State and local officials are looking for emergency response volunteers to help with the COVID-19 response. Your knowledge and skills can make a difference. If you’re interested in volunteering you can register with the “Arizona Emergency System for the Advance Registration of Volunteer Health Professionals” (AZ-ESAR-VHP) at Arizona Emergency System for the Advance Registration of Health Professionals.
New Crisis Standards of Care Decision-making Guidelines Established
The State Disaster Medical Advisory Committee met last week and approved Crisis Standards of Care Staffing Guidance for Short-Term Acute Care Facilities; COVID-19 Pre-Hospital Triage Guidance; and COVID-19 Guidance for Expansion of Healthcare Facility Staff.
If you go to those links you’ll see that the guidance provides suggestions for how to go through the decision-making process for alternate care standards rather than actually making alternate standards care decisions.
Here’s the Roster of people on that committee.
Pitt School of Medicine COVID-19 Vaccine Program Shows Promise
The University of Pittsburgh School of Medicine published a peer-reviewed paper this week in EBioMedicine suggesting that their COVID-19 vaccine candidate produces antibodies specific to SARS-CoV-2 (in mice), at quantities thought to be sufficient for neutralizing the virus. The vaccine would be delivered through a fingertip-sized patch. This is the 1st peer-reviewed study that describes a candidate vaccine for COVID-19.
The paper titled, “Microneedle array delivered recombinant coronavirus vaccines: Immunogenicity and rapid translational development” is in EBioMedicine.
The anti-vaccination crowd sure has been quite these days, don’t you think?
Hydroxychloroquine & Chloroquine Get FDA Emergency Use Authorization as COVID-19 Treatments
Last week the FDA issued an emergency use authorization for hydroxychloroquine and chloroquine as treatments for COVID-19. The authorization allows the drugs to be donated to the Strategic National Stockpile and distributed as well as prescribed by doctors to hospitalized adult COVID-19 patients as appropriate. They could have been used off-label before the authorization, but this determination remove the SNS administrative barrier.
On Saturday the governor issued an executive order limiting hydroxychloroquine prescriptions to people that need it for treatment (e.g. Lupas or COVID) and clarified that it can’t be used for prophylaxis (prevention). Good idea.
The CDC has a web page that summarizes the trials underway including for Remdesivir, which is an investigational intravenous drug with broad antiviral activity that inhibits viral replication through premature termination of RNA transcription and has in-vitro activity against SARS-CoV-2 and in-vitro and in-vivo activity against related coronaviruses. More information on trials can be found at: https://clinicaltrials.gov/.
The CDC is Recommending People Wear Cloth Masks Whether They’re Symptomatic or Not
Is There Evidence for this Intervention?
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People that have respiratory symptoms or fever should stay home and not be out and about right now (with or without a mask).
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Cloth masks or home-made masks and scarfs are fine for asymptomatic persons to wear in the community (but likely provide little protection for the wearer or community members).
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Members of the community should not wear manufactured medical masks if they are asymptomatic. Doing so puts additional pressure on the PPE supplies and putting additional strain on health care workers.
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However, cloth masks might remind people to stop touching their faces and also remind people to keep their distance from others (perhaps the mask can provide a visual queue to keep some distance).
The CDC is now recommending the voluntary use of cloth face masks by everyone in the community regardless of whether they’re sick.
There is some evidence to support the use of cloth masks for people that have any respiratory symptoms (during this pandemic) as a recent study supports the use of surgical face masks to prevent coronavirus transmission from symptomatic individuals. There’s widespread consensus that people working in healthcare and people that have any respiratory symptoms in the community should wear facemasks. But- there’s little if any evidence to support the use of face masks for those who are not symptomatic in the community.
Given the shortage of PPE in healthcare settings and the demand that would be placed on the supply chain from widespread use of manufactured medical masks, the only reasonable recommendation is for people without symptoms to wear cloth masks, scarves or homemade masks- not manufactured medical masks.
There’s very limited data on the efficacy of cloth masks. There are some small studies (1, 2, 3) showing that cloth masks can provide some level of marginal protection against particles which can contain viruses. If a covering gets wet (even from the moisture emitted when a person exhales) the fabric could be more likely to transmit the virus.
One randomized trial compared medical masks, 2-layer cotton cloth masks, and usual practice in hospital health care workers (n=1607). The cloth masks were 2-layer cotton masks. Participants were asked to wash them daily with soap and water. The study found that the highest rates of influenza-like illness were in the cloth mask group (RR =13.0 compared to the medical mask wearers).
Infections were also higher in the cloth mask group compared to the usual practice group. Cloth masks also had higher rates of laboratory confirmed virus in participants (RR 1.7 compared with the medical mask group). Penetration of cloth masks by particles was almost 97% compared to 44% in medical masks.
Healthcare Worker Personal Protective Equipment Still a Challenge
Arizona has now received 75% of our allocation of personal protective equipment (gloves, masks, gowns, hoods) from the Strategic National Stockpile. The goods come in to the ADHS warehouse from the SNS and are shipped to the county/tribal health departments, who then prioritize where the PPE will go. Most are continuing to prioritize inpatient facilities.
In the mean-time, individual hospitals, community health centers, skilled nursing facilities and healthcare providers of all sizes are continuing to pursue PPE from their usual wholesalers. I presume that the state of Arizona is doing the same.
The bottom line is that there is only so much PPE in the world and it is in super high demand everywhere. The primary manufacturers are in China, which is now just in the process of getting their manufacturing industries up and running.
It’s unfortunate- but for the duration of the pandemic healthcare providers of all types won’t have the personal protective equipment that they have been accustomed to having their entire career.
