Legislature(2019 - 2020)BETHEL

07/28/2020 02:30 PM HEALTH & SOCIAL SERVICES

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02:32:28 PM Start
02:33:43 PM Presentation: Covid-19 in Alaska: a Mid-summer Update on Pandemic Response & Containment Strategies
04:38:28 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Location Change --
-- Teleconference <Audio Only> --
+ Presentation: TELECONFERENCED
Covid-19 in Alaska: A Mid-Summer Update
on Pandemic Response & Containment Strategies
-- Testimony <Invitation Only> --
**Streamed live on akleg.gov**
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         Bethel, Alaska                                                                                         
                         July 28, 2020                                                                                          
                           2:32 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Tiffany Zulkosky, Chair                                                                                          
Representative Ivy Spohnholz, Vice Chair                                                                                        
Representative Matt Claman                                                                                                      
Representative Harriet Drummond                                                                                                 
Representative Sharon Jackson                                                                                                   
Representative Geran Tarr                                                                                                       
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Lance Pruitt                                                                                                     
                                                                                                                                
OTHER LEGISLATORS PRESENT                                                                                                     
                                                                                                                                
Representative Sara Hannan                                                                                                      
Representative Bart LeBon                                                                                                       
Representative Mike Prax                                                                                                        
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION:  COVID-19 IN ALASKA: A MID-SUMMER UPDATE ON                                                                       
PANDEMIC RESPONSE & CONTAINMENT STRATEGIES                                                                                      
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
NICHOLAS PAPACOSTAS, MD, Vice President                                                                                         
Alaska Chapter                                                                                                                  
American College of Emergency Physicians (ACEP)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified regarding ACEP's concern with the                                                              
rising number of COVID-19 cases in Alaska and urged a return to                                                                 
bold leadership as the way to flatten the curve.                                                                                
                                                                                                                                
THOMAS HENNESSY, MD, Infectious Disease Epidemiologist                                                                          
Affiliate Faculty Member                                                                                                        
College of Health                                                                                                               
University of Alaska, Anchorage (UAA)                                                                                           
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Provided  testimony regarding  why Alaska's                                                             
COVID-19 epidemic is rapidly worsening.                                                                                         
                                                                                                                                
JARED KOSIN, President & CEO                                                                                                    
Alaska State Hospital and Nursing Home Association                                                                              
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:    Provided testimony  describing  when  the                                                             
healthcare  system becomes  stressed and  advised that  the issue                                                               
before Alaska is the prevention of COVID.                                                                                       
                                                                                                                                
ELLEN HODGES, MD, Chief of Staff                                                                                                
Yukon-Kuskokwim Health Corporation (YKHC)                                                                                       
Bethel, Alaska                                                                                                                  
POSITION STATEMENT:  Provided  testimony regarding the healthcare                                                             
challenges in rural Alaska and  suggested tools for prevention of                                                               
COVID-19 in rural areas.                                                                                                        
                                                                                                                                
ROBERT ONDERS, MD, Acting Hospital Administrator                                                                                
Alaska Native Medical Center (ANMC)                                                                                             
Alaska Native Tribal Health Consortium (ANTHC)                                                                                  
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified that  Alaska is at a critical time                                                             
where decisions need to be made to change the current course.                                                                   
                                                                                                                                
ADAM CRUM, Commissioner                                                                                                         
Department of Health & Social Services (DHSS)                                                                                   
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Testified that DHSS has done  many items to                                                             
protect Alaska and is working with Alaskan communities.                                                                         
                                                                                                                                
ANNE ZINK, MD, FACEP, Chief Medical Officer                                                                                     
Office of the Commissioner                                                                                                      
Department of Health & Social Services (DHSS)                                                                                   
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
titled "COVID-19 in Alaska," dated 7/28/20.                                                                                     
                                                                                                                                
JOE MCLAUGHLIN, MD, State Epidemiologist                                                                                        
Chief, Section of Epidemiology                                                                                                  
Division of Public Health                                                                                                       
Department of Health & Social Services (DHSS)                                                                                   
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
titled "COVID-19 in Alaska," dated 7/28/20.                                                                                     
                                                                                                                                
