Is Arizona ready to reopen?
Ducey says the state meets White House guidelines to proceed
Arizona is entering its first phase of reopening after Gov. Doug Ducey said the state meets White House guidelines and it is time to “turn that dial on the economy.”
Those White House guidelines establish three phases of reopening after certain conditions are met on new coronavirus case numbers, hospitalizations and testing.
“This is a green light to continue going forward on the way out of this pandemic,” Ducey said at a news conference on Tuesday. “Now, this is not a green light to speed. This is a green light to proceed, and we’re going to proceed with caution.”
Each phase gradually opens more social activities. If the numbers don’t rebound after two weeks, the state then can move into the next phase, according to the guidelines.
But absolutes are elusive, both for state data and the White House guidelines.
For example, the governor and Dr. Cara Christ, the state health director, couldn’t say whether Arizona had reached a peak in cases.
“Has it peaked or not? Well, I don’t know. That’s what we’re doing is preparing for the worst-case
scenario,” Ducey said.
In some instances, the White House guidelines provide little detail on what exactly each criteria means or how to define it.
For example, the guidelines say patients must be treated without “crisis care,” but what that entails is not defined.
They also call for “robust” testing of health care workers, but what constitutes “robust” remains subjective.
The U.S. Centers for Disease Control and Prevention drafted a more thorough 17-page reopening document but it was shelved by the White House before publication, according to the Associated Press. The CDC report recommended criteria and specific health-focused steps for reopening schools, faith organizations, restaurants and bars and mass transit.
Arizona has chosen the White House reopening criteria and has not added other measurements. The state is not relying on any Arizona-specific criteria in its reopening decisions, Ducey spokesman Patrick Ptak said.
In other states, including New York, governors have set out criteria for how they will track their states’ ability to manage the disease. New York Gov. Andrew Cuomo has detailed several steps, such as hospitals need 30% capacity available, regions should have 30 contact tracers per 100,000 people and 30 tests should be administered per 1,000 people per month.
Ptak said the governor’s office works regularly with state and federal health officials to monitor Arizona data, particularly involving activity in hospitals.
It takes about two weeks before new COVID-19 cases are reflected in state data because of reporting lags and the time it takes for symptoms to appear, so the public won’t know how the reopening will affect the number of cases until a couple of weeks into the process.
Hospitalization data could show any potential effects of reopening sooner.
A major increase in testing in Arizona also makes it harder to evaluate the situation. It is difficult to tell whether the state’s case numbers are increasing because testing is more available than it was previously, or because the disease is spreading.
Some deaths that occurred weeks ago are just now being added to the state’s dashboard, making it difficult to measure if fatalities are increasing or not.
The three criteria necessary before a phased reopening are a decline in symptoms at hospitals, a decrease in cases or positive tests and adequate treating and testing, the White House guidelines say.
Here’s more details and how Arizona is doing in each area as it prepares to reopen.
Symptoms at hospitals declining
Criteria: “Downward trajectory of influenza-like illnesses reported within a 14-day period AND downward trajectory of COVID-like syndromic cases reported within a 14-day period.”
How Ducey says Arizona meets this criteria: Ducey said Arizona clearly meets the criteria on declining symptoms.
What that means: Arizona’s data dashboard shows the percentage of hospital inpatient and emergency visitors who reported COVID-like or influenza-like illnesses. Both markers have decreased steadily in recent weeks, although the most recently available data is from the week of May 3. Over the 14-day period from April 19 to May 3, Arizona hospitals saw a decreasing percentage of visitors with COVID-like or influenza-like illnesses.
Symptom surveillance for COVID- and influenzalike illnesses is compiled by hospitals by tracking terms and codes in the patient’s reason for the visit as well as diagnosis codes signed by health care providers. Information is stored in a national CDC online platform that allows for the rapid evaluation of health information to understand syndromic data, meaning people showing symptoms, across regions and the spread of disease.
What’s missing: Influenza season ends in April, so influenza-like illness reports have gone down since then, regardless of any correlation with COVID-19. Data is not yet available for dates after May 3, so it’s not clear what recent days have looked like for hospital-reported illnesses.
Percent-positives of all tests dropping
Criteria: “Downward trajectory of documented cases within a 14-day period OR downward trajectory of positive tests as a percent of total tests within a 14-day period (flat or increasing volume of tests).”
How Ducey says Arizona meets this criteria: Ducey said the trend of cases alone doesn’t show the necessary trend to meet the White House guideline. But because the guidelines offer an either/or option, Arizona only needs to meet one of the two criteria.
