Will Humble Disease Control, Wills Blog

Arizona’s January 2021 Total Mortality Rate A Shocking 64% Higher than January 2020

The COVID-19 pandemic is having a profound impact on public health in Arizona.

In our report that summarized total mortality during 2020 we found clear evidence that total mortality has substantially increased during 2020, particularly in June, July, and December. Indeed, the total mortality rate per 100,000 during July 2020 was 64% higher than July 2019. December 2020 was 61% higher than 2019.

The grim trend is continuing into 2021. Total mortality rates in AZ during January 2021 were 64% higher than the total mortality rate in January 2020 (see chart). The increases in deaths are the result of the effects of the pandemic including COVID-19 disease and delayed or suspended care for non-COVID illnesses.

For some perspective, if Arizona were a country, we would have the highest COVID-19 mortality rate in the world, edging out Belgium and Peru. Just think about that.

Editorial Note: Arizona’s poor performance has not been because of bad luck or fate as has been suggested by Governor Ducey and Director Christ. It is largely because of an inability to learn from policy successes and failures, bad decisions, misplaced priorities, and an inability to execute core responsibilities.

In Arizona we saw first-hand what worked to lower COVID case rates and save lives: face masks mandates implemented by cities/counties and mitigation/enforcement strategies in high-spread businesses like bars and nightclubs.

Sadly, many of these COVID cases and deaths could have been avoided if Governor Ducey and Director Christ had learned from their successes in the spring and early summer of 2020 and used evidence to drive their decision-making.

Because they did not, many thousands of lives will have been lost. It is an unimaginable tragedy. Everyone lost was a mother, a father, a sister or brother, or son or daughter. They had kids. They left loved ones behind.

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For more perspective you can see our reports including our COVID-19 reports

Will Humble Disease Control, Early Childhood, Public Health, Wills Blog

CDC Report: Operational Strategy for K-12 Schools through Phased Mitigation

The CDC published new guidance for schools to safely manage COVID risks. The report is called the K-12-Operational Strategy for mitigation strategies that K-12 school administrators can use to help protect students, teachers, and staff and slow the spread of COVID-19.

If mitigation strategies are strictly adhered to , K-12 schools can safely open for in-person instruction and remain open20. In addition, the association between COVID-19 incidence and outbreaks in school settings and levels of community transmission underscores the importance of controlling disease spread in the community to protect teachers, staff, and students in schools.

The document provides an operational strategy for safe delivery of in-person instruction in K-12 schools through the integration of a package of mitigation and control components.

  • Consistent implementation of layered mitigation strategies to reduce SARS-CoV-2 transmission in schools

  • Indicators of community transmission to reflect levels of community risk

  • Phased mitigation and learning modes based on levels of community transmission The following public health efforts provide additional layers of COVID-19 prevention in schools.

  • Testing to identify individuals with a SARS-CoV-2 infection to limit transmission and outbreaks

  • Vaccination for teachers, staff, and in communities as soon as supply allow

Regardless of the level of community transmission, the report says that it’s critical that schools use and layer mitigation strategies. Five key mitigation strategies are essential to safe delivery of in-person instruction and help to mitigate COVID-19 transmission in schools:

  • Universal and correct use of masks

  • Physical distancing

  • Handwashing and respiratory etiquette

  • Cleaning and maintaining healthy facilities

  • Contact tracing in combination with isolation and quarantine, in collaboration with the health department

Schools providing in-person instruction should prioritize two mitigation strategies:

  • Universal and correct use of masks should be required, at all levels of community transmission.

  • Physical distancing (at least 6 feet) should be maximized to the greatest extent possible. In hybrid instruction, scheduling should be planned to ensure physical distancing.

Will Humble Disease Control, Public Health, Vaccination, Wills Blog

What is COVAX & Why Does It Matter?

At an early stage during this pandemic, it quickly became apparent that to end this global crisis we don’t just need COVID-19 vaccines, we also need to ensure that everyone in the world has access to them. This triggered global leaders to call for a solution that would accelerate the development and manufacture of COVID-19 vaccines, as well as diagnostics and treatments, and guarantee rapid, fair and equitable access to them for people in all countries.

