‘Second wave’ worries health providers

COVID-19 cases spike, but below summer peak

Arizona health providers are braced for stressful months ahead as the state’s COVID-19 numbers are rising and hospitalizations are spiking again.

Compounding their worries are three complicating factors — winter visitors coming to Arizona from areas hard-hit by COVID-19; the upcoming Thanksgiving holiday; and having to compete with health systems in others states for extra, outside skilled hospital labor.

There’s no question about the trajectory of COVID-19 in Arizona — cases are going up, as they are across many parts of the U.S. As of Friday, new cases in the state had eclipsed 1,000 for 10 of the past 13 days, although case numbers are well below what they were in the summer peak.

The Navajo Nation last week warned of “uncontrolled spread” of COVID-19 within more than 20 of the tribe’s communities and ordered two consecutive weekend curfews.

The Yavapai County Community Health Services Department temporarily closed its Prescott office last week because of a COVID-19 outbreak among staff, officials said Thursday, confirming a report from The Daily Courier.

A growing number of school districts in Maricopa County are in the “red zone” for COVID-19, meaning county health officials have designated COVID-19 risk as “substantial” in those areas.

Banner Health officials said the number of people seeking COVID-19 tests at its Arizona State Fairgrounds site in Phoenix doubled over usual numbers last week.

“We are continuing to see numbers going in the wrong direction,” said Dr. Marjorie Bessel, chief clinical officer for Banner Health, which is Arizona’s largest health care delivery system.

“I believe this is a second surge, a second wave. The first wave peaked and

came down, so this is starting to peak as a second surge of that. So I would say this is separate from the first.”

Five weeks ago, Tucson Medical Center had two patients with suspected or confirmed COVID-19. This week it had 50, said Dr. Clifford Martin, an infectious disease doctor who is chief of the hospital’s medical staff.

“What I think has happened is what happens in any long-term effort: People started letting their guards down. We all are feeling fatigued, and as a result, we are seeing the predictable increase again,” he said.

Identified COVID-19 cases in Arizona rose by 1,996 on Friday to 254,764, and known deaths were at 6,109, according to the daily report from the Arizona Department of Health Services.

Banner Health: Winter volumes may exceed summer spike

Forecasting at Banner Health projects the number of patients in its hospitals this winter will exceed the summer surge, when COVID-19 cases overwhelmed medical centers statewide.

Some converted pediatric units and other spaces into COVID-19 areas, and many hospital systems brought in staff from out-of-state.

While forecasting can be subject to change, Banner officials say they are planning for a winter when they are “very, very stretched.”

“As we head into winter it’s respiratory season anyway, and now we have COVID to deal with as well, “Bessel said. “Our forecasts show our total volumes in our hospitals are going to exceed what we experienced with the July and June surge. Not all of that’s COVID. We have all of this other volume, other respiratory illness, and we do expect winter visitors to still come here.”

Hospitalizations statewide for people with confirmed and suspected COVID-19 on Wednesday hit 1,100, which was the state’s highest level since Aug. 17.

“We are definitely surging, there is no doubt about it,” said Judy Rich, who is president and CEO of Tucson Medical Center. “It’s the exponential nature of this that is so hard to predict — how two turns into four and how four turns into 16. Those are the numbers that are just completely unknown to us in terms of the future.”

‘It wears on your heart a little bit after a while’

Some front-line workers were able to take vacations in late August and September as cases slowed. Now they are bracing for busy months ahead, still haunted by the severe illness they saw during the summer.

“Being able to comfort them and care for them is incredibly challenging and it wears on your heart a little bit after a while, especially in the ICU,” said Krista Perry, an ICU nurse in a Phoenix hospital who cares for COVID-19 patients.

“The ones that do survive have significant disabilities. It’s not like we take the ventilator off and they are able to just jump right out of bed and go home.”

Perry said she’s hopeful she and other nurses don’t go back to working four or five 12-hour shifts in a week like she did during the summer. But she knows it may be required.

“The ICU is specialized. There’s not a ton of us that can do that advanced critical care. So we had to pick up a lot of hours,” she said. “It could very easily happen, though, if our numbers spike again the way that they did in July and if the public doesn’t get on board with these very simple measures that are recommended.”

Here are key factors to know about the rise in Arizona cases:

People 20-44 are driving the increase in cases

In a video released Thursday, Arizona Department of Health Services Director Dr. Cara Christ said people in the 20 to 44 age group account for almost 50% of the new cases reported in Arizona over the past month.

“Among this age group, college-age individuals are seeing the highest number of cases,” she said, but added that case numbers groups.

