Author: Will Humble

The modeling team from ASU produced a terrific new COVID modeling update for Arizona on Friday. It’s solid work and has lots of analytics about the epidemiological trends and predictions, hospitalization trends and deaths. You’ll be glad you checked it out.  Many of you will probably end up using this work as part of your job or to inform others.

Dr Gerald also distributed his weekly update today. As expected, it shows encouraging results especially related to COVID hospitalizations. The bottleneck of tests and slow turn-around time is complicating our ability to accurately characterize the magnitude of change on the epidemiological curve. Promises have been made that the backlog will be cleared by Friday – so hopefully that’s true and we can get a more clear assessment on the case trends next week.

It’s officially showtime for Arizona’s hospital system. Last week was an extremely busy week for health care systems with near capacity  ICU care across the state.

Reports from the Field

While the rate of increase for some key hospital-specific metrics appears to be leveling out, the total impact of patient need on current health system capacity remains at a record high – especially in the central & southern parts of Arizona.

COVID-19 hospitalizations in Arizona have increased with hospitals reporting nearly 3,500 COVID-19 inpatients and more than 900 patients in their intensive care units. Hospitals have activated additional beds in their facilities and have been hiring more more nursing staff.

In northern Arizona, variability in need and impact continues; some previously busy hospitals have experienced lower inpatient census for COVID-19 care while other facilities are experiencing new highs.

Out-of-State Healthcare Workers Coming to the Rescue

The AZ Surge Line continues to coordinate patient transfers to higher and lower levels of care. Some of the delays in patient placements last week were because of a statewide shortage of available staffed beds. 

Recognizing that Arizona’s hospital systems are at the breaking point staffing-wise, the ADHS contracted with Vizient, Inc. to bring in 600 critical care and medical-surgical nurses from out of state into Arizona to support expanded capacity within Arizona hospitals (here’s the contract).

Staff will be allocated and deployed using the Surge Staffing Initiative. Hospitals received the application forms this week. Here’s an the application questions and attestations. 

Hospitals that need this critical staffing support can get it for free  for up to six weeks up to 20% of their licensed capacity expenses to implement their surge plans to fill staffing gaps. The money to pay the contractor is coming from the Public Health Emergency Fund.  The governor deposited $50M into that fund last week.

Editorial Note: June and July are the 2 months of the year in which patient census is significantly lower than the annual average.  In fact, June typically has 1,700 fewer inpatients than the annual average and July about 1,200. August comes back closer to the annual average.  That means additional staffed bed demand will be increasing in the coming months as normal, non COVID, patients begin returning to hospitals.

HHS announced significant changes to the process for hospitals to fulfill the agency’s request for daily data reporting on bed capacity, utilization, personal protective equipment, and in-house laboratory testing data.

The CDC National Healthcare Safety Network COVID-19 module is no longer being used. Hospitals now have to either: 

• report data to their state health departments (if their state promises to then report the data to HHS; or

• report directly to the HHS TeleTracking portal.

HHS has made significant updates to the data fields it is asking for in daily reporting. For example, HHS is asking for information on both pediatric and adult patients and is asking hospitals for information about their inventory of remdesivir.

Editorial Note: This is a controversial decision in the public health and academic world. The CDC has built a trusted brand for decades and public health and academics alike trust that the CDC behaves on the up and up, makes data available and is committed to data integrity. There’s less confidence in HHS because there are far more political appointees there- whereas CDC is dominated by career folks. There is concern that the data will become less transparent and questions about whether HHS will edit the data.

COVID-19 testing plans from states, territories, and localities for the months of May and June were posted on the HHS website last week.  CDC awarded $10B in funding to states, territories, and localities to assist with the implementation of these plans. Here is the testing plan that AZ turned in.

An mRNA Vaccine against SARS-CoV-2

Moderna has completed their Phase I Trial in the U.S. of their mRNA-1273 vaccine. The results are promising. It induced anti–SARS-CoV-2 immune responses in all participants, and no trial-limiting safety concerns were identified. These findings support further development of this vaccine.  The Phase II trial is underway with results expected by late August. At that point, it will move to a Phase III Trial which will test safety and efficacy in much larger populations. NCT04283461.  

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EDITORIAL

Covid-19 Vaccine-Development Multiverse

• Penny M. Heaton, M.D.

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Characteristics of Persons Who Died with COVID-19

An early release MMWR outlines characteristics of people who died with laboratory-confirmed COVID-19 and was obtained through CDC’s case-based surveillance data and supplemental surveillance data from 16 public health jurisdictions.

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MMWR: Factors Associated with Cloth Face Covering Use Among Adults During the COVID-19 Pandemic 

Another early release MMWR discusses the findings of two internet surveys that assessed a sample of adults’ use of cloth face coverings and the behavioral and sociodemographic factors that might influence wearing a cloth face-covering out in public.

Within days of the release of the first national recommendation for use of cloth face coverings, most people who reported leaving their home in the previous week reported using a cloth face covering.

Testing continues to be a problem in Arizona. Demand far outstrips the supply of available tests and the time it takes to get samples back from the lab is too slow. Reports from the field suggest that samples sent to the Sonora Quest labs are coming back between 7-14 days after specimen collection.

That kind of turn around time doesn’t provide actionable information to persons that get tested because they don’t know their status in time and they are far less likely to go into isolation if they’re not sure whether or not they really have COVID. 

In addition, the county health departments get the data back from the lab too late to do an effective case investigation and conduct contact tracing. The case may have already recovered and infected their roommates, family members, co-workers and community persons. 

