Author: Will Humble

At the urging of Superintendent Hoffman, the governor signed Executive Order #51 last Thursday outlining a process to make better decisions about whether and how to set in-person instruction start dates. For the last several days, we, the Superintendent, teachers, and others have been advocating for a more evidence-based process to set school start dates. Our advocacy worked!

Prior to last Thursday, the governor had been setting proposed in-person instruction dates- but there had been no objective evidence-based criteria associated with those dates.

Last Thursday’s Order also requires face coverings for students over 5 years old when in-person services or instruction begins. There are exceptions for some students and during playground time when outside distancing is happening.

The Order requires the ADHS to develop public health benchmarks that school districts may use to inform their in-person instruction dates. The deadline for developing the criteria is August 7.

While the Order itself doesn’t mention how or whether the county health departments will be involved in setting the criteria, Superintendent Hoffman mentioned the importance of involving the county health departments- which is super-important as they are the public health retailers in Arizona.

While we still need to see what the criteria will be- this is certainly a victory for evidence-based public health policy and the students, parents and educators of Arizona.

The governor extended his executive order from 3 weeks ago that ordered the closure of gyms, bars, nightclubs, movie theaters, water parks, and tubing. The order also prohibits some organized events of more than 50 people. Cities and counties can approve them anyway if they believe there is enough mitigation. You can read EO #52 here.

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.