (2020)
Abstract:
Loosely folded face masks and bandana-style coverings provide minimal stopping-capability. Well-fitted homemade masks with multiple layers of quilting fabric and cone style masks were the most effective in reducing droplet dispersal.
_________
Testing for SARS-CoV-2 Infection Among Incarcerated and Detained Persons
A new MMWR report details an investigation conducted by CDC and the Louisiana Department of Health to determine SARS-CoV-2 infection prevalence in quarantined dormitories in a Louisiana correctional facility.
Applications are now open for the Fulbright Public Policy Fellowship. The program provides opportunities for U.S. early and mid-career professionals and practitioners to serve in placements in a foreign government ministry or institutions around the world.
The program includes an independent research component focusing on an issue related to the Fellow’s in-country work. Successful candidates will include early to mid-career entrepreneurial and self-starter professionals with a graduate degree in a public-policy related field (e.g., JD, MPA, MPH) and a minimum of three to five years of full-time work experience.
Postdoctoral candidates and practitioners active in the academic, public, or private sectors with a record of experience and accomplishment in a public policy related area are encouraged to apply.
In a series of 5 new executive orders, the governor has limited gatherings of people both indoors and outdoors to no more than 50 people, and has ordered a 30-day shutdown of bars, gyms, movie theaters, water parks and tubing. Another order delays the school start date until August 17, which he described as an “aspirational date”.
Gatherings of more that 50 people are allowed if a local government jurisdiction authorizes it and certifies that the even will have adequate mitigation measures.
The closing of bars is limited to places that hold a series 6 or 7 liquor license. A typical restaurant would hold a series 12 license and can therefore remain open.
However, series 6 or 7 license owners that get more than 1/2 of their revenue from food sales can remain open with dine-in or drink-in service. I’m not sure where the data is that documents whether a place gets more than half their revenue from food- hopefully there is a clear data set to make that determination- otherwise that’ll become a big loophole.
When the 30 day closure ends they must adhere to public health regulations, post them for the public. Cities and counties will be responsible for enforcement.
Compliance is king when it comes to public health interventions. Let’s see what compliance looks like before drawing any conclusions about the effectiveness of these interventons.
Last week the federal government filed a brief asking the Supreme Court to overturn the Affordable Care Act. If successful, about 300,000 Arizonans would lose health coverage.
Protections would be lost for more than 2.7 million Arizonans with pre-existing conditions. Insurance companies would once again be allowed to deny coverage to people who have reached their lifetime limits. 20,000 young adults in Arizona would not be allowed to remain on a parent’s health insurance plan until the age of 26.
Insurance companies would no longer be required to cover the 10 Essential Health Benefits and protections would be stripped from people with employer-based health coverage, those on a Marketplace plans, and families who use Medicaid, Medicare and/or KidsCare.
The US Supreme Court is set to hear the California v. Texas lawsuit (that’s new name for it) in the coming months. Arizona is among the states that has signed on urging the court to overturn the ACA. You can click here to sign onto the letter urging the Attorney General to drop AZ from the list of states that wants to overturn the ACA.
The US Supreme Court has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote. Since then, Gorsuch replaced Scalia and Kavanaugh replaced Kennedy. Both Scalia and Kennedy voted against the ACA- so not much on that score has changed.
Chief Justice Roberts voted with the majority that upheld the law. His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, the financial penalties for not having health insurance were removed from the IRS tax codes in the federal tax overhaul a few years ago, pulling out the structure that Roberts used in his argument.
In the 2012 Ruling, Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax… because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”
Roberts rejected the Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).
The bottom line is that the ACA, including its protections for folks with pre-existing conditions, may very well be in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.
Last week the ADHS announced that they’ve authorized “Crisis Standards of Care” within our hospital systems. The declaration allows for statewide triage protocols when the demand for healthcare exceeds the ability to provide care using normal standards of care.
Arizona is the only state to have made such a declaration and this is the first time it has ever been made in Arizona. See last week’s blog post to see how patients will be prioritized when Crisis Standards of Care are being used.
Here’s the document that officially activates the new crisis care standards for patient triage and prioritization. Now that we’re under the crisis standard, there are civil liability protections for healthcare providers and institutions who are following the approved Triage Protocol.
Hospitals are also urged to: 1) activate tactics identified in the Arizona Crisis Standards of Care; 2) prepare for surge; 3) limit surgeries; 4) activate hospital incident command; and 4) establish regular communication with local health jurisdiction.
These measures have become necessary because of the tremendous community spread of the virus in AZ and the resulting surge of patients into AZ hospitals.
The week ending June 28 recorded 22,388 new Covid-19 cases, which is an 8% increase over last week’s revised tally of 20733 new cases, marking a grim 4-week period with 50–70% increases per week. However, this week’s increase looks to be about 30% from the previous week.
But don’t celebrate too much… absolute levels of community-driven viral transmission have never been higher as evidenced by frequent daily and weekly record-setting numbers of newly reported cases.
While still reflecting enormous growth, it’s slightly less exponential suggesting that perhaps the local face covering ordinances may be showing a moderating effect on the still steep trajectory.
PCR testing capacity continues to increase but it’s not keeping pace with viral transmission as evidenced by the very high percentage of patients testing positive which was 21.8% this past week. This figure is the worst in the nation by a wide margin and likely the highest percent positive in the world right now.
Since the end of the stay at home order, COVID-19 hospitalization has increased 243%. Increases in general ward occupancy have been greater than increases in ICU occupancy (284% versus 140%).
Non-COVID patients are being squeezed our of hospitals as evidenced by the fact that while inpatient COVID hospitalizations are up over 250% all-cause occupancy is up 12% during that time period. This trend could be a result of non-COVID patients being triaged out of the hospital system. Continued increases in case counts are expected to drive additional hospitalizations for the foreseeable future.
Note: COVID patients are more labor intensive than typical ICU patients and therefore pose a more intense drain on provider resources.
The week ending June 21st is now the week with the largest number of reported deaths. Given that case counts are continuing to increase, a larger number of deaths in the coming weeks is expected.
Arizona State University Covid-19 Modeling and Evaluation Team – July 1 Update
The ASU Modeling and Evaluation Team updated their findings last week in their July 1 Update. provided selected findings from their July 1st update. A pre-print of their work with specific model specifications and additional results is also available.
The team projects Arizona will reach 100% of existing hospital capacity in early-to-mid July absent further reductions in non-Covid hospitalizations or increased bed capacity.