Business owners (especially assisted living and skilled nursing facilities) are also behind the 8-ball because the data on their employees comes back so late that there’s no real actionable information- and they’re unable to make evidence based decisions about who is safe to attend work.

Fortunately the governor and health director have committed to increasing statewide testing capacity to 35,000 tests per day by July 31 (2-weeks).  Great that they set a discrete goal – but I would have loved to see a SMART Goal something like this:

By July 31, Arizona will be testing 35,000 persons per day with 90% of tests returned to the patient within 72 hours. I  addition, I think we really need to have the ADHS dashboard track sample turn-around times. After all, What Gets Measured Gets Done.

Editorial Note: The governor has yet to use public health emergency authority to require assisted living and skilled nursing facilities to routinely test their staff in order to prevent the virus from leaking into these congregate settings. Folks in these facilities continue to be a very large portion of the hospital patient census, and better testing and infection control in these settings could improve available hospital capacity and save lives. 

Last week the FDA has granted emergency use authorization for pooled coronavirus testing for Covid-19. The approach involves combining samples from multiple people, which are only tested individually if the batch comes back positive. Perhaps this approach, along with increased use of antigen testing and requiring routine staff testing in congregate settings can help us out with our hospital capacity issues.

However, none of these things will work if the turn around times for samples continue to be insufficient.

School season is rapidly approaching. A huge public health policy question out there is “how do we decide when school can start this Fall (if at all) and under what circumstances”?  Thus far, the governor has been talking about when schools would be allowed to open for in-person instruction rather than under what circumstances.

A couple of weeks ago, he postponed the start of school until August 17, a date that he described as “aspirational”.  Setting a date for school to start is arbitrary if it’s not linked with evidence-based public health metrics. It makes a lot more sense to tie school openings to evidence-based performance criteria.

There are 2 categories of criteria that should be used to make the school opening decision:

• The quality of school district mitigation plans & their ability to execute those plans with fidelity; and

• Evidence-based criteria that measure community transmission. 

Both these factors should be in place before considering setting a date for in-person instruction to begin.

While many school districts have quality mitigation plans to lower the risk of spread, community transmission is too high right now to adequately protect kids and staff- even if they have good plans.  Testing capacity is inadequate, sample turn-around times are insufficient, contact tracers get tardy data, public health laws are inadequate and unenforced, and testing & infection control are inadequate in care homes.  All the above issues are fueling community spread and need to be improved before schools open this Fall.  But, how would we measure success?

Fortunately, we can come up with evidence-based performance measures to help determine whether community transmission is low enough warrant opening our K-12 schools for in person instruction.

Let’s explore the possibilities.  Consider the 4 bullets below as the criteria that would need to be met to set a date to open schools for in-person instruction:

• A 30-day reduction in the number of new COVID cases in the community measured by a 7-day moving average;

• A community percent positive rate of less than 5% for 2-weeks measured by a 7 day moving average;

• Eighty percent of case and contact tracing investigations completed within 96 hours of sample collection over a 21 day period; and

• Community hospitals open for elective procedures.

When a community meets all these criteria, the district could be free to set a date for in-person instruction (if their county health department has validated their mitigation plans).  County personnel could conduct periodic on-site validation of school’s mitigation plans.  If community transmission rebounds and the above criteria are no longer met, then districts would need to suspend in-person instruction.

Another advantage to this evidence-based performance criteria approach is that members of a community would have a common goal to work toward- as nearly everybody agrees that in-person school instruction is important and worthy of trying to achieve.  Having measurable criteria in place to make that happen can build additional community motivation to achieve and maintain the important mitigation measures that reduce transmission of the virus.

We just received Dr. Gerald’s latest COVID analysis. For the first time in many weeks there are some encouraging signs. New cases have stabilized (albeit at a very high level). Likewise, the percent positive drifted downward slightly in the last week. Hospitalizations for COVID also stabilized (although at extremely high levels). Take home for this week is at least things didn’t get worse- so by that standard- things got a little better.

For the week ending July 12th, Arizona recorded 15,160 new Covid-19 cases. However, this undercounts the actual number of new cases because as 50% of PCR results take more than 5 days to be reported. For example, last week’s tally has been revised up by 32% because of slow turn-around times.

The percent of patients testing positive drifted down slightly – going from 23% the week ending July 5 to 19% the week ending July 12. A declining test positive percentage in the face of declining testing capacity lends additional evidence that viral transmission is slowing in response to the public’s adherence with new face mask ordinances, additional business restrictions, and other recommended health behaviors.

On the hospitalization front, total Covid-19 hospitalization increased 311% from 1093 to 4487 occupied beds between May 22 and July 13. The good news is that In the last week total Covid-19 hospitalizations increased only 1% (going from 4384 to 4410 occupied beds). If the trend continues hospitals should see stabilizing or declining admissions over the coming weeks.

While these leading and contemporary indicators are stabilizing- no such luck for deaths. The week ending July 5th is now the week with the largest number of Covid-19 deaths (339). Because deaths lag new cases by about 2 weeks, deaths will continue to increase for the next week or two before moderating or declining.

The Arizona Hospital and Healthcare Association recently asked the ADHS for some regulatory relief so that their member hospitals can more effectively respond to the ongoing surge of COVID patients.

AzHHA asked for waivers that would allow the transport of patients in private vehicles, let hospitals send some emergency room patients to urgent care, and allow them to put adult and pediatric patients in the same room among other things. 

The ADHS responded later in the week and agreed to waive some but not all of the requests. Here’s the letter from ADHS and here’s the administrative order.