Dr. Gerald’s Weekly Epidemiology Report

Here is a summary of this week’s epi report by Dr. GeraldHis full report includes an in-depth look at the policy decision to open schools for in-person instruction.

  • This week saw a seventh straight week of meaningful declines in Covid-19 cases and hospital occupancy. In some communities, absolute levels of SARS-CoV-2 viral transmission have fallen below the 100 new cases per 100,000 residents per week threshold.

  • As of February 28th, new cases were being diagnosed at a rate of 94 cases per 100,000 residents per week. This rate is declining by 43 cases per 100,000 residents per week.

  • Compared to last week, the pace at which conditions improved quickened this week; however, improvements will likely slow over the coming weeks.

  • The test positivity rate for traditional nasopharyngeal PCR testing has reached 10% which is near the recommended 5 – 10% for optimal public health practice.

  • In some communities, absolute levels of transmission and test positivity have reached levels that warrant a return to in-person instruction using a hybrid mode or reduced attendance (see CDC Recommended Mitigation Strategies for K – 12 Learning Modes).

  • Hospital Covid-19 occupancy continues to decline in the ward and ICU. Access to care however, remains somewhat restricted as the backlog of medically necessary non-Covid procedures is addressed.

  • Arizona is still reporting a large number of weekly deaths and this count may underestimate true fatalities. The week ending January 17th will be Arizona’s deadliest with >1000 deaths. Arizona’s weekly tally of deaths ranks it 8th in the nation while its overall rank remains 6 th since the outbreak began.

  • According to the CDC, 11.7% of Arizona adults have received at least 2-doses of vaccine while another 11.8% have received 1-dose. The ADHS Dashboard is reporting slightly higher levels. To date, Arizona has administered 78% of its delivered doses.

Governor Eliminates Mitigation ‘Requirements’ Including Capacity Limits for Bars and Restaurants

Honestly, the Order Won’t Impact Anything in the Field

The Governor signed an executive order today that tweaks some of the existing mitigation expectations in Arizona. His Order officially eliminates the capacity limits and the guidance for business document that had been placed on bars and restaurants .

The Mitigation Executive Order says that he is rescinding the capacity limits that had supposedly been in place for the last few months (bars and restaurants were supposed to be at 50% of their fire code limit). Also rescinded are the other ADHS business requirements in the business guidance document.

To be honest with you – it’s really no big deal.

Why, you ask? Because those mitigation ‘requirements’ were just on paper anyway. They were never enforced by the ADHS and for all practical purposes never really existed. Businesses have been and will continue to do what they think their customers expect. They have known for many months that they don’t actually have to follow the mitigation measures ‘required’ by ADHS- because there has never been any enforcement.

Among the tens of thousands of bars, restaurants, and nightclubs that have been violating the ADHS capacity limits and other mitigation ‘requirements’ over the last 6 months there have been less than 20 enforcement actions (and those only happened when a video went viral on Twitter).

Basically, there never have been any enforced limits in Arizona since summer. The Governor’s EO makes it seem like those capacity limits and other requirements actually existed, when for all practical matters, they never did exist.

At least Director Christ and Governor Ducey are finally being honest that there isn’t any mitigation.

An open question remains what will happen at big sports venues like Suns games and DBacks games when they start. The Order says that those franchises need to turn in a mitigation plan to the ADHS but we have no idea what they will approve.

Probably just about anything that Mr. Kendrick or Sarver submit.

State Alters COVID Vaccine Prioritization Scheme

Persons with Developmental & Intellectual Disabilities Under 55 years-old Left Stranded

Yesterday the ADHS Director announced that she will do away with the former “numbered phase” system and switch to an age-based distribution model, starting with vaccinating anyone 55 and older at two non-county operated vaccination sites in Maricopa County. Counties can follow suit using a decision tree that the ADHS announced yesterday.

There is some merit to the new approach.  Most chronic medical conditions that put people at high risk for a bad outcome do occur in persons over 55 years old. So, in that respect, the decision makes sense. Also, it’s easier to verify eligibility based on age compared to a specific chronic medical condition. Can you imagine vaccinators asking people to prove that they have diabetes or a heart condition? That would have been super-awkward and hard to verify.

But, there’s an important group of folks under 55 years old who are at high risk that have been left out in the cold by yesterday’s decision by Director Christ.

NEW: View this episode of Sunday Square Off for a Concise summary of this injustice

I’m talking about persons enrolled in AHCCCS’ ALTCS or Arizona Long Term Care System.  ALTCS members are folks that have a disability (often an intellectual or developmental disability like Down’s Syndrome). Some ALTCS members live in a congregate setting but most receive support services in a home or community-based setting.

Before yesterday’s decision, ALTCS members were poised to qualify for a vaccine shortly (regardless of age) because of the chronic medical conditions that many of them have (most were in the former Category 1c). The 5,000 or so ALTCS members that live in a group home already qualified for a vaccine because they are in Category 1b because they live in a ‘congregate setting’.