That organization is called COVAX. Up until a couple of weeks ago the U.S. was not a member of COVAX, but we did join the organization on the first day of the Biden Administration.  Extraordinary, don’t you think?  The country with the highest GDP in the world and a leading democracy wasn’t a member?

Here’s a PowerPoint that I’ve prepared describing COVAX

Well, that changed on 1/21/21 along with the U.S. rejoining the World Health Organization.  What a difference a change in leadership can make!

COVAX brings together governments, global health organizations, manufacturers, scientists, private sector, civil society and philanthropy, to provide equitable access to COVID-19 vaccines. It is the only truly global solution to this pandemic because it is the only effort to ensure that people in all corners of the world will get access to COVID-19 vaccines once they are available, regardless of their wealth.

For lower-income funded nations, who would otherwise be unable to afford these vaccines COVAX is the only viable way in which their citizens will get access to COVID-19 vaccines. 

Last week COVAX published their first interim COVAX Global Supply Forecast. You can see that as of right now their supply of vaccine is dominated by the Johnson & Johnson candidate vaccine- which makes sense because it is most widely tested vaccine that is a single dose and it has simple storage and handling requirements.

Ninety-two low- and middle-income economies are eligible to participate in receiving vaccine through COVAX AMC… here is the list of countries authorized to receive vaccine under the program.

Here’s a PowerPoint that I’ve prepared describing the COVAX program

Will Humble Disease Control, Vaccination, Wills Blog

ADHS Could Do Much Better at Equitably Vaccinating Arizonans

Fix the Appointment System

Most states have a much better system that is not only less complex but more equitable than the ADHS’ convoluted appointment system. For example, in Minnesota, folks can register on the state health department website any time, any day. This levels the playing field for persons with jobs that require them to be at their post during the few minutes when appointments become available. 

As vaccines become available (about once a week), the health department randomly selects qualified registrants from the list. People that are selected are given a password that ensures them an appointment that week.

Folks without an email address or internet access are called to let them know they have an appointment, and they schedule it with them. Simple decisions could be made to make an allowance for a guest or two that is in a qualifying category (e.g. a spouse).

Such a system would allow us to ensure we are allocating vaccine with a lens to health equity. 

One could even look at the vaccination trends geographically. When  you see that certain low-income parts of the state (or city) have been under-served you could proactively make statistical adjustments to improve their chances of being selected.

A letter to the editor in the Arizona Republic this week by Kirk Kobert today said it well:

“Whose idea was this Lord of the Flies method for choosing who gets shots and who doesn’t? My old algebra teacher said, ‘Work smart, not hard’. Time to use technology and our God-given reason to do this better”.

Building a better system for allocating and distributing vaccine isn’t rocket science, but it does require some strategic thinking and a tad bit of creativity.

Equitably Allocate Vaccine

Arizona’s original vaccination system plan hinged on leveraging county health departments to execute their vaccination plans. A core element of all those plans include prioritizing hard to reach and under-served areas by making vaccine available at Federally Qualified Health Centers, mobile clinics and the like.

Those plans were jettisoned in early January when Director Christ began prioritizing “state run” sites over the needs and plans that the county health departments have.

Note: While the State Farm is branded as a ‘state run’ site, the vast majority of the coordination work is being done by Blue Cross Blue Shield of Arizona. 

ADHS is prioritizing “their” PODs for each week’s supply at the expense of the county health departments. In addition, weekly county allocation is highly erratic making planning at the county level next to impossible.

It also makes it impossible for the county health departments to implement their plans to reach into underserved areas.

For additional background on how the decisions that are being made by Director Christ and the ADHS are impairing county health departments ability to roll out vaccine equitably read this piece by Stephanie Innes and Alison Steinbeck in the Arizona Republic: Rollout of the COVID-19 vaccine differs along rural-urban lines.

Editorial Note: I write this with a sense of resignation. I realize at this point that Director Christ and Governor Ducey are going to do whatever they want to do regardless of the needs and interests of stakeholders like county health departments and their community vaccinator partners. Nevertheless, we will continue to expose what we see are unjust decisions if for no other reason than to document their actions and the impacts that their decisions are having on ordinary Arizonans.

