Please Consider A Charitable Donation to the Arizona Public Health Association: Your Independent Voice for Public Health

The Arizona Public Health Association is your independent voice for evidence-based public health policy. We couldn’t do that work without your support via Individual, Organizational, and Sustaining memberships, conference sponsorships, and donations

If you’re not yet a member of the Arizona Public Health Association, we’d love to add you to our collective voice! Our Individual Memberships are just $75/year. You can join here!

You can also include AzPHA in your annual charity giving. We are a 501(c)(3) nonprofit corporation supported via our memberships, conferences, grants, and tax-deductible contributions from people like you!

Remember: Your donations to AzPHA qualify as a tax deduction. A temporary IRS provision allows single filers to deduct up to $300 (joint filers up to $600) in annual donations even if you take the standard deduction & don’t itemize. For 2021 tax returns, donations must be made by December 31, 2021.

Please consider donating to AzPHA as you think about your end of the year charitable contributions!

Donate Here!

CDC Director Makes a Rookie Mistake: Announces a Major Policy Change Without Backing It Up with Evidence

CDC Could & Should Have Backed Up Their Isolation and Quarantine Policy Change with Evidence – A Major Unforced Error

Yesterday the CDC shortened the recommended isolation time for people that test positive for COVID-19 from 10 to 5 days if a person is asymptomatic (followed by 5 days of wearing a mask when around others). In their press statement the CDC wrote that:  “... the change is motivated by science demonstrating that the majority of SARS-CoV-2 transmission occurs early in the course of illness, generally in the 1-2 days prior to onset of symptoms and the 2-3 days after“.

CDC also updated the recommended quarantine period for those exposed to COVID-19. For people who are unvaccinated or are more than six months out from their second mRNA dose and not yet boosted, CDC now recommends quarantine for 5 days followed by strict mask use for an additional 5 days

There’s been a lot of push back in the public health and medical communities that believe the CDC’s new guidance counterproductive and not evidence-based… for good reason. While the CDC states in their media-release that their decision is based on “… science demonstrating that the majority of SARS-CoV-2 transmission occurs early in the course of illness, generally in the 1-2 days prior to onset of symptoms and the 2-3 days after” the CDC provided no evidence or even references to back up their statement- a major flaw for any administrator making such a sweeping change to the guidance.

Since the CDC neglected to include a literature review or provide any other evidence other than a statement without references, I went to the literature to see if their statement holds up for them. I found a few studies to support the CDC’s policy change. For example, He X et.al. found that infectiousness peaked between two days before and one day after symptom onset and declined within seven days.  Cheng HY et.al. evaluated 2500 close contacts of 100 patients with COVID-19 and found that all of the 22 secondary cases had their first exposure within 6 days of symptom onset. There were no infections documented in the 850 contacts whose exposure was after 6 days of symptom onset. I found some other studies similar results that they could have used to defend their decision (references included at the end).

Editorial Note: Director Walensky made a rookie mistake when she announced this major policy change without providing evidence to support her decision. The CDC is packed with talented epidemiologists that could have easily prepared a Morbidity and Mortality Weekly Report with a complete literature review to support her decision (there are some data to support the policy change). Instead, she chose to make a major policy change without presenting evidence to support the decision. As a result, the CDC lost some street credibility. This was a major unforced error.

Increasing Transmission in 20-39 Year Old’s (COVID’s Amplifiers) Suggests AZ is Poised for A Large Omicron Wave in January w/ Increased Hospitalizations 10 – 14 Days Behind

Arizona COVID_19 Update December 24

From Dr. Gerald’s Summary in this week’s report:

Arizona continues to experience high levels of community transmission attributable to the newly dominant Omicron variant and to a lesser extent Delta. Test positivity remains high reminding us that test capacity, accessibility, and/or uptake is inadequate. Given how quickly the Omicron variant impacted the United Kingdom and the US Northeast, Arizona is poised to experience another large wave of infections in January with increased hospitalizations lagging 10–14 days later.

