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An experienced AzPHA member working in state government recently developed the action plan below to more effectively respond to the COVID situation in Arizona. Because of the nature of the person’s they wish to remain anonymous.  I’m posting the person’s ideas here in hopes that it builds the inventory of ideas to enhance Arizona’s response.

Create clear criteria for discharge from an inpatient setting and leverage alternate care sites for Persons Under Investigation or asymptomatic/low symptom burden cases who require support to effectively isolate. quarantine. While such alternate care sites (e.g. “quarantine hotels”) have developed, their clinical oversight is variable, and they are not being utilized in a systematic or organized manner at present. When utilized with appropriate clinical oversight and proper technical assistance and support, they can be an effective tool in bending the curve.

ALL congregate settings, including non-healthcare settings – such as prisons and detention centers –  should have – a)routine screening and periodic testing procedures in place for all personnel working in the facility, b) strict standards for infection control c) guaranteed supply and use of appropriate PPE, d) personnel and pay policies that support those who are exposed or infected to stay home. Home care/ direct care workers, who serve vulnerable populations, should receive similar support from county/state agencies. One-time testing drives are insufficient.

The governor’s office should ensure more robust inter-agency collaboration in directing the response to COVID-19. ADHS should better leverage the academic workgroups that they have convened for modeling to help inform solutions. The modeling effort and disease response effort, clinical and operational functions should not remain as silos.

All counties should transparently state their contact tracing process. ADHS should set up clear standards for contact tracing, isolation/quarantine, case management and follow up by counties to include close contacts, primary AND secondary contacts beginning from 48-72 hours prior to onset of symptoms of the index case and through the infectious period.   Because of the significant impact of pre-symptomatic spread, merely tracing close contacts would be an insufficient response. 

Designate healthcare facilities  as Covid versus non-Covid. Concentrate testing, PPE, training/technical assistance, manpower, funding and monitoring into the Covid accepting facilities. This will allay anxiety among the public and allow people to seek the routine care that is so desperately needed, including childhood immunization.

Create a plan to ensure the control of vaccine preventable infections: including flu/ pneumonia, measles, newborn and childhood vaccines. Participation in the VFC program needs to be encouraged. Flexibilities for this program administration should be sought from the CDC to ensure the infrastructure for vaccine distribution is sustained through the emergency. This infrastructure will be essential should a COVID vaccine emerge.

Most important: ensure CLEAR, CONSISTENT, PROACTIVE messaging at each stage of the pandemic across state agencies. This has been a gap that leadership can correct.

Here’s a link to Dr. Gerald’s latest analysis. As expected given the numbers and trends on the various data dashboards, the trends aren’t encouraging. At least we now have some new interventions underway (view next blog post).

Reported cases and hospitalizations, but not deaths, continue to increase at a rapid pace signaling increasing community spread. While these trends differ by geographic region, Covid-19 is widespread in Arizona (see Appendix for county data).

Absolute levels of community-driven viral transmission have never been higher as evidenced by frequent daily and weekly record-setting levels of newly reported cases.

For most locales, additional government-mandated social distancing restrictions and/or mask-wearing are urgently needed to reduce the pace of community transmission.

The nature of the outbreak is changing such that new infections are shifting towards younger, working-age adults which has important implications for hospital utilization and deaths.

Covid-related hospital utilization continues to increase while excess capacity is declining. Adequate capacity currently exists, but excess capacity could be depleted by early-to-mid July.

Some hospitals are already near or at capacity for ICU care; therefore, local conditions will provide a better indicator of capacity than state-wide trends. Stated capacity may over-estimate actual capacity for structural reasons; therefore, surge beds may be need sooner than expected.

The number of Covid-19 tests is not keeping pace with rising case counts as evidenced by increasing PCR test positive rates. Positivity rates remain >3% indicating capacity is likely inadequate to meet clinical and public health demands. Test reporting lags appear to be about the same.

Stakeholder Advocacy Achieved Policy Success

Consistent and widespread advocacy by a host of Stakeholders achieved some policy success this week. Well done all!

Last Wednesday the governor issued a new Executive Order (E.O. 40) which includes some welcome intervention measures that collectively will help mitigate the spread of the virus. In addition to the new Executive Order, he also made some public commitments to implement other interventions. Here’s a run-down of the elements in the new Order and a discussion of the other promises made at last Wednesday’s press briefing:

Wednesday’s Executive Order allows cities and counties to require face coverings while in public spaces. Dozens of cities and several counties quickly jumped on-board the evidence-based policy express this week. Maricopa, Pima, and Santa Cruz counties even passed county wide ordinances that cover the entire county (not just the unincorporated places).