COLEMAN CUTCHINS, PharmD, BCPS, COVID Testing Coordinator                                                                       
Office of Substance Misuse & Addiction Prevention                                                                               
Department of Health & Social Services                                                                                          
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
titled "COVID-19 in Alaska," dated 7/28/20.                                                                                     
                                                                                                                                
TARI O'CONNOR, Deputy Director                                                                                                  
Division of Public Health                                                                                                       
Department of Health & Social Services (DHSS)                                                                                   
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
titled "COVID-19 in Alaska," dated 7/28/20.                                                                                     
                                                                                                                                
HEIDI HEDBERG, Director                                                                                                         
Division of Public Health                                                                                                       
Department of Health & Social Services (DHSS)                                                                                   
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
titled "COVID-19 in Alaska," dated 7/28/20.                                                                                     
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
2:32:28 PM                                                                                                                    
                                                                                                                                
CHAIR  TIFFANY  ZULKOSKY  called  the  House  Health  and  Social                                                             
Services  Standing  Committee  meeting  to  order  at  2:32  p.m.                                                               
Representatives   Jackson  (via   teleconference),  Claman   (via                                                               
teleconference),  Spohnholz  (via teleconference),  and  Zulkosky                                                               
were present at the call  to order.  Representatives Drummond and                                                               
Tarr  arrived   (via  teleconference)  as  the   meeting  was  in                                                               
progress.       Also    present    (via   teleconference)    were                                                               
Representatives LeBon, Hannan, and Prax.                                                                                        
                                                                                                                                
^PRESENTATION:    COVID-19  in  Alaska: A  Mid-Summer  Update  on                                                               
Pandemic Response & Containment Strategies                                                                                      
   PRESENTATION:  COVID-19 in Alaska: A Mid-Summer Update on                                                                
           Pandemic Response & Containment Strategies                                                                       
                                                                                                                              
2:33:43 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  announced that the  only order of  business would                                                               
be  a presentation  regarding COVID-19  in  Alaska: A  Mid-Summer                                                               
Update on Pandemic Response and Containment Strategies.                                                                         
                                                                                                                                
2:34:28 PM                                                                                                                    
                                                                                                                                
NICHOLAS   PAPACOSTAS,  MD,   Vice  President,   Alaska  Chapter,                                                               
American  College of  Emergency Physicians  (ACEP), testified  in                                                               
regard  to ACEP's  concern  with the  rising  number of  COVID-19                                                               
cases in Alaska.  He said ACEP  has more than 100 members who are                                                               
actively  practicing emergency  medicine in  various settings  in                                                               
urban and rural locations across Alaska.   He noted that he is an                                                               
emergency physician actively practicing in Anchorage.                                                                           
                                                                                                                                
DR.  PAPACOSTAS related  that ACEP's  members have  experienced a                                                               
possible  uptick  in patients  who  are  presenting to  emergency                                                               
departments  (EDs) across  the state  with COVID-19  symptoms and                                                               
cases.   He stated  that Alaska's  emergency physicians  are very                                                               
concerned  about the  trends they  are seeing  in total  cases as                                                               
well  as the  number of  patients beginning  to be  hospitalized.                                                               
Hospitalizations climbed by  60 percent during last  week and the                                                               
state's emergency  physicians know  that this  is going  to start                                                               
climbing even more quickly.                                                                                                     
                                                                                                                                
DR. PAPACOSTAS said physicians are  seeing patients in the ED who                                                               
are diagnosed with  COVID-19 but are not yet sick  enough to stay                                                               
in the  hospital.  Severe  illness, he explained, can  be delayed                                                               
by as  much as one  to two weeks  after initial diagnosis.   Many                                                               
patients  who are  going to  need to  be admitted  in one  to two                                                               
weeks  have already  been diagnosed.    It is  important to  take                                                               
action right  now, he advised,  because it has  been demonstrated                                                               
in other locations  that any public health  intervention takes at                                                               
least a  few weeks  to have  demonstrable effect  on the  rate of                                                               
increase in cases and hospitalizations.   Waiting until hospitals                                                               
are completely full before enacting  public health measures, such                                                               
as mask  mandates and cutting  down on large gatherings,  will be                                                               
too  late because  cases and  hospitalizations  will continue  to                                                               
increase for at least a few more weeks.                                                                                         
                                                                                                                                