January is poised to be a very difficult month for Arizona hospitals as 3 events will collide: (1) the tail of the Delta wave; 2), below average but still meaningful seasonal influenza; and 3) the coming Omicron wave.  Increasing viral transmission among Arizonans 20 – 39 years indicates that the Omicron wave is imminent.

COVID-19 hospital occupancy is at least temporarily declining but will continue to exceed 25% of all beds in the general ward and 35% of beds in the ICU for the remainder of the year. Access to care will continue to be restricted in the face of staff shortages in inpatient and outpatient settings.

As an updated mortality report from the Arizona Public Health Association indicates excess deaths are considerably higher than the official COVID-19 statistics. Considerably more Arizonans have lost their lives to COVID-19 than reflected by the ADHS Dashboard.

___________________________

The United Kingdom continues to publish excellent weekly summaries of Omicron’s impact (Dec 23): https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1043807/technical-briefing-33.pdf

For those wanting to track variant data, here are links to genomic state data (https://pathogen.tgen.org/covidseq-tracker/) and national data (https://covid.cdc.gov/covid-data-tracker/#variant-proportions). S-gene Target Failure (SGTF) from PCR testing is available from the ASU Biodesign Institute: https://biodesign.asu.edu/research/clinical-testing/critical-covid-19-trends.

Arizona has two documents that outline how doctors are supposed to make life and death decisions because there aren’t enough resources to treat all patients. These documents will be increasingly important documents for rationing care in January once the Omicron wave is in full force.

Arizona Crisis Standards of Care – Full Document
Arizona Crisis Standards of Care Addendum April 2021

Emerging Evidence Suggests Omicron has a Less Severe Clinical Presentation Compared with Delta

Arizona Will Remain in Contingency & Crisis Standards of Care in January – but the Worst-case Scenarios Are Now Less Likely

Evidence from the U.K and South Africa this week has lowered my freak out factor about what’s coming in January when Omicron rifles through Arizona. Omicron is far more contagious than Delta, but new evidence suggests it has a less severe clinical presentation compared with Delta. That doesn’t mean things won’t get even worse in Arizona in January – they will because of Omicron’s transmissibility and the Governor Ducey’s hostility toward evidence-0based interventions – but the magnitude of the catastrophe will be less than I thought (if the U.K. and South African observations hold up).

Why? Because researchers in England, Scotland, and South Africa found the risk of admission to a hospital because of an Omicron infection is between 45% and 80% lower than the risk with a Delta infection (in the U.K. and South Africa respectively). The findings have not been peer reviewed, and each have study limitations but the consistency if the findings provide at least a little bit of comfort.

From Neil Ferguson from Imperial College London:

“Our analysis shows evidence of a moderate reduction in the risk of hospitalization. However, this appears to be offset by the reduced efficacy of vaccines against infection with the omicron variant. Given the high transmissibility of the omicron virus, there remains the potential for health services to face increasing demand if omicron cases continue to grow at the rate that has been seen in recent weeks.”

Arizona’s hospital system will continue to be operating under Contingency Standards of Care during & Crisis Standards of Care at times in January, and many people will unnecessarily lose their lives as a result of the decisions that our governor and health directors have been making, but the worst-case scenarios that I discussed last week are less likely to occur given this new evidence about Omicron’s clinical presentation.

Now that Arizona Is In Crisis Standards of Care (for the Most Critically Ill COVID Patients), How Will Doctors Allocate Treatment?

Arizona Crisis Standards of Care – Full Document

Arizona Crisis Standards of Care Addendum April 2021

Early Assessment of Omicron Severity in South Africa Shows Encouraging Results: Don’t Do Handstands – We’re Still in Trouble

Early assessment of the clinical severity of the SARS-CoV-2 Omicron variant in South Africa | medRxiv

Today we got some encouraging results from researchers in South Africa who published a study (which is not yet peer-reviewed) suggesting that people diagnosed with Omicron in South Africa in October & November were 80% less likely to be admitted to hospital than those diagnosed with a Delta infection during the same period. People hospitalized with Omicron infections were 70% less likely to develop severe disease than those admitted with Delta between April and November. The team controlled for age and other risk factors known to put folks at higher risk for hospitalization. From the report:

When compared to non-SGTF (Alpha & Delta) infections, we found that SGTF (Omicron) infections had an 80% lower odds being admitted to hospital, but did not differ in the risk of severe disease among hospitalised individuals. When compared to Delta infections, SGTF (Omicron) infections were associated with a 70% lower odds of severe disease.

