The 2020 COVID-19 Pandemic in Arizona:

The Year in Review

This week marks the anniversary of Arizona’s initial case of COVID-19. The index case was a student at ASU that had recently returned from Wuhan. Over the next 12 months, Arizonans have been through a lot.

More than 12,000 Arizonans have lost their lives to COVID-19 and total mortality for the year was nearly 15,000 higher than 2019. Thousands have been hospitalized and recovered but are having long-term health problems. Many others have lost jobs and are at risk of eviction or even experiencing homelessness. Some have lost social connectiveness leading to mental health distress.

At this, the 1-year anniversary of the first case, Arizona continues to have the dubious distinction of experiencing the highest rate of community spread of the SARS CoV2 virus in the country for the last several weeks. This is the second time that Arizona has been on top in community spread. We were highest in the country and world in mid-July as well.

Arizona has recorded 14,972 more deaths in 2020 than in 2019. According to the Arizona Department of Health Services (ADHS) data dashboard, about 11,528 of these deaths have been a direct result of a SARS CoV2 infection. This suggests that an additional 3,444 deaths during this period may be indirectly attributable to the pandemic.

Arizona’s poor performance relative to the rest of the nation has not been because of bad luck or fate as has been suggested by Governor Ducey and Director Christ. It is largely because of an inability to learn from policy successes and failures, bad decisions, misplaced priorities, and an inability to execute core responsibilities.

We put together a summary of 2020 from a public health policy perspective. Our 10-page report is a timeline of the key critical control points and policy decisions that led us to where we are today. Below is an outline of the events that we cover in our 2020 policy review:

• The Start of the Pandemic in Arizona

• A Successful Stay-At-Home Order

• Stay-At-Home Order Ends With No Mitigation

• AZ Authorizes Hospital Crisis Standards of Care

• The “Pause” of Business Operations Begins

• The “Pause” Ends Without Mitigation Enforcement

• Predictive Modeling Team Asked to Stop Work

• Testing Bottleneck Impairs the Response

• Business and School Metrics Adopted

• Virus Goes Exponential Again

• Lack of Action Blamed on Lack of Safety Net

• Business Operation Standards Scrapped by ADHS

• Arizona’s Testing Debacle

• Second Hospital Crisis Begins

• Year-end All-Cause Mortality Report Presents Grim Picture

• Vaccination Rollout

• The Consequences of Missed Opportunities

Arizona’s experience has been tragic. Everyone lost was a mother, a father, a sister or brother, or son or daughter. They had kids. They left loved ones behind.

Will Humble, MPH

Executive Director,

Arizona Public Health Association

This week’s Public Health Policy Update provides an overview of Arizona’s pandemic experience. Over the last couple of weeks we have put together a couple of documents that highlight the epidemiology and a review of the events of 2020 Arizona’s experience.

Our all-cause mortality report examines total mortality over the course of 2020. Not surprisingly, we found a large increase in all-cause mortality in Arizona during 2020 as compared to previous years. Significant increases in all-cause mortality are seen in June and August with profound increases in July and December. January 2021 will likely be even more deadly than December and July 2020.

Inside our all-cause mortality report you’ll find a table highlighting the percent change between 2019 and 2020. July had the largest percent change, with a 64% increase in all-cause mortality compared to 2019. Total mortality in December 2020 was 61% higher than 2019. All-cause mortality for the year 2020 was 23% higher than in 2019.

Arizona recorded 14,972 more deaths in 2020 than in 2019. According to the Arizona Department of Health Services (ADHS) data dashboard, about 11,528 of these deaths have been a direct result of a SARS CoV2 infection. This suggests that an additional 3,444 deaths during this period may be indirectly attributable to the pandemic.

These additional deaths are likely in part due to the “great displacement” that occurred in 2020 as hospitals were filled to capacity because of the policy decisions that were made by Governor Ducey and Director Christ.

Hospitals have been operating under contingency standards of care for much of 2020 because evidence-based interventions that could have slowed the spread of the SARS CoV2 virus were not implemented by Governor Ducey and Director Christ.

Admission and discharge decisions have been altered out of necessity. Non-emergency procedures have been postponed and canceled during much of 2020.  Tens of thousands (perhaps hundreds of thousands) of procedures were postponed or canceled causing delays in care that may be responsible for many of the additional deaths.