2:36:00 PM                                                                                                                    
                                                                                                                                
DR. PAPACOSTAS  pointed out that  the American  healthcare system                                                               
is designed  to be  running at  maximum capacity  as much  of the                                                               
time  as possible,  a reality  that  makes it  very difficult  to                                                               
expand  capacity rapidly  when it  is needed.   Even  during non-                                                               
pandemic  times  hospitals  in  Alaska,  and  particularly  urban                                                               
hospitals,  routinely have  to board  patients  in the  emergency                                                               
department.  Emergency department boarding  is when a patient who                                                               
is deemed  sick enough  to require  hospitalization must  wait in                                                               
the ED for a prolonged period of  time before getting a bed in an                                                               
inpatient unit.   For  this reason, he  specified, the  state and                                                               
the governor  are not getting  the full  story if relying  on the                                                               
dashboards alone  to make  decisions about  when to  start taking                                                               
action to contain the spread of the virus.                                                                                      
                                                                                                                                
DR. PAPACOSTAS related  that an Alaska ACEP  member reported that                                                               
for several days last week  the member's facility had between two                                                               
and ten patients boarding in  the emergency department overnight,                                                               
and in one  case the patient waited more than  forty hours for an                                                               
inpatient bed.   Patients being  boarded in the  ED, particularly                                                               
for long  periods of time,  means that the hospital  has negative                                                               
bed space, he explained.  This  means that while the facility had                                                               
physical beds,  it didn't have  between two and ten  staffed beds                                                               
with skilled nurses and technicians  to care for all the patients                                                               
that were  admitted.  This  worries ACEP's physician  community a                                                               
great  deal, he  continued, as  the  peak of  COVID-19 cases  and                                                               
hospitalizations has  not yet begun that  is going to be  seen if                                                               
current trends continue.                                                                                                        
                                                                                                                                
DR. PAPACOSTAS further related that  while the statewide hospital                                                               
dashboard  shows green  with seemingly  plenty of  beds available                                                               
statewide, hospital capacity  in the Anchorage region  was in the                                                               
red  zone numerous  days last  week,  including last  night.   He                                                               
explained that many patients from  around the state who require a                                                               
high level of care for  illnesses or injuries other than COVID-19                                                               
are shipped  to Anchorage, and  Anchorage is  already approaching                                                               
hospital capacity based on metrics set forth by the state.                                                                      
                                                                                                                                
DR. PAPACOSTAS  expressed his  concern with  relying only  on the                                                               
hospital capacity  dashboard to  make decisions.   He  noted that                                                               
the dashboard  currently says there are  26 hospitalized patients                                                               
in Anchorage  and 35  intensive care  unit (ICU)  beds available.                                                               
However, he pointed out, not reflected  by the ICU number is that                                                               
it likely  includes pediatric and  neonatal ICU beds  and neither                                                               
of these  would be ready  to take  care of adult  patients today.                                                               
Thus, the ICU capacity is artificially inflated.                                                                                
                                                                                                                                
2:38:21 PM                                                                                                                    
                                                                                                                                
DR. PAPACOSTAS  further pointed out  that people may look  at the                                                               
dashboard and  see that  there are  91 ventilators  available and                                                               
conclude that the  state must be doing fine.   But, he cautioned,                                                               
that is not the full story.   [At the start of the pandemic] when                                                               
the press  was focusing on  the number of ventilators  that could                                                               
be produced and how quickly they  could be produced, that was the                                                               
wrong thing to focus on.   Having ventilators without the skilled                                                               
people to  run them is akin  to having a bunch  of airplanes full                                                               
of important cargo  that needs to get someplace  urgently but not                                                               
having pilots  to get them  there.  The tool  is only as  good as                                                               
the one  using it and in  the case of ventilated  patients it's a                                                               
team,  he  explained.    A   patient  on  a  ventilator  requires                                                               
extremely  specialized   close  care   with  an   intensive  care                                                               
physician  and  skilled  nursing  staff who  are  experienced  in                                                               
caring for those patients.   This includes respiratory therapists                                                               
who are  skilled at running  the ventilator themselves.   In most                                                               
places, the  usual nursing ratio  for ventilated patients  is one                                                               
nurse for every two, or a maximum of three, patients.                                                                           
                                                                                                                                