Under the former Executive Order, businesses bars and restaurants were encouraged to follow CDC recommended mitigation measures. Under the new E.O. these businesses are required to implement the measures.  Here are the new requirements for Businesses, Restaurants & Bars. Local jurisdictions will be able to ensure compliance with the requirements.

Over the last couple of months AARP had sent the governor 4 letters urging him to order more comprehensive measures to prevent the spread of the virus in assisted living and skilled nursing among other changes. That advocacy eventually worked. During the conference yesterday, the governor announced that the state will spend $10M for testing and PPE in these facilities and will now allow the Ombudsman to resume visits. Welcome changes indeed. Note: Some measures are already underway in this area- for example Maricopa County Public Health has also committed $10M toward testing and PPE in long term care facilities.

The new E.O. addresses contact tracing- stating that ADHS shall set statewide contact tracing standards and protocols and that all counties must follow them until “… ADHS determines that they have the needed infrastructure and resources…“.   I can’t figure out how this is helpful, as county health departments are currently working under existing contact tracing practices. He also committed to engaging about 300 national guard troops in contact tracing.

Editorial Note: Last Wednesday’s decisions demonstrate that evidence-based public advocacy (informed by academia) can drive policy change. Letters and other advocacy efforts by doctors, hospital systems, managed care organizations, the AARP, AzPHA and other groups built a critical mass of support for the policy changes that we’ve been advocating for over the last couple of weeks including:

1. Requiring face coverings in public;

2. Better mitigation compliance expectations for businesses;

3. Allowing cities to implement mitigation strategies;

4. More focus on infection control and testing in care homes; and

5. Enhanced contact tracing.

While the policy changes last week aren’t precisely what we’ve been advocating for, it’s a big step forward… and it’s solid evidence that vocal evidence-based public advocacy can drive policy change. 

Why do some people infected with the coronavirus suffer only mild symptoms, while others become deathly ill? A new study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19.

Variations at two spots in the human genome are associated with an increased risk of respiratory failure in patients with Covid-19 – one of these spots includes the gene that determines blood types. Having Type A blood was linked to a 50% increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

Learn more about what researchers found in the study here, which has not yet been through peer-review.

Disclaimer: COVID-19 modeling projections are not intended to be predictions or quantitative guesses about what may happen in the mid-range (weeks-to-months) or long-term (months-to-years). They are intended to reflect current trends projected into the future and the relative effects of changes in transmission, social distancing, weather sensitivity, current burden of disease and other epidemiological factors. As more testing and tracing data come online, and policies and behaviors change, the estimates will change.

Summary:

• When we model the rise in Arizona case counts our conclusion is that it is due to evidence of increased community transmission. This model estimates a 40% increase in transmission since May 11 (May 11-May 24). The model predicts a future exponential growth curve of COVID-19 cases going forward if this transmission rate persists, a very concerning public health trend.

• Decreasing the transmission rate and community spread of COVID-19 depends on increasing the adherence to strict social distancing, and particularly the wearing of masks. ASU recognizes the importance of wearing masks in public to reduce the spread of COVID-19.

• Our modeling predicts that, unless further adherence to non-pharmaceutical interventions can be made, the COVID case counts, hospitalizations and ICU bed use will continue to increase. How much and how soon is still uncertain. Very small errors in data can result in large uncertainties in the final projection numbers. We will know more in the weeks ahead as testing, tracing and hospital data continue.

• The state should continue to anticipate and prepare for the increased burden on its health care systems. If model predictions are realized, Arizona may have exhausted its available bed supply by late June/early July. At that point, capacity will need to be increased by putting beds in “surge capacity” areas to meet the growing demand.

You can view their full product at: https://biodesign.asu.edu/research/clinical-testing/critical-covid-19-trends

Maricopa County Public Health released a Request For Purchase (RFP) for testing in congregate settings a couple of weeks ago. The RFP closed last week and they’re in the final stage of reviewing the responses and hope to have contractors in place shortly. 

The contract will be used to increase testing in our Long Term Care facilities, assisted living facilities, jails, homeless shelters and other congregate settings needing testing and/or infection control training. 

A welcome intervention indeed!