Also, many persons voluntarily delayed care during the 2020 because of fears of coronavirus infections in healthcare facilities. These decisions may have also resulted in deaths indirectly related to the novel coronavirus.

Persons with a host of conditions such as chronic obstructive pulmonary disease may have developed a mild SARS CoV2 infection that worsened their underlying medical condition. Only a more detailed review of the medical record and death certificate would reveal that the coronavirus was a core cause of the death.

The Governor and Director Christ have previously suggested that increases in poisonings and suicide were in-part driving increases in mortality. We could find no such evidence in our analysis.

Here is Dr. Gerald’s Weekly Report. At least things aren’t continuing to get worse. Below is his narrative intro:

In a bit of an unexpected change, conditions markedly improved this past week. Cases as well as hospital and ICU occupancy were lower. Like everyone else, I am looking for a glimmer of hope but don’t want to get my (or your) hopes up as I don’t really understand why things are better. I worry there is the real possibility that this improvement could be short-lived.

It is tempting to speculate what might be occurring. Importantly, improvements appear to be country-wide (see Rt.live). This suggests a common thread independent of geography, climate, or local policy. This thread is likely to be a behavior that is structurally and/or culturally imposed. So, here is me crawling out on a limb…I’m going to put my money on university and K-12 closures over the holiday period (see Haug 2020 Ranking the Effectiveness of worldwide COVID-19 Government Interventions which identifies educational closures are the second most effective mitigation policy).

Arizona basically exited the exponential curve the first week of December following university closures. We saw an actual decline in cases beginning the first week of January following closures of K – 12 for Christmas. Yes, I know actual school activities varied widely across school systems but still. Agree or disagree, I am happy to hear your thoughts. If my hypothesis is true, cases could increase in the coming weeks as schools resume their pre-holiday level of activities.

Evidence Review Reinforces Evidence that Face Masks Work

For many months now, there has been clear evidence that proper mask wearing while in public spaces is a very effective way of slowing the spread of COVID-19. A new study of studies out this week reinforces that evidence. It also establishes that good adherence to mask wearing improves economic activity (GDP). Below is an excerpt from the study.

The available evidence suggests that near-universal adoption of nonmedical masks when out in public, in combination with complementary public health measures, could successfully reduce Rt to below 1, thereby reducing community spread if such measures are sustained. Economic analysis suggests that mask wearing mandates could add 1 trillion dollars to the US GDP.

Models suggest that public mask wearing is most effective at reducing spread of the virus when compliance is high. We recommend that mask use requirements are implemented by governments.

Such mandates must be accompanied by measures to ensure access to masks, possibly including distribution and rationing mechanisms so that they do not become discriminatory. Given the value of the source control principle, especially for pre-symptomatic people, it is not sufficient for only employees to wear masks; customers must wear masks as well.

Editorial Note: Despite the clear evidence that face coverings are very effective Arizona still does not have a statewide mask mandate. A meaningful mandate that focuses on business compliance would have clearly not only slowed the spread of COVID-19 in Arizona but also would have improved economic activity.

Nevertheless, Governor Ducey and Director Christ are not interested in such an intervention. Since they are the persons vested with the authority in ARS 36-787 – Public health authority during state of emergency or state of war emergency it is clear this high return on investment evidence-based intervention will not be used in Arizona.

Below is a summary of Dr. Joe Gerald’s weekly epidemiology and hospital capacity update. You can view his full analysis including all the charts and graphs here. As has been the case for some weeks now, the report paints a dire picture of the pandemic in Arizona due to woefully inadequate mitigation measures.

We continue to urge Governor Ducey and Director Christ to implement evidence-based mitigation measures to slow the spread of the virus (similar to those that were implemented during the summer “pause”). However, at this point, we have no confidence that either of them support any new measures whatsoever despite the dire situation in Arizona hospitals. We expect the virus to continue to rifle through Arizona with reckless abandon until Arizona reaches herd immunity- primarily because of viral infections rather than vaccine induced immunity.

Excerpts from Dr Gerald’s weekly report below:

“The SARS-CoV-2 virus continues to rampage through Arizona. Daily cases and fatalities could double, or perhaps quadruple, before declining under the weight of natural and/or vaccine-induced immunity later this winter. However, the arrival of a more transmissible UK variant could change this calculus for the worse. Arizona’s outbreak remains appallingly bad. A bit of good fortune (or preferably policy action) is needed to gain additional time to vaccinate Arizona’s most vulnerable citizens.”

