Virus Notes: May 23, 2020: Greed and Grudge Punch and Judy Show

MERCED (BLJ) – Merced County Public Health Department on May 22 reported 251 cases and six deaths.

California reported 90,631 cases (2,187 new) and 3,708 deaths (78 new).

The global report for May 23 was 5,267,452 cases (99.091 new) and 339,949 deaths (4.013 new).

On May 23 the tally for the Four Horsemen (Trump, Putin, Bolsonaro, and Johnson) was:

United States reported 1,652,157 cases (27,091 new) and 97,176 deaths (1,270 new).

Russia reported 335,882 cases (9,434 new) and 3,388 deaths (139 new).

Brazil reported 341.048 cases (21,979 new) and 21,682 deaths (1,141 new). Brazil pulled ahead of Russia in the latest report this weekend.--blj

United Kingdom reported 257,154 cases (2,959 new) and 36,675 deaths (282 new).

 

A Desert Sun analysis suggests more than 40% of California counties do not meet the state's contact tracing reopening standards and 94% do not meet the testing metric, based on information provided by responding counties. Both metrics allow county health departments to identify cluster outbreaks and prevent those clusters from catalyzing. 

“Without that you can’t even have a strategy because you’re just playing catch-up, which is what we’ve been doing the last several months," said Dr. Thomas Tsai, an assistant professor in health policy and management at the Harvard School of Public Health. – Olalde and Hayden, Palm Springs Desert Sun, May 19, 2020.

 

This observation orients Californians to the dangers ahead:  without adequate testing, contact tracing is almost meaningless. Secondly, throughout the state, local government is responding mainly to those “shock troops of the Right,” chambers of commerce, organizations who do not care for your health, they just want your money. And, of course, there is City of Atwater, a very special community. Business is compelling local government to resist the remarkably effective strategies against the virus that Gov. Gavin Newsom has enacted.

Just south of the Bay Area, for example, San Benito County barely met the state's criteria but was approved on Wednesday to begin reopening some nonessential businesses. At the same time, San Benito County Health Officer David Ghilarducci, continues to preach caution.

“We got lucky here in California,” he said. “We got lucky because we were able to buy some time before hospitals were hit with cases, and it would be a shame to loosen up restrictions too soon and lose that progress.” -- Olalde and Hayden, Palm Springs Desert Sun, May 19, 2020

Dr. Rebecca Nanyonjo-Kemp, director of the Merced County Public Health Department, stressed in her address to the county Board of Supervisors last week, the need to avoid fragmenting “the cadence of  the narrative,” which confuses the citizens.

The citizens might have thought the narrative of the pandemic was a waltz and not a foxtrot.

The director, it should be noted, is not a physician; she has a PhD in public health, a curriculum designed for the administration of public health bureaucracies, not to personally care for any patients. Before coming to Merced County, she was public health director for the Princess cruise-ship line, of off-shore San Francisco fame earlier this year.

The director has public-relations analytical tools, but she lacks historical perspective; namely, she doesn’t know Atwater, a community fragment that has been angrily buzzing around the county like an outcast hornet ever since it was abandoned by the US Air Force. Its medical advisor is neither an MD or a PhD but an OD, an osteopathic surgeon.

And, fragmentally speaking, we haven’t even gotten to the west side of the county yet.

The county supervisor representing Atwater is the prevailing Voice of Numbnut Knuckleheads throughout the county. Next to his soaring oratory, the Germ Theory never had a chance. Louis Pasteur is just an old, dead French anti-Trumpster.

The health director and the indispensable  Dr. Salvador Sandoval issue various directives allowing more businesses to reopen and you can practically hear them wring their hands at the medical consequences of political economic greed and grudge compelling them to pull their medical punches.

These two social pathologies “trump” the only known effective defenses against the virus:  sheltering in place and social distancing to protect yourselves; wearing masks in public to protect others. testing and contact tracing. These pathologies are the greed of the haves for more, and the grudge of the have-nots for not having more. Decent people can only choose for the have-nots, and the argument will go on and on, injustice being the rule of the land.