Small household gatherings, gatherings of college-age students and individuals congregating in public spaces are causing transmission, she said in the video.

The vast majority of people who contract the SARS-CoV-2 virus that causes COVID-19 do not get severely ill. But when the virus spreads through a community, it can end up infecting those who are unable to fight off illness, including people undergoing cancer treatment, transplant patients with compromised immune systems and elderly people.

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Winter visitors from hard-hit states could bring the virus with them

The U.S. for the past two days tallied more than 100,000 daily new cases for the first time since the pandemic began. Hot spots for those new infections include North Dakota, South Dakota and Wisconsin — all states with retirees who routinely head to Arizona for the winter.

Christ told The Arizona Republic on Friday that she expects residents from those states and others will be coming to Arizona in the coming months.

“We believe some still will. ... We’re not having the same significant increases of other states, especially in the North, the Northeast and the Midwest,” she said.

“They may be looking at it as going to a place that doesn’t have quite as much transmission.”

She recommends those winter visitors quarantine at home for their first 14 days before going out in public and said the department is working with state tourism officials to get out the message.

“If they are going to be here for a long time, for their safety and the safety of Arizonans, we would recommend that they try to stay at home, because that’s where they’ll be safest, for the first 14 days,” she said. “It’s a recommendation; it’s not a requirement.”

A lot of winter visitors are high risk anyway, so it’s safer for them to stay at home, avoid large groups and make sure any activities with others are outside, she said. She also said it’s extremely important for winter visitors to make sure they get a flu shot.

Arizona isn’t using aggressive COVID-19 policy interventions

Arizona does not have a universal, statewide mask mandate and or the strict requirements for incoming travelers of some other states.

New York state, for example, has travel requirements for visitors from out-of-state, including a COVID-19 test within three days. The state’s website says it has enforcement teams at airports statewide and requests that visitors complete a New York State Department of Health traveler form.

Travelers who leave the airport without completing the form will be subject to a $10,000 fine and may be brought to a hearing and ordered to complete mandatory quarantine, the state website says, adding that travelers going to New York through other means of transport, including trains and cars, must fill out the form online.

All visitors entering Massachusetts, including returning residents, who do not meet an exemption are required to complete a travel form prior to arrival unless they are visiting from a designated lower-risk state.

They must also quarantine for 14 days or produce a negative COVID-19 test result that has been administered up to 72 hours before arrival in Massachusetts. Failure to comply may result in a $500 fine per day, the state’s website says.

Thirty-three states and the District of Columbia have statewide mask mandates, including California, Colorado and Nevada, the AARP says. Arizona allows local jurisdictions to make their own mask requirements but has stopped short of a statewide policy.

The University of Washington’s Institute for Health Metrics and Evaluation estimates Arizona will have 9,151 COVID-19 deaths by Feb. 1 under current policies. If the state had a universal mask mandate, the deaths would be 8,006 by Feb.1, the IHME was projecting Friday.

Health workers have developed COVID-19 support programs

The Arizona Medical Association recently launched a physician peer support program where physicians can talk to other physicians about stressors they are having on the job.

The Virtual Doctors’ Lounge allows physicians to share concerns with someone who understands the daily strain of being a physician, especially with the added emotional stress and hardships stemming from the COVID-19 pandemic, association president Dr. Ross Goldberg said.

“It’s not psychiatry; it’s having a friend who understands what’s going on,” he said. “I see this as one of those impactful, bigger things that we can do because what we’re not talking about is the mental health aspect ... When you see that much significant death, it takes its toll on anyone.”

Another difficult part for doctors is having politicians and members of the general public who aren’t taking the pandemic seriously, he said.

The Arizona Nurses Association developed a support program for nurses that sends text messages to those who sign up. The formal name is RNConnect, but informally it’s known as “psychological first aid.”

Krista Perry is one of 3,000 nurses statewide who participated in the voluntary eight-week program, which included affirmations and links to resources.

“One of the issues nurses have — and it was amplified by working such crazy hours — we would go home from work and we were just exhausted,” she said.

“I don’t want to call a hotline or make an appointment with my providers and seek out care. RNConnect sent the resources to you in little digestible bits — like, one week it was about deepbreathing exercises.”

The cumulative effect of the digestible mental health resources was more powerful than seeking traditional services, she said.

“I would love to see that program to continue. It’s very important that resources are brought to people that are on the front line,” she said.

“What I feel now is I’m scared we’re going to go back. Our COVID numbers are not through the roof again, but we’re seeing reportable COVID deaths right now in our facility.