“As of January 8th, new cases were being diagnosed at a rate of 860 cases per 100,000 residents per week (Figure 11 in todays report). This rate is increasing by approximately 83 cases per 100,000 residents per week. According to the CDC, no other state is currently experiencing faster spread transmission.”

“Arizona is reporting >700 Covid-19 deaths per week (>100 per day) and this count may underestimate true fatalities by half (see Woolf, Woolf, or Weinberger). Many of these deaths were preventable if the state had more aggressively adopted evidenced-based public health practices. Arizona weekly tally of deaths ranks second behind Alabama. Last week’s leader, Rhode Island, has since dropped to 12th.”

“Hospital Covid-19 occupancy has at least temporarily plateaued at record levels this week in the ward and ICU. However, some of this could be attributable to coping mechanisms that are hidden from view.”

“Hospitals continue to postpone scheduled procedures to create additional capacity for Covid-19 patients at the expense of others with serious medical conditions. However, patients who would have been previously hospitalized are undoubtedly being treated in an outpatient setting.”

“Health professionals are being asked to work additional hours and assume duties outside their traditional scope of practice. Shortages and burn-out will degrade our capacity to provide critical care services over the coming weeks.”

“The test positivity rate for traditional nasopharyngeal PCR testing declined slightly this week, dropping from 35% to 33% positivity. This indicates viral transmission is growing more slowly than testing capacity is increasing. Nevertheless, our testing capacity is wholly inadequate to the scale of the problem and other regions.”

Last week was a busy one media-wise for AzPHA- in part because the pandemic is having such a tragic impact in our state. In fact, we are now number one in the world when it comes to viral transmission per capita. Here are a few of the stories that we contributed to this week:

Arizona, Roiled by Covid in Summer, Faces Even Worse Outbreak Now – The New York Times (nytimes.com)

“Only 136 intensive care unit beds are available out of nearly 1,800 statewide, according to state data, but beds are not the most pressing issue, Dr. Bessel said. Staff and resources are. Nurses are being quickly trained in new skills and hundreds of health care workers are being flown in from other states. Still, Dr. Bessel acknowledged, there comes a point when resources can be stretched no thinner and more drastic measures, such as rationing care, might have to be considered.”

As Arizona becomes world hot spot, focus put on governor– The Washington Post

“We have a governor and health director who don’t care. Their goal in my opinion is to vaccinate their way out of this,” said Will Humble, head of the Arizona Public Health Association “Eventually it will work. There’s just going to be a lot of dead people in the meantime.”

Health expert blames Arizona’s COVID crisis on lack of enforcement(ktar.com)

He said that even though thousands of businesses are subject to mitigation rules enacted by the state over the summer, the health department has done just 15 enforcement actions.

“You’re telling me that that’s meaningful enforcement of the mitigation measures? … I can’t say it plainly enough: If we had been doing better enforcement in those indoor environments, then I wouldn’t be sitting here talking on the radio about shutting those businesses,” he said.

“I think their attitude has been, ‘Look, we’re not going to try to mitigate this thing, we’re going to try to vaccinate our way out of it,’” he said.

Arizona has the highest rate of new COVID-19 cases in the US, CDC says(azcentral.com)

“I probably sound like a broken record- but I feel compelled to say again that the situation we now find ourselves in is not because of fate as the governor and state health director suggest,” Will Humble, Arizona Public Health Association director, wrote in a Jan. 3 policy update.

“It is largely because they have been unwilling to implement evidence-based interventions this fall including authentic enforcement of the existing ‘required’ mitigation measures for bars, restaurants and nightclubs. A requirement without enforcement is merely a suggestion.”

Vitalyst Spark Podcast– E57: COVID-19 Roundtable Update – 1/4 | Free Listening on Podbean App

Arizona Horizon | 1-4-21: Slow vaccine roll out 

Glitch in Arizona health’s website temporarily allowed anyone to register for COVID-19 vaccine | Coronavirus in Arizona | azfamily.com

Arizona Vaccine Rollout Delayed by Computer Glitches, County Says | Phoenix New Times

Dr. Christ addresses coronavirus vaccines in Arizona, refuses to take questions about rollout (abc15.com)

“With Arizona being the hardest spot in the world for COVID cases, ⁦@drcarachrist⁩ refuses to take questions after today’s public event.