But a new leader has emerged, stronger than all our leaders – medical and political -- and this little fellow (you can’t see him with the naked eye) exacts an absolute justice from which neither the feudal agribusinessman of the west side or the lowest malingering Atwater whiner is exempted. -- wmh

 

5-19-20

Palm Springs Desert Sun

California playing catch up on coronavirus contact tracing as counties push to reopen

Mark Olalde and Nicole Hayden,

Testing and contact tracing are key tools for limiting coronavirus spread as some activity and business closure restrictions are lifted — but most California counties are falling short on both, despite widespread approval of reopening requests.

Gov. Gavin Newsom on Monday relaxed some requirements for certain metrics — number of deaths and cases per 100,000 residents — saying he expects 53 of the state's 58 counties to receive approval to move into the second phase of Stage 2 reopening.

Counties now must have no more than 25 cases per 100,000 residents over a two-week span or no higher than an 8% positive rate among people testing for the coronavirus to qualify. 

Officials in more populous counties that had failed to meet the more rigorous criteria — including every county in Southern California, the Bay Area and all but one along the Central Coast  — are now hopeful that their requests will be approved.

However, contact tracing and testing metrics, which require a minimum daily rate of 150 tests per 100,000 residents and at least 15 contact tracers per 100,000 residents, hint otherwise.

A Desert Sun analysis suggests more than 40% of California counties do not meet the state's contact tracing reopening standards and 94% do not meet the testing metric, based on information provided by responding counties. Both metrics allow county health departments to identify cluster outbreaks and prevent those clusters from catalyzing. 

“Without that you can’t even have a strategy because you’re just playing catch-up, which is what we’ve been doing the last several months," said Dr. Thomas Tsai, an assistant professor in health policy and management at the Harvard School of Public Health.

The state is pushing counties to expand testing and contact tracing resources after the Centers for Disease Control and Prevention found that California's efforts failed at the outset of the virus, according to a CDC report. Travelers from Asia quickly maxed out the state's capacity to follow the spread as cases began popping up in February and March.

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A health care worker swabs the mouth of a woman for a coronavirus test at a walk-up testing site at Cathedral City library in Cathedral City, Calif. on Tuesday, May 19, 2020. (Photo: Vickie Connor/The Desert Sun)

In California, 80,430 people had tested positive for COVID-19 and 3,302 had died due to virus-related complications as of Monday. The state's per-capita testing rate was in the top half of the country last week, and was more than twice as high as neighboring Arizona and Oregon.

Testing rates across California, however, are uneven.

The Desert Sun reached out to all 58 counties in California to request: a count of each jurisdiction's contact tracers, how much these programs will cost, and the number of tests conducted in each county in late April and early May. Testing data, used to calculate daily testing rates for three weeks, may be incomplete due to lack of reporting requirements for public and private labs.

Thirty-nine counties provided information about contact tracing resources. Six counties either did not report coronavirus testing data, did not respond to The Desert Sun's request for data or only provided partial data. Those counties include Alameda, Alpine, Sacramento, San Joaquin, Siskiyou and Tulare counties.

About a quarter of California counties conducted fewer tests per day in the most recent week of The Desert Sun's analysis than they did a week earlier, suggesting that testing efforts might already be slowing in some areas like Solano, Plumas and San Luis Obispo counties.

Some jurisdictions are struggling to acquire vital testing supplies, and train or hire contact tracers. For some counties, the cost is burdensome. Merced County says the state's requirement is too high, while Placer County hopes state-provided resources will fill in their gaps, though state-promised technology has yet to be released.

How contact tracing works

While Newsom relaxed some reopening metrics this week, contact tracing and testing capacity requirements remain stringent. Counties must show:

A minimum daily rate of 150 tests per 100,000 residents

At least 15 contact tracers per 100,000 residents

Contact tracing works like this: As soon as a lab reports a positive coronavirus test to the county public health department, staff reach out to the patient and everyone in their household. Then, they work backwards to determine who the patient might have had contact with up to three days before the onset of symptoms. Those people are instructed to self-quarantine.

Every “reasonable effort” is made to track down potentially exposed individuals, said Brooke Federico, Riverside County spokesperson. During the conversations with the potentially exposed, tracers determine the individuals’ priority for testing based on symptoms and medical history.