DR. PAPACOSTAS  advised that the  question the state needs  to be                                                               
asking  of its  hospitals, if  it  truly wants  to make  informed                                                               
decisions  on when  the system  is  being stressed,  is how  many                                                               
skilled  ICU   nurses,  skilled  ICU  technicians,   and  skilled                                                               
respiratory therapists  does the  hospital have available.   This                                                               
is  because  unless  there  is  enough staff  to  run  all  those                                                               
ventilators  the  patients  who  are  on  them  will  have  worse                                                               
outcomes.  Early  studies in this pandemic have  been on patients                                                               
in hard  hit areas and  they demonstrated a 90  percent mortality                                                               
rate, he said.   Initially that made  physicians pessimistic that                                                               
mechanical  ventilation would  be of  benefit, but  later studies                                                               
have shown  that with high  quality ICU care when  the healthcare                                                               
system is not overwhelmed, mortality  can be much lower at around                                                               
30-40  percent.    This  drives  home the  point  that  when  the                                                               
healthcare  system is  allowed  to  become overwhelmed,  patients                                                               
that may have  survived will die despite  aggressive care because                                                               
there is  not enough human  capital to take  care of them.   This                                                               
will  only  be  exacerbated  when,  inevitably,  some  healthcare                                                               
providers are  forced to quarantine  because they  themselves get                                                               
COVID-19.                                                                                                                       
                                                                                                                                
DR. PAPACOSTAS stated that bold  and decisive leadership early in                                                               
the  pandemic led  to an  incredible flattening  of the  epidemic                                                               
curve in Alaska.   It provided time to build  heath care capacity                                                               
and learn  more about  the virus.   While  it's important  not to                                                               
discount economic  hardships mandates  would have,  he continued,                                                               
it would  be a disservice not  to take action now  to contain the                                                               
spread of  COVID-19; otherwise, economic sacrifices  endured will                                                               
have  been for  naught  and  the pandemic  will  be  paid for  in                                                               
economic cost  as well as  in lives.  He  urged a return  to bold                                                               
leadership now  to stem the rising  tide of cases while  there is                                                               
opportunity  and before  it  is too  late.   Alaska's  healthcare                                                               
workers are  working hard  to care for  their patients  and state                                                               
leadership is  needed to ensure they  have the capacity to  do so                                                               
in the best way they can.                                                                                                       
                                                                                                                                
2:41:58 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  recalled the statement that  hospitalizations had                                                               
increased 60 percent in the last  week.  She inquired whether Dr.                                                               
Papacostas anticipates that those  numbers will continue to climb                                                               
and, if so, the rate of climb.                                                                                                  
                                                                                                                                
DR.  PAPACOSTAS  replied  that he  thinks  hospitalizations  will                                                               
continue to increase.  While  Alaska's absolute numbers are still                                                               
low, he said  the concern is the week-over-week  rate increase of                                                               
patients being  hospitalized.  His  physician colleagues  who are                                                               
seeing  patients in  EDs are  worried that  they are  seeing more                                                               
patients getting  diagnosed with COVID-19 who  have risk factors,                                                               
and those patients  will get sick and come back  to the hospital.                                                               
The epidemic curve  for number of cases has  started to increase,                                                               
so  hospitalizations  are  going  to  start  following  the  same                                                               
epidemic curve as  inevitably the patients who  have already been                                                               
diagnosed start  to develop  more significant  illness.   Most of                                                               
the time there is a lag  time between being diagnosed and getting                                                               
sick  enough to  be hospitalized.   He  said he  is worried  that                                                               
Alaska's hospitalization curve will  increase given the diagnosis                                                               
and case count increase.                                                                                                        
                                                                                                                                