Will Humble Disease Control, Wills Blog

Dr. Joe Gerald’s Weekly AZ COVID Epidemiology Summary

Dr. Gerald released his weekly Epidemiology and Hospital Capacity report over the weekend. You can view the full report here. There is some encouraging news, but absolute levels of transmission and test positivity remain 2 -3X higher than recommended for in-person instructional activities (see Arizona Department of Health Services Benchmarks). However, as you know, the ADHS no longer supports their own benchmarks and they are really cosmetic at this point- as they have no influence on actual policy.

With sustained declines in viral transmission and hospital occupancy, Arizona has transitioned from a period of crisis to one of elevated risk. With continued improvements being forecast over the next 4 weeks, hospital capacity is adequate to meet Arizona’s most critical needs.

With continued improvements being forecast over the next 4 weeks, hospital capacity is adequate to meet Arizona’s most critical needs. Nevertheless, it will be many months before the backlog of non-Covid care can be fully addressed.

Arizona is still reporting large number of weekly deaths and this count may considerably underestimate true fatalities (see Woolf, Woolf, or Weinberger). The week ending January 17th will likely be Arizona’s deadliest with approximately 1000 deaths once all are made known.. Arizona’s weekly tally of deaths ranks it 4th in the nation. Overall, we rank 8th since the outbreak began.

Will Humble Disease Control, Vaccination, Wills Blog

ADHS Vaccine Appointment System Favors the Wealthy & Creates Health Disparities

For a few weeks we’ve been calling on ADHS to disclose the demographic information on the distribution of COVID vaccines so we can determine whether the vaccine is being equitably distributed.

We have been concerned that the ADHS appointment system provides an advantage to the wealthy. 

Last week, ADHS released some demographic information. Here’s the link to that site: ADHS – Data Dashboard. Click on the vaccine tab (they didn’t disclose the most important data- the vaccination rates by Zip Code). 

Fortunately, Maricopa County Public Health Maricopa posted maps last week that do exactly what we have been asking the state to do- and much more.  The MCDPH maps display the percentage of ELIGIBLE persons that have been vaccinated by Zip Code.

That means they have controlled (using census data) for any bias that would have been present because of an uneven distribution of healthcare workers, teachers, law enforcement etc.

The method that Maricopa County used undercuts the argument made by Director Christ at last Friday’s media briefing. She argued that the disparities exist because of the phased rollout.

Maricopa used census data to control for occupation and age. The maps show a disparity that is not related to the phased vaccine rollout. 

The maps show a sharp economic disparity largely due to the ADHS appointment system that favors the wealthy and well-educated. This quote from a the US News and World Report from yesterday tells it like it is:

“It’s no surprise when you look at the way the appointment system is set up, the Darwinian aspects of it,” said Will Humble, executive director of the Arizona Public Health Association, referring to the state registration website. “You’ve got to have a good computer. You’ve got to have Wi-Fi. You have to have a flexible job that lets you be home those minutes when appointments become open.”

Maricopa’s coded maps show that upscale areas have a high vaccination rate. For example, in Paradise Valley, almost every eligible person has gotten at least one dose of the vaccine. The same is true in one part of Scottsdale. In contrast, Phoenix’s 85009 Zip Code, less than one in five eligible people got the vaccine.

One way to flatten out the disparities would be to create a vaccine lottery system, or, better yet, a weighted lottery system that gives applicants from low saturation neighborhoods a statistically better chance of being chosen in the lottery.

The ADHS could create such a system in a few days. The computer code would be simple to write. Sadly, the Director Christ is highly unlikely to make significant changes. That would require admitting that the current system is favoring the wealthy and creating disparities, something that she is unlikely to do.

As I said in the AZ Capitol Times Yellow Sheet last Friday:

“There are ways to be proactive about it but if we just keep this Darwinian system, it’s just gonna keep getting worse,” he said. Humble again called on the Governor’s Office and Dept of Health Services to recognize they have a problem, saying if the map doesn’t do that, he doesn’t know what will.

Here are a couple of highlights regarding vaccine equity. This column by Laurie Roberts last week highlights one such solution: How Arizona could do a ‘great job’ on COVID-19 vaccine appointments.

