Author: Will Humble

It’s looking more and more like we’re going to need them

Unless some policy changes like those below are implemented in the coming days, it’s looking more and more like Arizona will need to go into surge hospital status and implement crisis standards of care for folks that become infected with the virus and need care later this summer. Here are some things that we could implement to avoid crisis care:

• Mandatory cloth masks in public indoor environments (with penalties for noncompliance- managed by cities).

• Allow cities to implement mitigation strategies.

• Stronger compliance incentives; modify EO 36 to include penalties for businesses not complying with CDC guidelines. Complaints could be followed up on by cities. 

• More focus on testing and infection control in assisted living and skilled nursing. For example, setting up routine weekly testing of assisted living and skilled nursing staff w better infection control. MCDPH is about to award a contract related to this. It appears the state is unwilling to use their regulatory authority here.

• Continue to enhance contact tracing capacity. It would have been nice to tie ending the stay at home to some level of contact tracing to motivate supervisors to resource this- so that was a missed opportunity.

At the beginning of the pandemic, hospitals were ordered to submit (to ADHS) plans to increase their bed and ICU capacity by an additional 50% over their currently licensed capacity and implement crisis standards of care.  I’m certain that given the data trends, hospitals are working to implement those surge plans.

On the alternate care site front…  a couple of months ago there was a press event out at the old St. Luke’s hospital and a declaration by the governor and others that the facility would become a contingency acute care hospital strictly for COVID patients.

Several journalists and others have been trying to fund out what the status of the facility is. In other words, how ready is it to be used if needed?

Statements from the governor’s spokesperson this week in the Republic suggested that it is ready to go and can be operational in 48 hours.  However, journalists and others have been unable to find a contract with an entity that would run the facility.

Later in the week, some journalists heard that the St. Luke’s is no longer an acute care alternate care site, but more of a step down facility. 

Perhaps we will learn more soon. It’s an increasingly important question because with all the indicators pointing in the wrong direction, there’s an increasing chance that a site like this might be needed.

Dr. Joe Gerald just sent me his new data analysis and model run summary. Terrific work as usual. There’s more detail in this week’s report because of all the action related to both with the data and the public health policies (or lack thereof) in the last week. Here are some of the more interesting information nuggets from today’s report:

Since May 17, cases have increased 138% (3,061 to 7,286) while testing has increased by 17% (46,206 to 54,078) providing compelling evidence that increasing case counts largely reflect increased community transmission- not increased testing.

Since the week ending May 17th, the percent of PCR specimens that are positive has increased from 5.3% to 11.1% suggesting that testing capacity is not keeping pace with transmission.

From a May 22 to June 12, Covid-19 total hospitalization has increased 70% (from 1093 to 1859 occupied beds). Increases in Covid-19 general ward occupancy were greater than increases in ICU occupancy, 80% and 45%, respectively. Because of a decline in non-Covid hospitalizations, the all-cause hospital census has only increased 9% from 7173 to 7785 occupied beds. Continued increases in case counts is expected to drive additional hospitalizations for the foreseeable future.

As of June 12, 1412 (18.3%) of Arizona’s 7705 general ward beds were occupied by patients with suspected or confirmed Covid-19 infection, a 10% increase from last week. An additional 1237 (16.1%) beds remain available. Similarly, 447 (26.9%) of Arizona’s 1664 ICU beds were occupied for Covid-19 care, a 14% increase from last week.

A projection of non-surge general ward and ICU capacity suggests Arizona could reach general ward capacity sometime between in July or August assuming no mitigation efforts are instituted and past trends continue uninterrupted.

The possibility that Arizona might exceed its ICU capacity is supported by CovidActNow which shows markedly rising ICU utilization through June. A similar projection is made by the Institute of Health Metrics and Evaluation.

Once “normal” operating capacity is exceeded, patients will be admitted to jury-rigged settings, treated with second-line agents owing to shortages of critical resources, and cared for by nurses and physicians recruited from non-critical specialties. This is not to disparage the heroic measures these facilities and caregivers will make to ensure quality care but rather to caution against an overly idealistic view of the equivalence of surge care.

At the end of the report, Dr Gerald has a terrific analysis regarding the Governor’s June 11 Covid-19 Press Briefing. I won’t summarize this here, but it is very good. Take some time to take a peek.