2:44:11 PM                                                                                                                    
                                                                                                                                
THOMAS   HENNESSY,   MD,   Infectious   Disease   Epidemiologist,                                                               
Affiliate  Faculty  Member,  College  of  Health,  University  of                                                               
Alaska,  Anchorage  (UAA),  stated  that before  joining  UAA  he                                                               
served  as  a commissioned  officer  in  the U.S.  Public  Health                                                               
Service  and  worked for  the  Centers  for Disease  Control  and                                                               
Prevention (CDC) for 25 years.   He served as the director of the                                                               
CDC Arctic  Investigations Program  in Anchorage  from 2006-2019.                                                               
He  said  he  currently  leads  a  team  of  UAA  faculty  aiding                                                               
Anchorage's    COVID-19   response    through   data    analysis,                                                               
mathematical  modeling, community  surveys, and  policy analysis.                                                               
He  noted that  he also  advises  the university  on medical  and                                                               
public  health aspects  of the  university's reopening  plan, and                                                               
that  he meets  regularly with  Dr. Zink  and Dr.  McLaughlin for                                                               
information sharing and coordination.                                                                                           
                                                                                                                                
DR. HENNESSY  warned that Alaska's  COVID-19 epidemic  is rapidly                                                               
worsening.   He said this  is obvious  from the data,  the record                                                               
number of  daily cases,  the record number  of active  cases, the                                                               
increase in the percentage of  COVID tests that are positive, and                                                               
the increased number  of regions with new case rates  in the high                                                               
alert level  established by the  State of Alaska.   This increase                                                               
in cases  was predictable and  was predicted by  the mathematical                                                               
models  after relaxation  of  the  community mitigation  measures                                                               
that had  worked to flatten  the curve  in April.   This happened                                                               
because the  shelter-in-place and  other statewide  measures were                                                               
stopped.   Alaska still had ongoing  transmission, COVID-19 cases                                                               
were still  being imported  with travelers  and workers,  and not                                                               
enough Alaskans followed the advice of public health.                                                                           
                                                                                                                                
2:45:54 PM                                                                                                                    
                                                                                                                                
DR. HENNESSY  specified that the  danger zones have been  hit for                                                               
two of the three key pandemic  measures followed in the state and                                                               
the third  one is  on track  to be overwhelmed  soon.   These key                                                               
areas include  the number of  new cases  and the rate  of growth.                                                               
The  second key  area is  the state's  public health  capacity to                                                               
identify  cases  and  their  contacts  and  to  enact  quarantine                                                               
measures to  prevent further  spread.   His colleagues  in public                                                               
health are no longer able to keep  up with the case load and they                                                               
have asked  the general public  and medical providers to  take up                                                               
these responsibilities.   This is  an alarming  and unprecedented                                                               
step,  he said,  and  is a  sign that  the  Alaska public  health                                                               
response   is   overwhelmed.      Medical   and   public   health                                                               
professionals in  the State  of Alaska  and the  Anchorage Health                                                               
Department  have been  extremely conscientious  and energetic  in                                                               
battling this  pandemic.  However,  he advised, they do  not have                                                               
the personnel  and technology resources  needed to  be successful                                                               
with case investigations and contact  tracing at this level.  Dr.                                                               
Hennessy  stated  that  the  third key  area  is  the  healthcare                                                               
capacity   to  care   for  COVID-19   cases  and   other  medical                                                               
conditions.    The metrics  that  are  tracked include  available                                                               
hospital beds,  ventilators, and  intensive care unit  (ICU) beds                                                               
and, of these, ICU beds are the most sensitive.                                                                                 
                                                                                                                                