The CDC has a website with some practical guidance to help healthcare providers conserve their PPE – they call it strategies to optimize the use of PPE. The site has separate guidance for masks, gloves, gowns, respirators, and ventilators. There’s also a PPE Burn Rate Calculator to help facilities calculate the use as they go.
Most facilities are probably already using Contingency Level conservation methods- and there is a good chance that’ll progress to the Crisis Level at some point in the next few weeks. Here’s a link to the state’s Contingency PPE Guidance.
Updated Case and Infection Fatality Ratios for COVID-19
Last week The Lancet published a new study examining the case and infection fatality ratios for the pandemic. The case fatality ratio is an estimate of the fraction of people that have been confirmed to have the disease that end up passing away. The infection fatality ratio on the other hand is the fraction of people that pass away that have been infected with the virus (the infection fatality ratio includes asymptomatic cases).
The author’s best estimate of the case fatality ratio is 1.38%. Of course, there’s a big difference in the case fatality ratio by age. The ratio was a lot bigger in older age groups, with a CFR of 13% among people aged 80 years or older. Their estimated overall infection fatality ratio is 0.66%, also with an increasing profile with age.
State Allocates Some of the $100M in Rainy Day Money
On Friday state agencies told the legislature what they intend spend some of the $100M in rainy day funds on. So far, they’ve allocated $35M from the $50M medical fund and $6.7M from the other $50M contingency fund.
They’re planning to spend $10M on ventilators, and $8.5M for medical masks, $5.8 million to help county health departments, and $1.2 million to tribes for local preparedness and response. Another $1.1M is going to the Boys & Girls Clubs & $2.4M to the YMCA to expand childcare options for essential workers. $3M will go toward buying lab equipment and other supplies for testing. $1.8M is headed to DEMA & $750K for a “hospital build-out”.
You can see the spending plan for both of the $50M funds here.
What Health Insurance Options Are Out There for Folks that Have Been Laid Off?
Beyond the public health impact of the virus itself, the social distancing interventions are causing their own public health impacts by adversely impacting the social determinants of health. When people lose their ability to make a living it can cause a cascade of harmful outcomes. It’s a good thing that the recent $2.2T fiscal stimulus is on the way (especially the increase in unemployment insurance benefits) – but that’s just a patch.
Among things that folks that have been laid off are worrying about is health insurance. Some people that have been laid off may be OK for now if their employer is temporarily carrying their group insurance (at least for April). Most people that have been laid off will probably be losing their employer-based health insurance at the end of the month in which they were laid off. Those folks have a few different options.
Medicaid
Medicaid may be an option for some folks recently laid off. AHCCCS is recommending that people apply for AHCCCS health insurance as soon as they’re laid off. To apply online, folks can visit the Health-e-Arizona PLUS online application portal. Here’s AHCCCS’ Enrollment Information Webpage with a summary of the qualifying criteria including income eligibility requirements.
In most instances for initial eligibility determinations, the actual (or anticipated) income to be received in the application month is considered. The application form allows you to indicate that you’ve lost your income. AHCCCS has stated that additional unemployment insurance payments and the upcoming stimulus checks won’t be counted as income when determining medical eligibility, so that’s good.
The bottom line is that a lot of things are in flux right now and there’s nothing to lose by applying right away. People can schedule a free phone appointment with a certified assister to learn more. Call 1-800-377-3536 or by visiting www.coveraz.org/connector.
Marketplace Insurance
People recently laid off can also buy health insurance through the federal marketplace under the Affordable Care Act. Enrolling in Marketplace plans is usually limited to the open enrollment period, but when a person is laid off and loses their employer based health insurance it’s called a “qualifying event” and they can buy Marketplace insurance even though it’s not open enrollment. So that’s another option. And remember, Marketplace plans come with subsidies for folks that financially qualify.
COBRA
For decades there’s been a law in place called COBRA – which allows people to maintain their employer-related group health insurance- except that they need to pay both the employer and employee side of the premium (which can be expensive). So, folks that have been laid off can ask their employer for a COBRA application and get coverage that way.
Other Help
There are other programs out there that can help people with resources in times of need like this. A good place to explore the potential benefits is a website called Arizona Self Help. It’s a free and easy way to find out if your family can get help from 40 different health and human services programs. The website provides Program list/descriptions, Contact information, List of items you may need to bring to an eligibility interview, and Program applications.
Does Your Blood Type Influence Whether You’ll Get COVID-19?
Maybe.
Researchers in China have discovered some interesting evidence suggesting that persons with Type A blood have a higher risk of getting COVID-19 when compared to non-A blood type people. The researchers in China compared the blood group distribution in 2,173 patients with COVID-19 from three hospitals in China with that in normal people from the corresponding regions near those hospitals.
Their Meta-analysis on the pooled data (which has not been peer-reviewed) found that blood group A had a statistically significantly higher risk for COVID-19 (odds ratio 1.20) compared with non-A blood groups. Blood group O had a statistically significant lower risk for the disease (odds ratio 0.67) compared with non-O blood groups.
Their report concluded that “People with blood group A have a significantly higher risk for acquiring COVID-19 compared with non-A blood groups, whereas blood group O has a significantly lower risk for the infection compared with non-O blood groups.”
However, always remember to check the odds ratio on studies like this. In this case you’ll see that the odds ratio for the blood group A is 1.2 which basically means that folks with Type A blood are 20% more likely to get the illness. The odds ratio for the Group O folks suggests that they are roughly 30% less likely to be confirmed as a case. Not exactly a huge difference, but it was statistically significant.
Also, the study hasn’t been peer-reviewed which means that it hasn’t been examined for its accuracy and shouldn’t be used to guide clinical practice.