It’s really hard. It’s tough on the families and it’s really hard to be that person that’s there at that time; it’s just challenging. The end-of-life care for these patients is very challenging.”

Arizona has the 9th-highest COVID-19 death rate in US

The COVID-19 death rate in Arizona was 84 per 100,000 people as of Friday, according to the Centers for Disease Control and Prevention’s COVID Data Tracker, putting it ninth in the country in a state ranking that separates New York City and New York state. The U.S. average is 71 deaths per 100,000 people, the CDC says.

Behind New York City, at 286 deaths per 100,000 people, the CDC reported the highest death rates in New Jersey, Massachusetts, Connecticut, Louisiana, Rhode Island, Mississippi and the District of Columbia.

Moving forward, Rich of Tucson Medical Center said she is not anticipating the same level of COVID-19 death rates her hospital saw in July. Medical providers are better at treating COVID-19, and outcomes are improving, she said.

“I do think that we have learned a lot in the hospital about how to care for the patients, how to intervene earlier, so our length of stay is lower,” she said. “Our ability to manage these patients has been fine-tuned. We’re still having people die from this disease but not in the way it was in the early months.”

The difficulty with COVID-19 is that it’s so hard to predict who it will affect in a severe way. Older patients and patients with underlying health conditions are more likely to get extremely ill from COVID-19, but there are always exceptions.

For example, a 35-year-old bodybuilder from the Gila River Indian Reservation ended up spending 20 days in a Phoenix hospital for COVID-19, including two weeks on a ventilator. He had no underlying health conditions and told the Arizona Republic that he never thought him very sick.

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Thanksgiving could exacerbate the spike

Thanksgiving brings together all the factors that the coronavirus loves, Bessel said — people coming together, often congregating for hours, sometimes traveling and staying in relatives and friends’ homes, and taking off their masks to eat.

“Certainly the safest thing to do is to only celebrate with your nuclear family that you are already living with, that is kind of your own circle, so that you are not breaking that circle or introducing new factors,” she said.

“It’s a really tough message. I get it. People are tired. They are very fatigued about all of this. My message is that we still have a little ways to go here. Look forward to Thanksgiving of 2021, when life will certainly be different from what Thanksgiving 2020 looks like.”

Small gatherings appear to be driving the spread of coronavirus in Arizona right now, Bessel and other health experts said.

“It’s not the people you live with every day and you guys are deciding to go out to dinner, or have a backyard picnic,” Bessel said. “It’s when you invite your cousins or your aunt and uncle that you haven’t seen in awhile.”

That puts Thanksgiving “right square into a very potentially difficult holiday for the spread of COVID,” she said, and also goes against how many people traditionally celebrate at Thanksgiving.

“For me it kind of becomes reminiscent of Memorial Day weekend and what happened in the aftermath of that,” Bessel said.

One factor Arizona does have working in its favor is the weather.

While people on the East Coast are increasingly moving indoors because of cold temperatures, many Arizonans are beginning to move outside as our tripledigit heat goes away. For that reason, it will be easier for people to eat outside, which creates a lower risk than being inside.

The CDC recommends avoiding these high-risk activities around the Thanksgiving holiday:

● Going shopping in crowded stores just before, on, or after Thanksgiving

Participating or being a spectator at a crowded race

Attending crowded parades

Using alcohol or drugs, which can cloud judgement and increase risky behaviors

● Attending large indoor gatherings with people from outside of your household

It’s not too late to flatten the curve

The growth in Arizona cases right now is incremental rather than exponential, Bessel said, which differs from early June, when cases were spiking at a more rapid rate. There’s still time to flatten the curve.

Rich of Tucson Medical Center said, “It doesn’t have to continue like this.”

Goldberg of the Arizona Medical Association said if everyone wore a mask, got a flu shot and followed social distancing guidelines, the curve of new cases in Arizona would be far more likely to go down or flatten, instead of going up.

He cited a recently published state study that showed COVID-19 cases in Arizona went down 75% after most cities and counties enacted mask requirements in June.

“We all do what we need to do to maintain, but there is a concern if we go back, about the stress that puts on us,” said Goldberg, who is a general surgeon at Valleywise Health in Phoenix.

Unlike some other health professionals, Goldberg doesn’t categorize what’s happening in Arizona right now as a surge. He calls it a “warning bell” that we all need to be following prevention guidelines.

“I think if we’re smart about it and everyone participates, we could get ahead of this thing,” he said. “Wear a mask, maintain physical distancing, get a flu shot. All of these together help.” Altavena, Steinbach