2:47:19 PM                                                                                                                    
                                                                                                                                
DR. HENNESSY explained that his  UAA group has tracked healthcare                                                               
capacity  throughout  the   epidemic  by  employing  mathematical                                                               
models that use  Alaska case data and bed availability.   He said                                                               
it's important to understand that  the purpose of these models is                                                               
to  show  what might  happen  under  current conditions.    These                                                               
mathematical models  don't show what  will happen - real  life is                                                               
complicated -  and the models  are imperfect approximations.   He                                                               
advised that models often lead  to changes in policies to prevent                                                               
a predicted outcome.   This was the case for  the COVID-19 models                                                               
[the  UAA group]  evaluated in  March, which  predicted that  the                                                               
healthcare capacity  in Alaska could  be exceeded.   Fortunately,                                                               
those scenarios did  not come to pass, he  continued, not because                                                               
the models were  wrong but because Alaska took  action to prevent                                                               
the spread  of COVID-19.   Dr. Hennessy further advised  that the                                                               
models also  predicted that COVID-19  cases would  increase after                                                               
the lifting  of shelter-in-place and other  control measures, and                                                               
that is  what is  being seen  now.   In early  June based  on the                                                               
epidemic conditions at the time,  these models predicted that the                                                               
ICU  bed  capacity  in  Anchorage   would  not  be  exceeded  for                                                               
approximately  16-20  weeks.   Using  data  through 7/26/20,  new                                                               
models  now  predict that  ICU  capacity  in Anchorage  could  be                                                               
overwhelmed  by 9/20/20.   These  are conservative  estimates, he                                                               
noted,  because  they  do not  include  patients  transferred  to                                                               
Anchorage from other parts of  the state.  So, Anchorage's safety                                                               
cushion  has  shrunk  from  20  weeks to  8  weeks  for  the  ICU                                                               
capacity.     We   have  never  been  closer   to  exceeding  our                                                               
healthcare capacity at any point in this epidemic," he stated.                                                                  
                                                                                                                                
2:49:02 PM                                                                                                                    
                                                                                                                                
DR. HENNESSY stated  that it can be seen  where Alaska   COVID-19                                                               
epidemic is  headed.  He advised  that what is being  done now to                                                               
control the  outbreak is not  working.  Disasters  of preventable                                                               
illness and  deaths exploded  in places like  Italy and  New York                                                               
City; despite  extensive healthcare capacity they  were surprised                                                               
by the speed  of the pandemic.  More recently  are the healthcare                                                               
crises  in Florida,  Texas, Arizona,  and  California where  they                                                               
reopened too  soon and responded  too slowly even after  they saw                                                               
that  they were  in  trouble.   This could  soon  be repeated  in                                                               
Alaska, he warned.                                                                                                              
                                                                                                                                
DR.  HENNESSY cautioned  that the  time for  effective action  to                                                               
control the  epidemic in Alaska  is running  out, but that  it is                                                               
not too late  to prevent a healthcare crisis.   The Alaska COVID-                                                               
19 epidemic is now  like a large ship headed for a  reef - it has                                                               
weight and momentum, and it will  only turn slowly.  Measures are                                                               
followed  that lag  behind the  current situation,  he explained.                                                               
Cases reported  today may have been  exposed two weeks ago.   The                                                               
persons in  the ICU now  may have been  exposed three weeks  to a                                                               
month  ago.   If all  virus  transmission was  stopped today,  it                                                               
might take  two weeks before being  able to measure it.   Because                                                               
of this lag,  Alaska cannot wait until its ICUs  are full to take                                                               
stronger action.   That will  be too late,  and the cost  will be                                                               
paid  by   Alaska's  most  vulnerable,  by   Alaska's  healthcare                                                               
workers,  and by  their respective  families.   The time  to take                                                               
effective statewide action is now.                                                                                              
                                                                                                                                
2:50:46 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  CLAMAN  related  that  a mask  mandate  has  been                                                               
imposed in  Anchorage.  He  requested Dr.  Hennessy's perspective                                                               
on whether a mask mandate statewide is good public policy.                                                                      
                                                                                                                                
DR. HENNESSY responded  he would like to see the  State of Alaska                                                               
take  a lead  in enacting  several mandates  to help  protect the                                                               
public health.    He said small communities  need this leadership                                                               
because they  may lack  the capacity to  enact those  measures on                                                               
their own.   A statewide mandate for the use  of facial coverings                                                               
and to follow social distancing  and hygiene practices would send                                                               
a strong signal  to Alaskans that taking action is  needed, so he                                                               
agrees with that.   Also, mandates could be  established to limit                                                               
the size  of group  gatherings.  In  addition, mandates  could be                                                               
established  for capacity  restrictions,  social distancing,  and                                                               
facial coverings  in bars,  pubs, restaurants,  and gyms,  as has                                                               
been done in Anchorage.                                                                                                         
                                                                                                                                