It’s looking more and more like we’re going to need them

Unless some policy changes like those below are implemented in the coming days, it’s looking more and more like Arizona will need to go into surge hospital status and implement crisis standards of care for folks that become infected with the virus and need care later this summer. Here are some things that we could implement to avoid crisis care:

• Mandatory cloth masks in public indoor environments (with penalties for noncompliance- managed by cities).

• Allow cities to implement mitigation strategies.

• Stronger compliance incentives; modify EO 36 to include penalties for businesses not complying with CDC guidelines. Complaints could be followed up on by cities. 

• More focus on testing and infection control in assisted living and skilled nursing. For example, setting up routine weekly testing of assisted living and skilled nursing staff w better infection control. MCDPH is about to award a contract related to this. It appears the state is unwilling to use their regulatory authority here.

• Continue to enhance contact tracing capacity. It would have been nice to tie ending the stay at home to some level of contact tracing to motivate supervisors to resource this- so that was a missed opportunity.

At the beginning of the pandemic, hospitals were ordered to submit (to ADHS) plans to increase their bed and ICU capacity by an additional 50% over their currently licensed capacity and implement crisis standards of care.  I’m certain that given the data trends, hospitals are working to implement those surge plans.

On the alternate care site front…  a couple of months ago there was a press event out at the old St. Luke’s hospital and a declaration by the governor and others that the facility would become a contingency acute care hospital strictly for COVID patients.

Several journalists and others have been trying to fund out what the status of the facility is. In other words, how ready is it to be used if needed?

Statements from the governor’s spokesperson this week in the Republic suggested that it is ready to go and can be operational in 48 hours.  However, journalists and others have been unable to find a contract with an entity that would run the facility.

Later in the week, some journalists heard that the St. Luke’s is no longer an acute care alternate care site, but more of a step down facility. 

Perhaps we will learn more soon. It’s an increasingly important question because with all the indicators pointing in the wrong direction, there’s an increasing chance that a site like this might be needed.

Dr. Joe Gerald just sent me his new data analysis and model run summary. Terrific work as usual. There’s more detail in this week’s report because of all the action related to both with the data and the public health policies (or lack thereof) in the last week. Here are some of the more interesting information nuggets from today’s report:

Since May 17, cases have increased 138% (3,061 to 7,286) while testing has increased by 17% (46,206 to 54,078) providing compelling evidence that increasing case counts largely reflect increased community transmission- not increased testing.

Since the week ending May 17th, the percent of PCR specimens that are positive has increased from 5.3% to 11.1% suggesting that testing capacity is not keeping pace with transmission.

From a May 22 to June 12, Covid-19 total hospitalization has increased 70% (from 1093 to 1859 occupied beds). Increases in Covid-19 general ward occupancy were greater than increases in ICU occupancy, 80% and 45%, respectively. Because of a decline in non-Covid hospitalizations, the all-cause hospital census has only increased 9% from 7173 to 7785 occupied beds. Continued increases in case counts is expected to drive additional hospitalizations for the foreseeable future.

As of June 12, 1412 (18.3%) of Arizona’s 7705 general ward beds were occupied by patients with suspected or confirmed Covid-19 infection, a 10% increase from last week. An additional 1237 (16.1%) beds remain available. Similarly, 447 (26.9%) of Arizona’s 1664 ICU beds were occupied for Covid-19 care, a 14% increase from last week.

A projection of non-surge general ward and ICU capacity suggests Arizona could reach general ward capacity sometime between in July or August assuming no mitigation efforts are instituted and past trends continue uninterrupted.

The possibility that Arizona might exceed its ICU capacity is supported by CovidActNow which shows markedly rising ICU utilization through June. A similar projection is made by the Institute of Health Metrics and Evaluation.

Once “normal” operating capacity is exceeded, patients will be admitted to jury-rigged settings, treated with second-line agents owing to shortages of critical resources, and cared for by nurses and physicians recruited from non-critical specialties. This is not to disparage the heroic measures these facilities and caregivers will make to ensure quality care but rather to caution against an overly idealistic view of the equivalence of surge care.

At the end of the report, Dr Gerald has a terrific analysis regarding the Governor’s June 11 Covid-19 Press Briefing. I won’t summarize this here, but it is very good. Take some time to take a peek.

Landmark Study Establishes that Cloth Masks are Very Effective, High ROI

A new comprehensive study was published Friday that unequivocally shows that cloth mask wearing in pubic is super effective. It’s undoubtedly the highest return on investment intervention available right now.