Before doing handstands… consider that the levels of immunity in the population from previous infections and vaccinations is likely a big reason for the reduced severity they observed. As the authors state in their report, “It is difficult to disentangle the relative contribution of high levels of previous population immunity versus intrinsic lower virulence to the observed lower disease severity.”

Incomplete vaccination data, and the fact that the majority of re-infections were likely not detected,
resulted in incomplete adjustment for the effect of prior immunity in our analyses.

To get a picture of the level of community immunity that exists in South Africa, consider that an estimated 60% to 70% of people in South Africa have had a prior COVID-19 infection. In terms of vaccination status, 58% of individuals aged ≥60 years, 55% aged 50-59 years, 43% aged 35-49 and 24% aged 18-34 years are fully vaccinated there (one dose of J&J or two doses of Pfizer-BioNTech or AztraZeneca). Because Delta infections happened earlier that the Omicron infections, community immunity was higher during the Omicron era.

There are many limitations in the study outlined by the authors and the results may be different in the U.S., but this is at least somewhat encouraging.

Remember, Omicron is at least twice as contagious as Delta and evades some of the immunity built via infections and the vaccines. That means that even if Omicron infections really are 80% less likely to require hospitalization vs Delta infections, we’ll still have an influx into our already overwhelmed hospitals because of the sheer number of infections that are on the way because of the complete absence of mitigation in Arizona (except in Pima County) and the greatly increased transmissibility of Omicron.

Meanwhile, Governor Ducey & Interim ADHS Director Herrington are MIA.

View the Study Here

Open Letter to Governor Ducey & Interim Director Herrington Urging Immediate Interventions

Open Letter to Governor Ducey, Interim Director Herrington, Dr. Carmona, Healthcare Leaders & Policymakers
Letter Sponsored by Right 2 Safe Schools

Arizona’s healthcare system is in crisis. Our healthcare workforce is suffering from moral injury and burnout from the sustained onslaught that wave after wave of COVID has had on us, our families, and our communities. The COVID-19 pandemic is running unmitigated throughout the state and is straining our hospitals and affecting patient standards of care. Our current situation is unsustainable. 

We – the undersigned physicians, nurses, allied healthcare workers, Public Health professionals, and other clinical support staff from across the state of Arizona – unite together in our nonpartisan call for health system leaders and elected officials to immediately respond to the current crisis by implementing preventative measures that will dramatically reduce the spread of COVID-19 and protect our communities.

In order to rapidly reduce the spread of COVID-19 and to make every attempt possible to avoid worsening the crisis in Arizona hospitals, we implore our leaders to implement these interventions

If Arizona continues on its current course in the face of combined Delta + Omicron surges, we will face collapse of our healthcare system, including the need to triage hospital resources, accelerated loss of life and long-term disability in our high vulnerability state, and worsening of severe healthcare workforce shortages.

To minimize these impending catastrophes, Arizona leaders must act swiftly to implement multiple measures that will slow the spread of COVID-19 and protect the health of all Arizonans.

The healthcare workers who have signed on to this letter demand that our elected officials and healthcare leaders work together to immediately implement the interventions outlined above to mitigate the impact of this crisis. 

Lives will be lost unnecessarily, and our healthcare system will fall deeper into crisis if you do not act now, and with urgency.

Sincerely,

The undersigned Arizona healthcare workers (physicians, nurses, allied healthcare workers, Public Health professionals, and other clinical support staff) from across the state of Arizona.