“Oftentimes, the contact tracing will reveal that maybe there was a gathering or a household or workplace that we need to dig into," San Benito County Health Officer David Ghilarducci said.

Public health officials expect to identify about 10 potential contacts for every positive case they trace, according to Suzanne Grimmesey, Santa Barbara County's chief quality care officer.

State far below goal for tracer workforce

Approximately 3,000 staff from county health departments across the state are involved in contact tracing. That means statewide there are fewer than eight contact tracers per 100,000 residents, far below the state's own target metric of 15 per 100,000 residents.

The governor set a workforce goal of 10,000 in the first phase of Stage 2 reopening, and a total of 20,000 as a second goal, according to a state spokesperson.

While phase one of Stage 2 currently allows retail and restaurants to offer curb-side pick-up, phase two of Stage 2 would allow other services such as limited dining-in at restaurants, if individual counties win state approval.

Later, a state spokesman said "the specific goals are important for the reopening of California, but are not tied to specific phases of the reopening." How the Newsom administration is going to treat populous counties seeking to accelerate reopening remains unclear. For example, Riverside County's data show it at 98 tests per 100,000 and two contact tracers per 100,000, both far from the state's "stringent" metrics. 

Despite the state's push for expanded resources, at least three counties — Del Norte, Placer and Tehama — have been approved to move forward into the second phase of Stage 2 with an inadequate numbers of contact tracers, based on Desert Sun analysis and attestation forms filed with the state. These counties, however, did lay out plans to work toward required numbers in the future.

Many of the counties that hit the state's contact tracing benchmark are smaller, rural counties.  Alpine, Mono and Modoc counties had the highest number of tracers at 177, 173 and 170 per 100,000 residents, respectively. Larger metropolitan areas, like Sacramento, Riverside, San Bernardino and San Diego counties, were far below the metric with just two or three tracers per 100,000 residents.

Some county health officials question whether the state has set its standards too high.

Merced County, for example, doesn't have enough contact tracers to meet the state's criteria, but Kristynn Sullivan, the county's supervising epidemiologist, says staff is already meeting the need and is able to trace all a patient's potential contacts within 24 hours.

"This is another place where the state requirement is a lot, actually," Sullivan said. "With the number of cases we’re having per day, we have people doing other things.”

The state’s contact tracing metric does not require every tracer be full-time. This means counties can reassign current staff to take on contact tracing duties.

Placer County, for example, only has about a quarter of the necessary tracers, but its attestation form was approved as it plans to increase its capacity four-fold in the coming weeks. It is also requesting staff from the state to help alleviate that burden, said Katie Combs Prichard, county press officer.

A state spokesman would not say how many state contact tracers are available to support individual counties, but said the state will be redirecting state staff in six-month deployments to assist local health departments.

Counties trying to address resource burden

Contact tracing isn't cheap. 

Sacramento County has budgeted $400,000 “to help support staff surge for response activities including but not limited to contact tracing,” county spokesperson Janna Haynes said. Sacramento County, like many other jurisdictions, expects to be reimbursed through federal emergency dollars from the CARES Act, which includes funding for contact tracers. The county's 30 total tracers equates to just two per 100,000 residents, falling far below the state's standard.

Elsewhere, Tulare County already has spent $288,160 on 33 contact tracers, or seven per 100,000 residents, which is also inadequate according to state metrics. 

Other counties are considering using volunteers to close the gap. 

San Diego County has only a third of the contact tracers required to reopen. While county officials anticipate tracers will be paid, they have received many volunteer offers from trained medical professionals in the community, said Sarah Sweeney, San Diego County spokesperson.

The California Department of Public Health has launched an online training academy to help counties grow their arsenal of contact tracers. The system is able to train 1,000 people each week, but some smaller counties vying for limited seats were only able to secure two or three spots in the virtual training sessions in the upcoming weeks.

Experts: Digital contact tracing is needed

Experts say that calling every infected person might prove too onerous a task to be handled by an inadequate supply of contact tracers.

There's some hope the state will release an app that will provide additional tools to better conduct contact monitoring and data collection. San Francisco-based software company Salesforce has partnered with the state to work on this, a company spokesperson confirmed, but he declined to provide further details about the project.