Researchers examined the transmission pathways by analyzing the trend and mitigation measures in Wuhan, Italy, and NYC from January 23 to May 9. They found that airborne transmission is the dominant way that the virus is spread (as opposed to surfaces etc.).

The authors examined the difference in spread with and without mandated cloth face covering and found that masks “significantly reduces the number of infections”. Mask wearing alone reduced the number of infections by over 78,000 in Italy from April 6 to May 9 and over 66,000 in New York City from April 17 to May 9. 

When mask-wearing went into effect in New York, the daily new infection rate fell by about 3% per day. Infection trends shifted dramatically when mask-wearing rules were implemented on April 6 in northern Italy and April 17 in NYC.

The study concludes that “… wearing of face masks in public corresponds to the most effective means to prevent inter-human transmission, and this inexpensive practice, in conjunction with simultaneous social distancing, quarantine, and contact tracing, represents the most likely fighting opportunity to stop the COVID-19 pandemic“.

Editorial Note: Ok… so lets think about this for a second. Here we have a very effective intervention that’s proven and is the single most efficient way to slow the spread of the virus. The intervention costs essentially nothing. Compare that to the cost of another stay at home order or the interventions like expanding hospital capacity and canceling elective procedures.

This is the easiest call in the world. We should have a statewide requirement requiring everybody to wear a mask in indoor environments when they’re in public.

Source: 

Identifying airborne transmission as the dominant route for the spread of COVID-19

The Proceedings of the National Academy of Sciences; the official journal of the National Academy of Sciences

Renyi Zhang, View ORCID ProfileYixin Li, Annie L. Zhang, View ORCID ProfileYuan Wang, and Mario J. Molina

PNAS first published June 11, 2020 https://doi.org/10.1073/pnas.2009637117

Even before Friday’s landmark study, there has been growing body of evidence that wearing a cloth mask can provide some protection to both the mask wearer and others… and that when folks wear masks it reduces respiratory disease transmission in the community (1,2).

Cloth masks made of household materials provide about 60% filtration of particles of droplet size (range from 3-86%) coming into the wearer (3,4,5).

There is also abundant evidence that masks keep particles inside the mask (source control), which is important due to the high number of people who are infected both without symptoms and before symptoms occur (2).

Mask efficiency improves when multiple layers of fabric are used and when using fabric combinations (6). For example, filtration efficiencies of hybrid materials (such as cotton–silk, cotton–chiffon, cotton–flannel) was >80-90%. Cotton performs better at higher weave densities (i.e., thread count). Gaps caused by improper mask fit can decrease effectiveness, so having a good fit is important.

1. Howard, J.; Huang, A.; Li, Z.; Tufekci, Z.; Zdimal, V.; van der Westhuizen, H.; von Delft, A.; Price, A.; Fridman, L.; Tang, L.; Tang, V.; Watson, G.L.; Bax, C.E.; Shaikh, R.; Questier, F.; Hernandez, D.; Chu, L.F.; Ramirez, C.M.; Rimoin, A.W. Face Masks Against COVID-19: An Evidence Review. Preprints 2020, 2020040203

2. C. Raina MacIntyre , Abrar Ahmad ChughtaiView Of The Efficacy Of Face Masks And Respirators Against Coronaviruses And Other Respiratory Transmissible Viruses For The Community, Health- Care Workers And Sick Patients, International Journal of Nursing Studies (2020), doi: https://doi.org/10.1016/j.ijnurstu.2020.103629

3. A. Davies, et al., Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic? Disaster Medicine Public Heal. Prep. 7, 413–418 (2013).

4. S Rengasamy, B Eimer, RE Shaffer, Simple Respiratory Protection. Evaluation of the Filtration Performance of Cloth Masks and Common Fabric Materials Against 201000 nm Size Particles. The Annals Occup. Hyg. 54, 789–798 (2010).

5. Mvd Sande, P Teunis, R Sabel, Professional and Home-Made Face Masks Reduce Exposure to Respiratory Infections among the General Population. PLOS ONE 3, e2618 (2008).

6. Abhiteja Konda, Abhinav Prakash, Gregory A. Moss, Michael Schmoldt, Gregory D. Grant, and Supratik Guh. Aerosol filtration efficiency of common fabrics used in respiratory cloth masks. ACS Nano. 2020;14:6339-6347.