Jennifer Martinez from FOX10 also explores issues with vaccine access equity: Some fear vaccination efforts are leaving ethnic minorities behind.

Will Humble Disease Control, Vaccination, Wills Blog

New Data Published On the Key AztraZeneca Vaccine: Promising Results

A new publication of the Phase III AstraZeneca candidate vaccine found that it not only protects people from serious illness and death but also substantially slows the transmission of the virus. The (not yet peer-reviewed) study was published in The Lancet this week.

This study was different from some clinical trials in that the research team measured the impact on transmission by swabbing participants every week. They found a 67%  reduction in positive swabs among those vaccinated compared to the placebo group.

The team found that a single dose of the vaccine was 76% effective at preventing Covid-19. 

Interestingly, they also found that the vaccine is more effective when the interval between the two shots was longer than the normal 28-day gap.  The vaccine was 82% effective when there was 3 months between the 1st and 2nd jab compared to 55% when the doses were given less than six weeks apart.

AstraZeneca says they’ll have enough data by early March to ask the FDA for EUA. The UK authorized the vaccine before New Years and has deployed missions of doses. The E.U. authorized the vaccine last week. I can’t figure out why it’s taking so long in the U.S.

HHS has a contract for delivery of 300M doses of the vaccine but neither the company nor HHS has said when and in what quantities those doses will be available after the vaccine is approved.

Below is an excerpt from the study:

“Vaccine efficacy after a single standard dose of vaccine from day 22 to day 90 post vaccination was 76% (59%, 86%), and modelled analysis indicated that protection did not wane during this initial 3-month period. Similarly, antibody levels were maintained during this period with minimal waning by day 90 day (GMR 0.66, 95% CI 0.59, 0.74). In the SD/SD group, after the second dose, efficacy was higher with a longer prime-boost interval: VE 82.4% 95%CI 62.7%, 91.7% at 12+ weeks, compared with VE 54.9%, 95%CI 32.7%, 69.7% at <6 weeks.

Will Humble Uncategorized, Wills Blog

AzPHA Member Public Health Policy Update

February 7, 2021

New AzPHA Report:

COVID-19: The Leading Cause of Death in AZ During the Pandemic

One of our newest AzPHA members, Allan N. Williams, MPH, PhD (he recently retired from at the Minnesota Department of Health and moved to AZ) analyzed ADHS vital statistics data and developed our newest epidemiology report entitled: “How Do COVID-19 Death Rates Compare to the 15 Leading Causes of Death in Arizona?”  

Not surprisingly, the report found that COVID-19 has been the leading cause of death in Arizona (Nationally, it has been the third third leading cause of death). The fact that COVID deaths are currently comparable in prevalence to our two long-standing major killers – heart disease and cancer – is a sobering statistic and represents a deadly failure to control this pandemic.

As previously noted in our January 24, 2021 AzPHA Report 2020 All-Cause Mortality Trends in Arizona During the COVID-19 Pandemic, 2020 mortality data show a significant increase (14,972 additional deaths) in overall deaths compared to 2019. While most of this increase is clearly attributable to COVID-19 deaths, the AzPHA mortality analysis indicated that some 3,444 of the excess deaths were not reported as COVID-19 deaths.

This is consistent with estimates indicating that 35% of COVID-19 deaths are unreported.  It is also possible that deferral of care for serious non-COVID-19 medical conditions or reduced screenings during the pandemic also account for a portion of the non-COVID-19 excess. 

While there is room for optimism as vaccinations slowly ramp up and new vaccines are now imminent, there is at the same time growing concern about the rapid spread of more transmissible variants of the SARS-CoV-2 virus and whether current vaccines will be less effective against these variants. Unfortunately, COVID-19 will remain a significant cause of death well into 2021.

A huge thanks to Dr. Williams for his work bringing this important information to light.

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Drama Over Discarded Vaccine: Telling the Truth Matters

There was some drama last week  about how much vaccine has been discarded at the various mass vaccination sites.

Journalists submitted public records requests to Maricopa County Department of Public Health and the ADHS asking for how many doses of vaccine were unusable at the various PODs. Maricopa County immediately produced the data, sharing that a total of 553 doses out of 153,196 administered have been discarded at their county PODs between December 17, 2020 – Jan. 20, 2021.

