Author: Will Humble

A recent randomized trial tested to see whether dexamethasone (a steroid treatment) is useful for folks hospitalized with COVID. They found that it reduced deaths by 33% in ventilated patients and by 20% in patients receiving oxygen only.  There was no benefit among those patients who did not require respiratory support.

Here’s the media release that describes the findings.  The results haven’t yet been published in a peer reviewed journal, so beware, these are just preliminary results and not peer reviewed.

The FDA has revoked the Emergency Use Authorization for hydroxychloroquine and chloroquine as treatments for COVID-19 due to new evidence that demonstrates the treatments don’t work for COVID-19 and have serious side effects.

CDC updated their guidelines for COVID-19 testing in nursing homes, clarifying testing recommendations for residents and staff, testing procedures in response to an outbreak, and new recommendations for testing for other pathogens like influenza.

They also updated their web page with information on how COVID-19 spreads, providing more detail on person-to-person transmission through respiratory droplets. Respiratory droplet exposure has been established as the dominant mode of transmission of the virus- reinforcing the importance of face coverings as the single highest return on investment intervention that we have.

• Ensure your schedule allows for a 5-8 hour commitment for at least 8 weeks (12 weeks is ideal).

• Complete the ASTHO Making Contact: A Training for COVID-19 Contact Tracers

• Register with the Arizona Emergency System for the Advance Registration of Volunteer Health Professionals  

In early June the ADHS discussed modifying 2 important documents to further guide contingency and crisis standards of care for when we move into surge status: 1) Remdesivir Allocation Guidance; and 2) Allocation of Scarce Resources in Acute Care Facilities. They’ll post the final guidance documents here.

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.