Elective Procedure Ban Partially Lifted

Arizona’s hospitalization data and the predictive models have consistently shown that there is enough hospital bed and ICU capacity overall with a margin of safety (except for a hot spot in the northeast part of the state).  The overall safety margin for hospital capacity and the improving PPE situation means that hospitals should now be able to safely make their own decisions about what procedures to allow. 

Last week the governor declared that elective surgeries can resume if hospitals meet certain criteria starting May 1, 2020. We support this decision. 

This change will be a very good thing for many Arizonans who have been waiting for important procedures that have been canceled and or delayed. There is a common mis-perception that elective procedures are cosmetic procedures. That’s not the case, the vast majority of elective procedures are important surgeries like hip and knee replacements, and some kinds of cancer and cardiac surgeries etc.

Medical facilities can now ask the ADHS permission to proceed with elective procedures if they meet some criteria like:

  • Having more than 14 days worth of personal protective equipment for medical staff on hand;

  • Maintaining adequate staffing and bed capacity;

  • Screening staff, patients and visitors for COVID-19 symptoms;

  • Developing discharge plans for patients being transferred to nursing facilities that include COVID-19 testing; and 

  • Implementing an “enhanced” cleaning process for waiting areas.

You can read the governor’s announcement here.

Suicide Surveillance Report from Pima County

It’s no secret that economic distress and social isolation are risks factors for suicide. Mark Person from the Pima County Health Department published a suicide surveillance report with some disturbing results. Normally I would do some interpretation of the data- but in this case I think I’ll provide some excerpts from the surveillance report.

Recent suicide data has displayed a spike in the number of deaths recorded in Pima County for the first 28 days of March 2020. The sharpest increases were observed over the second half of March when 15 suicides were recorded in a 14-day time frame for an average slightly above one per day. This spike was more than double the amount from the previous 14 days

Although we cannot accurately estimate how much of this increase is being influenced by the current environment, we have been able to verify through record review that several of these deaths were influenced by isolation and the constant stream of negative media which exaggerates the sense of risk and fear associated with the COVID-19 pandemic.

For these reasons, this alert also comes with a reminder of the psychological trauma that occurs as a result of exaggerated reporting and misused statistics presented out of context. This paired with uncertainty, financial stress, isolation, and reduced access to resources has placed all of our most vulnerable populations at a much higher risk than usual. The current statewide response to the pandemic is rightfully aimed at protecting individuals most susceptible to the virus.

However, given what we know about isolation, poverty, and the profound influence of social media, it’s of equal importance to focus on our most vulnerable populations who are absorbing a disproportionate amount of the consequences stemming from social distancing and financial decline.

The Number of Diagnostic Kits is Expanding

The FDA has a very streamlined process for authorizing the emergency use of a host of testing kits for the novel coronavirus (2019-nCoV).  Some are the classic PCR tests and some are antibody tests (IgM and IgG).

So far there are 30 different tests on the Emergency Use Authorization list.  Here is a link to the FDA’s  Test Kit Manufacturers Table which includes the manufacturer and their contact information, fact sheets for providers and patients and instructions.  

Guidance on COVID-19 Case Finding & Contract Tracing

The Association of State and Territorial Health Officials collaborated with Johns Hopkins University to produce A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US. The report calls for a robust and comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case, and outlines a vision—complete with resources and specific action steps—to accomplish this goal. Here’s the media release.

Also, the Singapore Ministry of Health has built a Contact Tracing App that conducts scaled contract tracing and involves public engagement in the process. They recently announced they’re making it open source.  The advantage of something like this is its value in identifying pre-symptomatic contacts, while maintaining confidentiality. 

I downloaded the App to test it out but couldn’t activate it because on the verification screen they have Singapore’s country code hard wired.

Federal Government Issues Reopening Guidelines

The federal government issued new guidelines to help state and local government officials with decision criteria to consider to relax some of the interventions currently in place without jeopardizing public health from exceeding hospital treatment capacity.

It’s a three-phase set of guidelines for governors and others to consider with the goal of mitigating the risk of resurgence and protect the most vulnerable. The guidelines specify symptoms, cases, and hospital capacity criteria that must be satisfied before proceeding to a phased comeback.

Take a look at the guidelines for yourself.  My take was that it is reasonably well thought out but there wasn’t any gating criteria emphasis (page 1) regarding diagnostic and antibody testing availability. 

That seems like a pretty big oversight to me- as testing availability is important for contact tracing (once community spread wanes).  Widespread accurate antibody testing is also important information for businesses to have access to as they plan their individual re-openings.

The guidelines don’t even mention predictive modeling as a gating criteria component.  Predictive modeling can provide important information for decision makers- arguably more important than the information provided by looking at simple trends in case counts (gating criteria number 2).

There’s also a big emphasis on syndromic survieillance in the gating criteria that (in my opinion) is given too high of a priority. I would have replaced the syndromic surveillance gating criteria with predictive modeling outcomes.