This represents 0.3% or 3 of every 1,000 thousand doses that have been administered through these PODs to that date. For perspective, standard wastage for all vaccines in doctors’ and pediatric offices is normally between 3% and 5%.

I did a few interviews on the issue of accidents and problems that can happen when administering vaccinations including this one from FOX10 saying that a 0.3% wastage rate is a testament to good performance at the PODs. By comparison, wastage rates at pediatric offices are typically between 3-5%.

The drama came when Governor Ducey tweeted the following statement:

“The COVID19 vaccine is a precious and limited resource – that any doses would be wasted is shocking and unacceptable. This has not and will not happen at any state-run sites, and local leaders must prevent it from ever happening again at any county-run site.”

– Governor Douglas A. Ducey

The statement that no problems have come up nor mistakes made at their branded State Farm POD is, of course, preposterous. There’s no way that a mass vaccination site like State Farm has never had an issue that led to a discarded vaccine.

Furthermore, Director Christ has still not disclosed how many vaccines have been discarded at State Farm, but I can guarantee you that it is not zero. I’m hopeful but not optimistic that Director Christ will respond to the existing records requests about their own data about vaccine waste.

If there is any concern about the quality of the vaccine or any information is not readable on the label, manufacturers have advised providers to throw out the vaccine to maintain a safe operation.  That can mean things like:

A vial does not have a readable label or expiration date and cannot be used;There is particulate matter or “floaters” present in the vial and all 5 doses are wasted;A vial is partially filled and none of the contents can be used;Equipment malfunction, such as a bent needle, recapping issues, or the plunger is depressed accidentally; andDraw-up issues like having a bubble in the syringe or a needle stick injury or an error mixing the dose.

These are issues that occur any time vaccines are given, particularly during large volume operations (this is not an exhaustive list of ways that vaccine doses can be unusable). Any large vaccine administration site that claims that “no doses are wasted” is not operating safely or not being honest about wasted doses.

Editorial Note: The fact that a small number of issues may have come up at State Farm and some vaccines have been discarded isn’t the issue.

The problem is a when the Governor makes a false statement disparaging the performance of a key partner (performance that is, in fact, good) when the state itself is unwilling to disclose its own performance on that same metric… and then he fabricates a tale that no vaccine has ever been discarded at the state branded site.

Persons in key elected and appointed positions should be honest and transparent with the people of Arizona. We deserve at least that.

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Johnson & Johnson Submits Emergency Use Authorization Application to FDA

Johnson & Johnson applied for Emergency Use Authorization (EUA) for their candidate vaccine last Thursday. Their candidate is a single dose vaccine that uses a weakened cold virus as the vehicle for the antigen that stimulates the immune response.

The FDA has scheduled a Vaccines and Related Biological Products Advisory Committee (VRBPAC) on Feb. 26, 2021, to discuss the request. They will likely make a recommendation whether to authorize or not during that meeting. The FDA Commissioner will then likely make a decision shortly thereafter.

Note: Former FDA Commissioner Hahn resigned and has been replaced by Acting Commissioner Janet Woodcock M.D. Dr. Woodcock is a Career FDA professional – having served at the FDA since 1984.

The company says they have vaccine immediately ready for shipment as soon as the FDA authorizes emergency use of the vaccine. The FDA hasn’t posted the application data on their website yet, but I’ll keep an eye out for it.

The J&J press release (not published data) said that their clinical trial of 43,783 participants “met all primary and key secondary endpoints”. The topline safety and efficacy data are based on 43,783 participants accruing 468 symptomatic cases of COVID-19.

They say that their vaccine candidate: 

“… is 66% effective overall in preventing moderate to severe COVID-19, 28 days after vaccination. The onset of protection was observed as early as day 14. The level of protection against moderate to severe COVID-19 infection was 72% in the United States, 66% in Latin America and 57% in South Africa, 28 days post-vaccination.”

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New Data Published On the Key AztraZeneca Vaccine: Promising Results

A new publication of the Phase III AstraZeneca candidate vaccine found that it not only protects people from serious illness and death but also substantially slows the transmission of the virus. The (not yet peer-reviewed) study was published in The Lancet this week.