Landmark Study Establishes that Cloth Masks are Very Effective, High ROI

A new comprehensive study was published Friday that unequivocally shows that cloth mask wearing in pubic is super effective. It’s undoubtedly the highest return on investment intervention available right now.

Researchers examined the transmission pathways by analyzing the trend and mitigation measures in Wuhan, Italy, and NYC from January 23 to May 9. They found that airborne transmission is the dominant way that the virus is spread (as opposed to surfaces etc.).

The authors examined the difference in spread with and without mandated cloth face covering and found that masks “significantly reduces the number of infections”. Mask wearing alone reduced the number of infections by over 78,000 in Italy from April 6 to May 9 and over 66,000 in New York City from April 17 to May 9. 

When mask-wearing went into effect in New York, the daily new infection rate fell by about 3% per day. Infection trends shifted dramatically when mask-wearing rules were implemented on April 6 in northern Italy and April 17 in NYC.

The study concludes that “… wearing of face masks in public corresponds to the most effective means to prevent inter-human transmission, and this inexpensive practice, in conjunction with simultaneous social distancing, quarantine, and contact tracing, represents the most likely fighting opportunity to stop the COVID-19 pandemic“.

Editorial Note: Ok… so lets think about this for a second. Here we have a very effective intervention that’s proven and is the single most efficient way to slow the spread of the virus. The intervention costs essentially nothing. Compare that to the cost of another stay at home order or the interventions like expanding hospital capacity and canceling elective procedures.

This is the easiest call in the world. We should have a statewide requirement requiring everybody to wear a mask in indoor environments when they’re in public.

Source: 

Identifying airborne transmission as the dominant route for the spread of COVID-19

The Proceedings of the National Academy of Sciences; the official journal of the National Academy of Sciences

Renyi Zhang, View ORCID ProfileYixin Li, Annie L. Zhang, View ORCID ProfileYuan Wang, and Mario J. Molina

PNAS first published June 11, 2020 https://doi.org/10.1073/pnas.2009637117

Even before Friday’s landmark study, there has been growing body of evidence that wearing a cloth mask can provide some protection to both the mask wearer and others… and that when folks wear masks it reduces respiratory disease transmission in the community (1,2).

Cloth masks made of household materials provide about 60% filtration of particles of droplet size (range from 3-86%) coming into the wearer (3,4,5).

There is also abundant evidence that masks keep particles inside the mask (source control), which is important due to the high number of people who are infected both without symptoms and before symptoms occur (2).

Mask efficiency improves when multiple layers of fabric are used and when using fabric combinations (6). For example, filtration efficiencies of hybrid materials (such as cotton–silk, cotton–chiffon, cotton–flannel) was >80-90%. Cotton performs better at higher weave densities (i.e., thread count). Gaps caused by improper mask fit can decrease effectiveness, so having a good fit is important.

1. Howard, J.; Huang, A.; Li, Z.; Tufekci, Z.; Zdimal, V.; van der Westhuizen, H.; von Delft, A.; Price, A.; Fridman, L.; Tang, L.; Tang, V.; Watson, G.L.; Bax, C.E.; Shaikh, R.; Questier, F.; Hernandez, D.; Chu, L.F.; Ramirez, C.M.; Rimoin, A.W. Face Masks Against COVID-19: An Evidence Review. Preprints 2020, 2020040203

2. C. Raina MacIntyre , Abrar Ahmad ChughtaiView Of The Efficacy Of Face Masks And Respirators Against Coronaviruses And Other Respiratory Transmissible Viruses For The Community, Health- Care Workers And Sick Patients, International Journal of Nursing Studies (2020), doi: https://doi.org/10.1016/j.ijnurstu.2020.103629

3. A. Davies, et al., Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic? Disaster Medicine Public Heal. Prep. 7, 413–418 (2013).

4. S Rengasamy, B Eimer, RE Shaffer, Simple Respiratory Protection. Evaluation of the Filtration Performance of Cloth Masks and Common Fabric Materials Against 201000 nm Size Particles. The Annals Occup. Hyg. 54, 789–798 (2010).

5. Mvd Sande, P Teunis, R Sabel, Professional and Home-Made Face Masks Reduce Exposure to Respiratory Infections among the General Population. PLOS ONE 3, e2618 (2008).