Sign On Here

Delta Wave Ebbs in Advance of Arizona’s Omicron Tsunami

View Dr. Joe Gerald’s Epidemiology & Hospital Occupancy Weekly Report

Arizona continues to experience a high number of cases, hospitalizations, and deaths. With waning vaccine efficacy and a potentially short duration of acquired immunity, herd immunity is not achievable. As time progresses, more individuals will become susceptible. While the previously vaccinated and previously infected will remain mostly protected from severe outcomes, they will contribute to community transmission.

There was a 15% decrease in COVID cases last week with little reduction in testing and declining test positivity. There was also a slight ebb in hospital occupancy indicating that transmission is temporarily slowing in advance of the coming Omicron wave.

January 2022 is poised to be the worst of the entire pandemic in terms of hospitalizations and deaths as three events collide: 1) the tail of the Delta wave; 2) the amplification of what will be a very large Omicron wave; and 3) below average but meaningful seasonal influenza.

Given how poorly prepared Arizona is…  it’s going to be an ugly January for unvaccinated persons, folks that will need care for injuries, accidents, and people requiring hospital care for things unrelated to COVID.

AzPHA Total Mortality Report Finds 36,000 Excess Deaths Occurred in AZ During the Pandemic – The Largest Percent Increase in Excess Deaths of Any State

View Our Report

On January 21, 2021, the Arizona Public Health Association documented a large and unprecedented increase in all-cause mortality in Arizona during 2020 as compared to recent years. Beginning in February 2020, overall mortality was elevated every month compared with the same month in 2019. The peak excess was seen in July with a total mortality rate 64% higher than the rate in July of 2019.  While most of the excess was attributed to COVID-19, other causes were also elevated.

Today we publish a new report that provides an update on the excess of all-cause mortality in Arizona since the start of the COVID-19 pandemic. We analyzed weekly, monthly, and annual all-cause and selected cause-specific deaths during 2020 and 2021 (through mid-November) using the CDC/NCHS “Excess Deaths Associated with COVID-19 data sets to compare observed deaths to expected deaths based on statistical models of recent trends and seasonality from historical data.

As expected, we found significant excess mortality throughout the course of the pandemic. Since the start of the pandemic, an estimated 36,000 excess deaths have occurred in Arizona due directly or indirectly to the COVID pandemic.  The total number of deaths in December. 2020 (9,053) was 73% higher than in 2017-19. The largest peak of excess deaths followed in January 2021 when the largest COVID-19 surge occurred; 10,055 total deaths were reported that month, a death toll 78% higher than the average 5,642 deaths during that same month in 2017-19.

Key Findings of Our Report

  • Since the start of the pandemic, an estimated 36,000 excess deaths have occurred in Arizona due directly or indirectly to the COVID pandemic.
  • Overall deaths in Arizona exceeded expected deaths by 29% in 2020 (trailing only New York City’s excess of 50%). Overall Arizona deaths exceeded expectation by 24% in 2021, the largest percent excess deaths of any state.
  • The largest monthly excess of deaths occurred in January 2021, when deaths exceeded expectation by 78%; the largest weekly excess of deaths occurred in the week ending January 16, 2021, when deaths exceeded expectation by 83%.
  • Excess deaths from causes other than COVID during the pandemic include but are not limited to respiratory diseases, heart diseases, strokes, hypertensive diseases, diabetes, and Alzheimer’s.
  • Over the course of the pandemic, COVID deaths accounted for approximately 58% of the total excess deaths based on CDC data.

Editorial Notes: Major contributors to excess all-cause mortality include underreporting/misreporting COVID deaths (especially earlier in the pandemic when testing was extremely limited), limited or delayed access to medical care due to fear of COVID and healthcare systems, and staff that were – and remain – overwhelmed with COVID cases. The root cause of the excess mortality relative to the other states is the inept management of the pandemic by Governor Ducey, former ADHS Director Cara Christ and current Interim ADHS Director Don Herrington.