The guidelines do “provide an either/or,” Ducey said, citing the state’s surge in testing.
“With more testing, you are going to naturally see more cases,” he said. “So what we want to measure is what percentage of those tests result in COVID-19.”
What that means: Percent positive is defined by the percentage of positive test results out of all COVID-19 testing completed in Arizona. Overall, 7.5% of all diagnostic tests performed in Arizona have come out positive. That overall percentage has dropped steadily over recent weeks and days, likely as more and more people have gotten tested. As of the week of March 1, 12% of tests were positive. By the week of March 8, just 3% of all tests were positive for COVID-19. The overall percentage of positive tests rose gradually until hitting 11% the week of April 12. The percentage has been declining since then and reached 6% the week of May 3.
What’s missing: The number of cases in Arizona has generally increased over time, with a few dips day to day.
The governor is correct that the percent of positive cases has decreased over time. But that is likely to happen as testing increases rapidly — as it has with Arizona’s weekend testing blitzes and the relaxation of criteria needed to get tested. When people could only access tests if they had serious symptoms or were high-risk, the percent who tested positive was higher because the bar to meet the testing criteria was higher. With testing more open and available, it stands to reason that the percent of positive tests would decrease.
The White House guidelines offer states the ability to use either cases or percent-positives, and the downward trajectory of cases would be harder for Arizona to meet than the percent of positive tests.
Experts have said that a decline in the percent of positive diagnostic tests alone isn’t enough to show that cases are declining.
“The test positive rate itself isn’t a goal,” Dr. Thomas Tsai, assistant professor in health policy and management at the Harvard Global Health Institute, told The Arizona Republic on May 6. “The goal is to get fewer number of cases, fewer number hospitalizations, fewer people dying from COVID-19.”
During last week’s news conference, Ducey combined diagnostic test results and antibody test results in a slide, which showed a larger decline in percentpositives than the diagnostic results alone show. Both measures show declines in the past two weeks. But combining diagnostic results with antibody results isn’t proper, public health experts say, because the two tests measure different things.
Ducey did not answer precisely why the percent of positive cases was a meaningful measure of the disease spread in Arizona when testing is increasing significantly, despite several questions from the media seeking an answer.
He instead referred back to the White House guidelines, which allow this measure to be used, and said the state has not been testing people “willy nilly.”
He said the percent of positive tests was likely the “most important number” for the state to see.
“That means a decrease in the number of people that are contracting a virus that is already widespread,” he said.
After the news conference, Ptak told The Republic that assuming the percent of positive tests would go down because of increased testing was “predetermining the data.”
“If the percentage of positive cases were going up, it would tell a very different story, and no one would be saying that this isn’t a meaningful statistic,” Ptak said.
“It’s not the only data point with which we’re making decisions, and it’s not the only data point that’s part of the CDC requirements. But it’s one of a handful that give you a full picture. That includes what’s happening in the hospitals, it includes syndromatic cases. We’ve been cautious and careful to work through those gating requirements. They’re set up that way for a reason. They’re set up by the foremost experts in the field, in Washington, D.C., for a reason, and that’s what we’ve continued to have as a guide.”
Hospitals prepared for treating and testing
Criteria: Treat all patients without crisis care AND robust testing program in place for at-risk health care workers, including emerging antibody testing.
How Ducey says Arizona meets this criteria: Ducey said that “Arizona meets the White House gating criteria for hospitals, to put us safely and squarely into phase one.” He pointed to hospital data showing available capacity, the ability to provide additional beds if a surge happens and increased testing.
What that means: Ptak said crisis care would include triaging patients and not being able to meet demand. The state has also increased capacity and has the ability to stand up additional locations, like St. Luke’s hospital, Ptak said. A contractor is currently working to address some needed alterations to the previously closed St. Luke’s to get it ready, should it be needed, Ptak said.
The state currently is able to meet demand in its hospitals, and various models have shown that it will continue to do so, Ptak said. But there’s no specific guideline on hospital capacity that would trigger a response or changes to how the state is operating, Ptak said.
“I don’t have a threshold to give you, but it’s something that we track daily with these numbers that come in. … We’ll continue to make sure Arizona is prepared for these worst-case scenarios, if needed,” Ptak said.
What’s missing: The White House guidelines define neither “crisis care” nor “robust testing.” There is no explanation for what crisis care means, be it triaging, a shortage of hospital beds or anything else.
Nor are there criteria for testing such as how many tests should be completed each day or week per capita or what percentage of the state population must be tested before reopening. For at-risk health workers, there’s no indication of how often testing must occur or how to balance diagnostic and antibody tests for front line health employees.