Combs Prichard, Placer County press officer, said the technology platform "will facilitate communication between state and local contact tracing teams and allow ongoing, automated monitoring of cases and contacts.” 

A spokesman for the state declined to provide details about the technology platform.

There's also talk of apps that tell users whether they came in close proximity to someone carrying the virus. Google and Apple in April announced a partnership to build contact tracing directly into smartphones. 

Creative technology-based solutions will inevitably become necessary to fully trace viral transmission, although individual civil liberties need to be taken into account, Tsai said.

“We clearly need a digital strategy as well because the manpower needed for doing phone-based contact tracing might not be enough," he said. "Obviously, there are privacy concerns, but we need to open up all the tools we have in the toolbox.”

Testing improving, but still insufficient

Effective contact tracing isn't possible without robust coronavirus testing efforts. A single test is the catalyst for a contact tracing investigation which then often leads to a need for additional testing. Each county needs enough testing resources to support that full arc of response and mitigation.

Like contact tracing, Newsom's testing requirements remain firm, yet the majority of counties are still lagging behind the state's testing reopening metric.

Toward the end of April, California was conducting about 52 tests per day per 100,000 residents. That number rose to 79 in early May and to 95 this past week. Even that number is a long way from the 150 tests per day per 100,000 residents that Newsom is targeting. 

Only three counties — Marin, Mariposa and San Francisco — exceeded Newsom's standard of 150 tests per 100,000 residents per day as of May 11, according to The Desert Sun's analysis. 

Riverside County proved to be a bright spot, with its daily testing rates rising 32% to nearly 100 tests per day per 100,000 residents. Meanwhile, nearby Los Angeles County, which has seen nearly 1,700 COVID-19 deaths and did not respond to multiple requests for comment from The Desert Sun, is far behind at 61 tests per day per 100,000 residents — less than halfway to the state's metric.

San Bernardino County — home to more than 2 million Californians — remains one of the most egregious case studies of testing failures, as it is pushing aggressively to reopen yet has the lowest testing rates across all of Southern California. As of mid-May, the county was still only testing at a third of the rate necessary to move into the second phase of Stage 2.

And nearly one in 10 coronavirus tests in San Bernardino County is coming back positive, which is 2.5% higher than the state as a whole, and an indication that the virus is still spreading.

San Bernardino County officials did not answer The Desert Sun's questions regarding contact tracing or testing.

Elsewhere across the state, shortages in testing supplies persist 20 weeks after the virus was first known to infect human populations.

In San Benito County, health officer Ghilarducci said an order for testing swabs was filed through the state. The county only recently received just 10% of what they requested. 

“I also understand that some of our hospitals are running machines to do testing, but they don’t have enough chemicals to do the tests,” Ghilarducci said. “There are still supply issues along the whole chain of testing. We are getting better, but we are not there yet.”

The California Department of Public Health had accepted applications from 24 counties for a variance from statewide reopening criteria before taking down the public site on Monday.

Placer County, with about 400,000 residents, is by far the most populous county to earn state approval. Together, the 24 counties that had been added to the list through Saturday have fewer than 2 million combined residents, only 5% of California's population.

Tsai, the doctor and researcher affiliated with Harvard, explained that less densely populated rural counties don't require the same per-capita tracking and mitigation efforts as their urban counterparts. For example, he said, "it didn’t make sense to have the same testing capacity in rural Idaho as it did for Brooklyn."

However, in interviews with The Desert Sun, local public health officers expressed an acceptance that there would be a second wave of cases once society reopened. The question, then, is whether area hospitals have excess surge capacity. 

And with lower numbers of beds in hospital and intensive care units, "the rural areas are the most at-risk of being overwhelmed," Tsai said.

Just south of the Bay Area, for example, San Benito County barely met the state's criteria but was approved on Wednesday to begin reopening some nonessential businesses. At the same time, San Benito County Health Officer David Ghilarducci, continues to preach caution.

“We got lucky here in California,” he said. “We got lucky because we were able to buy some time before hospitals were hit with cases, and it would be a shame to loosen up restrictions too soon and lose that progress.”