COVID Cases Continue to Escalate Unabated as AZ Hospitals Enter the Winter Abyss

Low rates and uptake of vaccinations and Governor Ducey & Interim Director Herrington’s resistance to implementing evidence-based interventions like universal indoor public masking requirements and vaccine mandates will lead to many more preventable hospitalizations and deaths among Arizona residents.

Please Consider Donating to AzPHA as You Think About Your End of Year Giving

A Public Health and Sanitary Conference was held at the University of Arizona in April 1928 to ‘bring together officials and workers interested in community health and welfare’. That April 1928 meeting brought together public health and health care workers to discuss their problems and to gain a new enthusiasm.

By the end of the meeting, the attendees had dedicated themselves to forming the Arizona Public Health Association and committed to meet each year to continue the discussion of health and sanitary questions. At the conclusion of the meeting, F.T. Fahlen, M.D – State Superintendent of Public Health (1928) said that: This organization should do much to increase the interest of the people in health matters by working to accomplish better things for Arizona”.

Ever since that day more than 93 years ago, the Arizona Public Health Association has been your “independent voice for evidence-based public health policy“. 

We are a membership organization for public health professionals and organizations. We protect and improve health in Arizona by being a voice on public health issues through advocacy and meaningful and relevant professional development and networking opportunities.

We’ve tried our very best to be the voice of evidence and reason during the pandemic. We’ve also dedicated ourselves to providing clear information, without spin (especially when objective information wasn’t forthcoming from Arizona’s Executive Branch).

If you’re not yet a member of the Arizona Public Health Association, we’d love to add you to our collective voice! Our Individual Memberships are just $75/year. You can join here!

AzPHA is a 501(c)(3) nonprofit corporation supported via our memberships, conferences, grants, and tax-deductible contributions from people like you!

Please consider donating to AzPHA as you think about your end of the year charitable contributions!

Donate Here!

COVID Cases Continue to Escalate Unabated as AZ Hospitals Enter the Winter Abyss

View This Week’s Epidemiology & Hospital Resource Report

Arizona is in Contingency Standards of Care in our hospital system, with some areas in Crisis Standards of Care. Another all-time low for hospital bed availability was set this week at 392 theoretically available beds. However, any hospital administrator will tell you that a “licensed bed” is NOT a “staffed bed”. Because ADHS uses ‘licensed beds’ as the denominator for all of their reports they are artificially inflating bed availability.

I talked with 3 hospital administrators this week and each said that they are only able to actually staff 80% of their licensed beds. What that means is that Arizona is actually at closer to 120% of capacity rather than what ADHS reports (92%).

Seven-hundred fifteen (715, 40%) of Arizona’s 1770 ICU beds were occupied by COVID-19 patients, a 9% increase from last week’s 656 occupied beds. An additional 86 (5%) ICU beds remained available for use. Another all-time low for ICU availability was set this week at 78 beds.

AZPHA Blog Post: How Will Doctors & Hospitals Allocate Treatement Now that Arizona Is In Crisis Standards of Care?

The Delta/Ducey wave has seen 119 days with a combined occupancy >2000 patients whereas the summer 2020 and winter 2021 waves saw 57 and 98 days, respectively. We have now had >3000 combined occupancy for 23 days whereas the summer 2020 and winter 2021 waves saw 35 and 78 days, respectively.

Transmission among working-age adults and seniors continues to increase. However, transmission among children has generally declined over the past two weeks presumably because of holiday break and reduction of school exposures.

Arizona has been experiencing >200 COVID-19 deaths per week since August 22nd; and, beginning the week ending November 14th there have been >300 deaths a week. So far, 22,947 Arizonans have lost their lives to COVID-19 making it Arizona’s leading cause of death, the only state to achieve such a dubious distinction

Editorial Note: Other governors are implementing measures to mitigate spread in light of even tight hospital capacity (ours is overwhelmed already and getting worse). For example, NY Governor Hochul Announced Major Action to Address Winter Surge and Prevent Business Disruption as COVID-19 Cases and Hospitalizations Rise Statewide. Sadly, Governor Ducey couldn’t care less and has no intention of doing anything whatsoever.

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