2:51:54 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  recalled Dr. Hennessy  stating that  the modeling                                                               
is  showing that  Alaska's ability  to control  the pandemic  has                                                               
shrunk.   She requested Dr.  Hennessy to restate that  portion of                                                               
his testimony.                                                                                                                  
                                                                                                                                
DR. HENNESSY  explained that these mathematical  models have been                                                               
conducted at intervals  throughout the pandemic and  are based on                                                               
several  factors.    One  factor   is  the  available  healthcare                                                               
capacity, which can vary day to  day as stated by Dr. Papacostas.                                                               
It is also based on some  assumptions about the rate of growth of                                                               
the pandemic,  which is  tracked in a  number of  different ways,                                                               
but basically  has to do  with the reproductive number,  which is                                                               
an estimate of how many  people each infected person can transmit                                                               
the infection to.   Right now, that reproductive  number is about                                                               
1.3,  he related,  meaning  that each  COVID-19  case on  average                                                               
transmits  the  infection to  one  and  possibly one-third  other                                                               
persons.  Left  on its own the reproductive number  of this virus                                                               
appears to  be around 2.0-2.50, which  is what was seen  in China                                                               
and  other  places  when  it was  uncontrolled.    Clearly,  some                                                               
control   has  been   gained  over   the  pandemic   because  the                                                               
reproductive number  is lower, and  that is probably due  to some                                                               
of the good practices Alaskans have  put in place and some of the                                                               
public measures, also.                                                                                                          
                                                                                                                                
DR. HENNESSY specified that to  actually control the epidemic the                                                               
reproductive  number must  be below  1.   To actually  reduce the                                                               
number of  infections, each infected  person must not  infect yet                                                               
another person,  he said.   To get to  that point, Alaska  has to                                                               
reduce transmission  by about 30  percent, which is a  big number                                                               
and would take a lot of action.   When [his UAA group] ran models                                                               
in early  June of reproductive  numbers around 1.2,  it predicted                                                               
about  20 weeks  before  Alaska's ICUs  would  be overwhelmed,  a                                                               
sufficient cushion  at that  time in the  epidemic.   However, he                                                               
explained,  in re-doing  those models  on 7/7/20,  that timeframe                                                               
shrank from  early to mid-October  to about 9/20/20.   That level                                                               
of  about eight  weeks remains  about the  same today,  and eight                                                               
weeks is  not a  lot of  time to make  an impact  on transmission                                                               
dynamics.    It  took  a month  of  shelter-in-place  and  really                                                               
stringent controls  on businesses,  travel, and  other activities                                                               
to bring the  epidemic under control in March, and  that was when                                                               
Alaska  had  many  fewer  cases and  the  state's  public  health                                                               
capacity could keep up with it.   Right now, with Alaska's public                                                               
health  capacity overwhelmed,  Dr.  Hennessy  continued, many  of                                                               
those  people  who  are  infected   are  walking  around  in  the                                                               
community  without the  advice  given to  them  by public  health                                                               
early  in the  epidemic.   That  means they  may be  transmitting                                                               
unwittingly  to other  people  in the  community,  which is  only                                                               
going  to  enhance the  spread.    This  is  why the  window  has                                                               
shortened  and why  Alaska's  healthcare  capacity is  threatened                                                               
more so now than it ever has been at any point in the epidemic.                                                                 
                                                                                                                                
2:55:48 PM                                                                                                                    
                                                                                                                                
JARED KOSIN, President  & CEO, Alaska State  Hospital and Nursing                                                               
Home Association,  offered his full  agreement with  all previous                                                               
testimony and  stated that today's  intent is to  alarm committee                                                               
members  because  the  picture  is  bleak.   He  said  he  would,                                                               
however, recommend  a path  forward.   He reported  that hospital                                                               
capacity today,  and only for  today, is functioning  normal with                                                               
no major concerns from a  safety standpoint at this given moment,                                                               
but  the problem  is  that this  is  not a  normal  moment.   The                                                               
concept of staffed beds discussed  by Dr. Papacostas, he advised,                                                               
is a  nuance that  is going to  drive all of  this.   If staffing                                                               
falls apart, all the beds in the world will make no difference.                                                                 
                                                                                                                                