This study was different from some clinical trials in that the research team measured the impact on transmission by swabbing participants every week. They found a 67%  reduction in positive swabs among those vaccinated compared to the placebo group.

The team found that a single dose of the vaccine was 76% effective at preventing Covid-19. 

Interestingly, they also found that the vaccine is more effective when the interval between the two shots was longer than the normal 28-day gap.  The vaccine was 82% effective when there was 3 months between the 1st and 2nd jab compared to 55% when the doses were given less than six weeks apart.

AstraZeneca says they’ll have enough data by early March to ask the FDA for EUA. The UK authorized the vaccine before New Years and has deployed missions of doses. The E.U. authorized the vaccine last week. I can’t figure out why it’s taking so long in the U.S.

HHS has a contract for delivery of 300M doses of the vaccine but neither the company nor HHS has said when and in what quantities those doses will be available after the vaccine is approved.

Below is an excerpt from the study:

“Vaccine efficacy after a single standard dose of vaccine from day 22 to day 90 post vaccination was 76% (59%, 86%), and modelled analysis indicated that protection did not wane during this initial 3-month period. Similarly, antibody levels were maintained during this period with minimal waning by day 90 day (GMR 0.66, 95% CI 0.59, 0.74). In the SD/SD group, after the second dose, efficacy was higher with a longer prime-boost interval: VE 82.4% 95%CI 62.7%, 91.7% at 12+ weeks, compared with VE 54.9%, 95%CI 32.7%, 69.7% at <6 weeks.

Will Humble Disease Control, Vaccination, Wills Blog

Are You (or do you know) An Arizona Resident Age 18 – 26 Years Old?

If so, please take this 3-minute survey on COVID-19 vaccination

Insights from this survey will be submitted to the Arizona Local Health Officers Association to inform their vaccination efforts across AZ. 

A team of AzPHA member student researchers from the Arizona Area Health Centers Scholars program (in partnership with UA, ASU & NAU) is conducting a survey about perceptions and likelihood of getting vaccinated for COVID-19.

If you’re between 18 and 26 please participate in this short survey. If you are older than that, please consider forwarding this email to somebody who is in the 18-26 year old age bracket.

Please take the survey here  

Your participation is voluntary. We respect your privacy, and your data will be kept anonymous. 

If you have questions, please contact Alyssa Dukes at [email protected]

Will Humble Disease Control, Vaccination, Wills Blog

Feds Launching New Retail Pharmacy Program This Week

The White House announced efforts to increase vaccine supply with next week’s launch of the first phase of the Federal Retail Pharmacy Program for COVID-19 Vaccination.

Starting on February 11, select retail pharmacies will begin to get the vaccine. This first week 1M Moderna doses will be distributed (that’s about 20,000 doses for Arizona). The participating pharmacies in AZ are Safeway, Fry’s and Walgreens. I also saw that some appointments will be available at a few Federally Qualified Health Centers. Importantly, appointments can be made without going through the convoluted ADHS appointment website.

Here’s a link to the Maricopa County Department of Public Health website where you can look for appointments.

The program will be expanded in subsequent weeks will be based on vaccine availability. The ultimate goal is to include more than 40,000 locations (that would be about 800 pharmacies in AZ- or about ½ of all AZ pharmacies).

The federal pharmacy program will become increasingly significant when the Johnson & Johnson vaccine is authorized later this month. The J&J vaccine is perfect for pharmacies to use. Storage and handling for that vaccine is just like most other vaccines.

The FDA committee is meeting on February 26 to consider the J&J emergency use application. I expect authorization to happen by March 1 with shipments starting March 2. Hopefully the destination for many if not most of the J&J vaccines will be through this new federal pharmacy program.

February 16, 2021 Update: CNN is reporting that “… a J&J official stated that the company currently has less than 10M doses manufactured and available for distribution in the US”. This is a disappointing number as it amounts to about 200,000 doses for Arizona. At least this is a single dose vaccine so it’s equivalent to 400,000 doses of Moderna or Pfizer.

This is a big deal that will become an even bigger deal in coming weeks folks!

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