6. Abhiteja Konda, Abhinav Prakash, Gregory A. Moss, Michael Schmoldt, Gregory D. Grant, and Supratik Guh. Aerosol filtration efficiency of common fabrics used in respiratory cloth masks. ACS Nano. 2020;14:6339-6347.

The Maricopa County Department of Public Health is now requiring employees to wear masks when physical distancing isn’t possible.  In addition, all 3 of our state universities are now also requiring faculty, staff and students to wear masks when physical distancing isn’t possible (announced at Friday’s Board of Regent’s meeting).

For example, employees, students and visitors at ASU are also now required to wear face masks on campus. ASU previously announced face masks would be required for the start of the fall semester in buildings and outdoor community spaces where social distancing isn’t possible. 

Both policies are effective immediately. ASU’s policy includes all indoor spaces as well as outdoor community spaces, garages, parking lots, shuttles, bike rack areas and sidewalks.

Leadership by example!

CDC has released guidance to support the needs of people with disabilities during the pandemic, including resources for direct service providers, group homes for individuals with disabilities,people with developmental and behavioral disorders, as well as additional information for direct service providers, caregivers, parents, and people with developmental and behavioral disorders.

Arizona State University has a PPE Response Network for supply chain leaders at hospitals and clinics to discuss best practices, share information on vendors and local manufacturers, and better understand and address evolving clinical shortages in PPE, testing supplies, and other equipment due to COVID-19.

As part of this effort, ASU has also been working closely with supply chain and leaders and clinicians to rapidly design, prototype, 3-D print, and test innovative solutions on an ad-hoc basis (e.g., UV and H202 sterilization chambers and intubation boxes). 

• Learn more about the PPE Response Network here: https://asunow.asu.edu/20200416-arizona-impact-luminosity-lab-3d-printing-health-care-ppe

• Enroll and submit requests for PPE and other supplies here: https://pperesponsenetwork.asu.edu/  

• Watch this video to guide you through the enrollment process: https://vimeo.com/408869037)

All the county health departments are ramping up their contact tracing capabilities. This week I’ll focus on what Maricopa County has been doing. They have a 2 pronged approach- staffing up internally and contracting with AZ 211 for extra help.  Here’s a previous blog post on the what contact tracing entails. 

Maricopa has 52 new people who now work in their Epidemiology program to support the contact tracing investigations teams. There are an additional 27 folks in the hiring process.  Every week, new investigators begin training and become independent. Once training is complete, all investigators go full force into interviewing cases, which includes identifying every close contact while they were infectious. The detailed contact tracing is handled by Maricopa County staff while following up with close contacts is handled by the team at AZ 211, who are hiring an additional 50 tracers.  

The folks who work for AZ 211 don’t require as much training because they don’t perform an extensive investigation requiring medical knowledge nor do they have confidential information related to cases. They provide the contacts with standardized information about what symptoms to watch for, what to do if they get symptoms and how to avoid spreading disease to others.  They also answer any questions the contact has and determine if additional services are needed. 

Maricopa is also implementing a plan to load case and contact information into a secure automated system which will monitor contacts for symptoms and alert staff.  That system (when it comes on-line) will also inform cases when they no longer require isolation.

When the automated system is implemented it’ll take a big workload off both the investigators and contact tracers, who can then focus on enhanced tracing.

Once the remaining new 27 in-house, Maricopa county employees are trained, they’ll have 76 new investigator team members interviewing cases and contacts 7 days per week. At this staffing level, they’ll be able to interview roughly 500 cases per day with the goal of completing the interview within 24 hours of receipt.

Editorial Note: Effective contact tracing requires robust testing in the community as well as fast turn around times from the laboratories. If the labs fall behind (as I have anecdotally heard) case data gets to the investigators after the horse has already left the barn and the case investigations and contact tracing efforts are a lot less effective. Lab turn-around time matters!

This week’s journal article addresses the question whether outdoor environments are as bad as indoor environments for spreading the virus. An important question given the outdoor protesting that has been going on- as well as the prolific indoor clubbing that happens in AZ.  

The study below found that indoor SARS CoV2 transmission in indoor environments is 19 times greater than outdoor environments. 

Closed Environments Facilitate Secondary Transmission of Coronavirus Disease

https://doi.org/10.1101/2020.02.28.20029272