Serology Study Suggests Infections Greatly Exceed Confirmed Cases

A new serology (antibody) study conducted in Santa Clara County suggests that COVID infections are 25 to 50 times higher than the number of confirmed cases.  During the study period, SC county had 1870 cases and 73 deaths reported among its 1.7 million residents. The serology study estimated that 2.5% – 4.2% of county residents have been infected – which converts to between 48,000 – 81,000 total infections…  exceeding the number of known cases by a factor of 25–50.

If confirmed, this would suggest the overall infection fatality ratio would be approximately 0.1 – 0.2%, much lower than the current overall estimate.

Note:

The University of Arizona will begin providing antibody tests for 250,000 health care professionals and first responders who are on the front lines in the battle against COVID-19.  The UA will administer the antibody tests to check for antibodies through an individual’s blood sample to determine if they were exposed to COVID-19, had the virus and recovered.

I didn’t see when this actual work will begin, but that’s probably because there will be some type of approval that needs to happen first. These results will be the first good look we have into where we really are when it comes to herd immunity here in AZ.

Maricopa Association of Governments Produces Health Assets Viewer

The Maricopa Association of Governments Regional Analytics team has developed a statewide health assets viewer to assist with coordinating the COVID-19 response.  The new tool features population concentrations; a vulnerability index based on demographics such as age, income and access to medical care and technology; congressional and legislative districts; medical care locations with contact information and bed capacity; and weekly charts with the number of cases per county.  Users can sort the information by county, jurisdiction, or zip code.

Remdesivir Study Shows Lower Mortality Rate in Severe COVID-19

Remdesivir is emerging as an early leader in the quest for antiviral medications against SARS-CoV-2, the virus causing COVID-19. Overall mortality in treated patients was 13%, lower than in previously published studies of non-treated COVID-19 patients with serious symptoms.

Results from a clinical study showed that clinical improvement was observed in 68% of patients (36 of 53). The trial’s findings, funded by the drug’s manufacturer Gilead Sciences, were published in the New England Journal of Medicine.

Evidence Mounts that Existing AZ Hospital Capacity is Adequate with a Wide Margin of Safety

Evidence continues to mount that the public’s social distancing measures are slowing the spread of new COVID-19 infections in AZ, and that existing hospital capacity is adequate with a wide margin of safety.

The newest run of the IHME model predicts that Arizona has already reached our peak hospital demand (with the in the last few days). Future demand is predicted decline slowly over the next 4 weeks. The model no longer shows any scenarios in which capacity is likely to be exceeded (in the short-term).  Importantly, this model outcome assumes that we continue to maintain our social distancing efforts over the coming weeks.

Our statewide mitigation success provides policy makers with an opportunity to revise some earlier policy decisions that will improve public health while continuing to ensure that Arizona has the hospital surge capacity to meet peak demand for patients with COVID-19. 

Elective Procedures

The resulting safety margin for hospital capacity and our hospital system’s improving planning regarding the use of personal protective equipment provides an opportunity to relax the limitations on elective procedures under Executive Order 2020-10. We believe that adjusting Executive Order 2020-10 to allow hospitals to conduct elective procedures would improve public health outcomes for patients and allow for continued adequate surge hospital capacity.

Hospital Capacity

Under Executive Order 2020-16, Arizona hospitals have already implemented plans to increase hospital capacity by 25%. The Order further directs that hospitals implement an additional 25% increase by April 26. Given the success of Arizona’s control measures, and the predictive models suggesting that Arizona already has adequate capacity to meet peak demand, we urge the suspension of E.O. 2020-16 (the directive that Arizona hospitals increase capacity by another 25% by April 26).

Alternate Care Sites

The State has been preparing to stand up alternate care sites to handle the surge that was expected using model runs from a month ago (e.g. opening the closed St Luke’s Hospital).  Data and predictive modeling is now making it clear that scaled alternate care sites won’t be needed- and those financial resources and staff effort would be better served by improving testing and contact tracing capacity in my opinion.

Follow-up Hydroxychloroquine Studies Disappointing

While Hydroxychloroquine showed some early indications that it may be helpful as a therapy to treat COVID-19 – recent trial results suggest that it’s probably a dead end.A French study this weekshowed that the drug is not clinically efficient for use of patients with COVID-19. The study retroactively looked at the medical records of 181 patients diagnosed with COVID-19 and whom developed pneumonia and required oxygen.

Forty-eight hours after being admitted, 84 patients were given Hydroxychloroquine and doctors found that there was no statistically significant difference in death rates. A side effect of taking of the drug is abnormal heart rhythms.

While a small study, it shows that this drug may not be suitable to use on COVID-19 patients. Additional studies are needed with larger sample sizes. This study has not been peer-reviewed and does not state how long patients remained in the hospital or have symptoms after taking the drug.