With the new age-based system, ALTCS members under 55 years old who don’t live in a group home will have to wait a lot longer to get a vaccine. This puts this them at risk for complications if infected. Basically, they will need to wait until their age is called despite the vulnerability that their disabilities pose.

For example, many ALTCS members are persons with Down Syndrome. After adjusting for age and sex, ethnicity, BMI, care home residency, and congenital heart disease, research shows that folks with Down’s Syndrome have a 10 times higher risk of death if diagnosed with COVID-19.

There are about about 20,000 ALTCS members between 18 and 54 years old. About 4,000 of them live in group homes (and have had an opportunity to get vaccinated), which means we’re talking about 16,000 vulnerable adults enrolled in ALTCS and living in the community who will now need to wait even longer for an opportunity to get vaccinated.

Persons with intellectual and developmental disabilities contribute much to our lives and communities. Yesterday’s decision by Director Christ to go to a strictly age-based system without considering the special needs of persons with intellectual and developmental disabilities undervalues their contributions and sends a message that they’re not important.

Surely Director Christ can find it in within herself to add persons living with intellectual & developmental disabilities under 55 years old to the list of folks that qualify for a vaccine right now.

At least you’d hope so.

Note: If you’d like to show additional support, you can contact the Arizona Department of Health Services at 602.542.1025 or contact Director Christ at cara.christ@azdhs.gov and urge her to take into consideration the special needs of persons living with intellectual and developmental disabilities and add them to the list of persons that can get vaccinated right now.

FDA Allows More Flexible Storage and Transportation Conditions for Pfizer Vaccine

Here is FDA’s decision that allows undiluted frozen vials of the Pfizer-vaccine to be moved and stored at normal freezer temperatures for up to two weeks. Previously, the Pfizer vaccine had to be held at an  ultra-low temperature freezer (-80ºC to -60ºC). The FDA updated their Fact Sheet for Healthcare Providers Administering Vaccine to reflect this change.

This newfound storage and handling requirement makes the Pfizer vaccine perfect for community vaccination sites- and makes additional vaccination mega-sites less attractive as a way to get vaccine to the people.

It’s Time to Prioritize Vaccine Distribution to Pharmacies & Clinics Now That Vaccines Are More Flexible 

Two big developments this week have turned the tables on the more efficient way to get folks vaccinated. The FDA is now allowing the Pfizer vaccine to be stored at normal freezer temperatures (just like Moderna) and we now have the Johnson & Johnson vaccine which is uber-flexible and requires just refrigerator storage temps.

With these new developments, the most efficient way to get folks vaccinated is to decentralize vaccine allocations toward clinics, community health centers pharmacies, and primary care offices. That means we need to prioritize vaccine allocations toward community vaccinators and away from any additional (or expanding current) mega-sites.

At the beginning of the COVID vaccination effort, it made some sense to set up mega-sites. That’s because the Pfizer vaccine lended itself to mass-vax sites because of the restrictive cold-holding temperature requirements and the fact that employment groups like healthcare workers and teachers were prioritized.

Last week’s 2 big developments re J&J and Pfizer have turned the tables. 

At first blush, vaccination mega-sites might seem like a logical and efficient solution to vaccinating large numbers of people. They make for dramatic television footage and look impressive. But are they really the most efficient way to get vaccine out?  Not any more.

Look at it this way… there are about 1,500 pharmacies in Arizona, most located a short distance from people’s homes. Let’s say we could get 1,000 of them to participate in COVID vaccinations now that all 3 of the vaccines are so much more flexible to store and use.

Imagine for a moment that each pharmacy can vaccinate 50 people per day (not a big ask). That equals a capacity to vaccinate 50,000 people per day or 350,000 vaccinations per week – all happening near people’s homes.

Compare that to state government’s flagship mega-site which is vaccinating about 6,000 people per day. Even if they could really expand to 10,000 per day, why would you prioritize allocation of vaccine to more mega-sites where people need to book appointments on a complex website with limited slots when you could instead prioritize the vaccine to thousands of pharmacies, clinics and doctors offices.

The short answer is that the state government has established a brand at the mass vaccination sites that they see as helping their image. I expect them to continue to prioritize vaccine allocations toward the mega-sites at the expense of community vaccinators like clinics and pharmacies because the mega sites get favorable press coverage.

However, if state government would take a cold hard look at what’s most efficient, they would see that prioritizing vaccine toward  pharmacies and clinics is actually the best way to go.

Fortunately, the federal government recognizes the value in getting vaccine directly to pharmacies and community health centers with the implementation of their federal pharmacy and FQHC direct shipment systems.

See our blog post entitled Federal Pharmacy Program Making Significant Inroads Toward Vaccine Access