Arizona has started a program with the University of Arizona, which is conducting antibody testing of health care workers. The university intends to test 250,000 people.
Arizona has routinely fallen toward the bottom — and even briefly landed 51st out of 50 states, Washington, D.C., and Puerto Rico — for diagnostic testing per capita. While testing has increased over the past several weeks, it still trails most states.
As of Tuesday, 122,842 diagnostic tests had been performed, amounting to just 1.7% of the state’s population tested.
Deborah Birx, the White House’s COVID-19 response coordinator, said in mid-April that states and cities should run about 30 tests per 1,000 people per month. Arizona has not met this threshold.
What the White House phases entail
In the first phase, vulnerable people would remain at home. Social distancing measures would remain in place in public areas, and gatherings of more than 10 people should be avoided, the White House guidelines say. Travel should still be avoided if not essential.
Employers would continue to encourage working remotely during the first phase, and common areas where employees would normally hang out would be closed.
More broadly, schools and other youth activities that are closed would remain closed. People still would not be allowed to visit senior living facilities or hospitals. Theaters and other large venues, like sit-down restaurants, could operate if they adhered to strict distancing protocols. Elective surgeries could resume. Gyms could open with distancing and sanitation protocols. Bars would stay closed.
If the disease doesn’t rebound in the first phase, and the state meets the criteria again, states could move on to the second phase and then, if another rebound doesn’t happen, the third.
Phase two can proceed when states satisfy the three criteria a second time and have no evidence of a rebound. Vulnerable individuals should continue to stay home. Employees may continue to telework and physical distancing should be maintained in public, with gatherings of more than 50 people only with appropriate distancing. Nonessential travel can resume, schools and daycare can reopen and large venues can open with moderate physical distancing. Bars can open with decreased capacity.
In the third phase, vulnerable people can start going out more, but should still practice distancing measures, the guidelines say. Low-risk people should “consider” spending less time in crowded environments. Offices wouldn’t have restrictions. Visits to long-term care facilities and hospitals could resume. Large venues can operate with limited distancing. Gyms can remain open and bars can increase standing-room occupancy.
Does state meet White House’s list of responsibilities?
The White House guidelines also include “core state preparedness responsibilities” for reopening. Here’s how Arizona stacks up on these responsibilities:
❚ “Ability to quickly set up safe and efficient screening and testing sites for symptomatic individuals and trace contacts of COVID+ results”: Testing has improved, though some counties say they do not have adequate supplies to test at the proper level. Contact tracing, particularly in Arizona’s more populous counties, needs improvement to fully track contacts.
❚ “Ability to test Syndromic/ILI-indicated persons for COVID and trace contacts of COVID+ results”: This depends on where in the state you are. Some areas of the state say they are able to test and trace, while others are not.
❚ “Ensure sentinel surveillance sites are screening for asymptomatic cases and contacts for COVID+ results are traced (sites operate at locations that serve older individuals, lower-income Americans, racial minorities, and Native Americans)”: It’s unclear if this is happening. Testing should begin to increase at long-term care facilities and prisons, the state said Tuesday.
❚ “Ability to quickly and independently supply sufficient Personal Protective Equipment and critical medical equipment to handle dramatic surge in need”: Some counties say they lack necessary PPE for the current situation, much less a “dramatic surge.”
❚ “Ability to surge ICU capacity”: Arizona has increased ICU beds and has locations in place that can add to capacity, if needed.
❚ “Protect the health and safety of workers in critical industries”: This is a subjective measure. It’s unclear if this is happening.
❚ “Protect the health and safety of those living and working in high-risk facilities (e.g., senior care facilities)”: Long-term care facilities in the state have generally restricted any visitors. ADHS director Christ said Tuesday that the state would be increasing testing of patients and workers at these facilities.
❚ “Protect employees and users of mass transit”: Valley Metro has encouraged customers to use public transit only for “essential or critical” trips. Riders are asked to stay six feet apart from others and are strongly encouraged to wear face coverings. Riders are not able to approach the operator because nearby seats are blocked. It’s unclear what is happening with other mass transit in the state.
❚ “Advise citizens regarding protocols for social distancing and face coverings”: The state has recommended people wear face coverings in public and maintain social distancing. Ducey previously said people should minimize their time accessing spaces like stores and salons and mostly stay at home.
❚ “Monitor conditions and immediately take steps to limit and mitigate any rebounds or outbreaks by restarting a phase or returning to an earlier phase, depending on severity”: No guidelines have been articulated for what would constitute a rebound or how the state would mitigate it.