MR. KOSIN  stated he  is going  to use the  beds in  Anchorage to                                                               
provide a sense of what this  looks like because Anchorage is the                                                               
state's  population center  and  is where  most  of the  COVID-19                                                               
cases are happening.  He  said that without considering staffing,                                                               
Anchorage  has  92 ICU  beds  and  632 non-ICU  in-patient  beds,                                                               
generally called med/surg  beds.  These are  not perfect numbers,                                                               
he qualified, but  they give a sense of what  is being looked at.                                                               
He noted he won't focus on  just ICU because the vast majority of                                                               
COVID patients that  come into the hospital will not  go into the                                                               
ICU, they will spend considerable  time on the med/surgical unit,                                                               
and either be discharged from there or the event will play out.                                                                 
                                                                                                                                
MR. KOSIN  explained that beds  are regularly occupied,  which is                                                               
normal.   On  average in  Anchorage last  week, he  specified, 61                                                               
percent of  ICU beds were  occupied on a  given day.   On average                                                               
last week, 79  percent of med/surg beds were occupied  on a given                                                               
day.   Many hospitals, especially  in urban areas,  especially in                                                               
Anchorage, can  run close  to full.   But [before  getting full],                                                               
limitations start  to manifest and  the key limitation in  all of                                                               
this is  staffing.  Sicker  patients require more staff  care, so                                                               
the ability to manage certain  staffing levels essentially erodes                                                               
and becomes stretched too thin.   The hospital's system is backed                                                               
up  when it  must board  patients [in  the emergency  department]                                                               
because  so many  patients are  coming in  at the  same time  and                                                               
staffing isn't available at that given  time.  When a pipeline of                                                               
COVID-positive  cases is  waiting and  those cases  are going  to                                                               
translate to hospitalization, it gets stressful.                                                                                
                                                                                                                                
2:59:08 PM                                                                                                                    
                                                                                                                                
MR. KOSIN  addressed the question as  to when stress occurs.   It                                                               
is completely  variable, he said,  and is based on  patient load,                                                               
patient   acuity,  staffing   availability,  and   other  things.                                                               
Occupancy fluctuates constantly  and there can be  big swings, he                                                               
related.   One  day can  have  several patients  boarding in  the                                                               
emergency department waiting for a bed  and then the next day can                                                               
have several discharges, which means  patients are recovering and                                                               
going home.  That clears space  and hence the hospital could have                                                               
a lower patient population on  that given day.  With fluctuations                                                               
come peaks.   Over last  week in Anchorage, ICU  occupancy peaked                                                               
at 67  percent and med/surg occupancy  peaked at 89 percent.   In                                                               
the Anchorage  setting this is  normal, but the unusual  thing is                                                               
this growing pipeline of likely  hospitalizations that are coming                                                               
based on the high daily COVID case counts.                                                                                      
                                                                                                                                
MR. KOSIN continued his discussion  of when does the stress begin                                                               
and when  can it  start to  be felt.   Since  it is  variable, he                                                               
posed  a scenario  in which  stress on  the healthcare  system is                                                               
considered to  begin when there  is a consistent patient  load of                                                               
80 percent occupancy  in the ICU and 90 percent  in med/surg.  To                                                               
describe what that would look like,  he pointed out that based on                                                               
last  week's averages  in  Anchorage, this  would  be an  average                                                               
daily increase of 18 ICU patients  and 63 med/surg patients for a                                                               
total  of 81  COVID  hospitalizations.   He  said  81  is a  lot,                                                               
especially on  a sustained basis,  but advised that  the question                                                               
needing  to be  asked is  whether COVID  can take  the number  of                                                               
regular  admissions  in  Anchorage  to  81.    He  laid  out  the                                                               
statistics:   On [7/26/20] there  were 36 COVID positives  in the                                                               
hospital  statewide, 26  of them  in  Anchorage.   One month  ago                                                               
there were  4 COVID positives in  the hospital, 2 weeks  later it                                                               
grew to  16 COVID positives in  the hospital, a week  ago it went                                                               
to 21,  and now it  is averaging  35-36 a day.   In one  month it                                                               
went from 4  COVID positive patients in the hospital  to 36.  So,                                                               
without  even   considering  staffing,  will   that  hypothetical                                                               
stressor  of 81  new regular  hospitalizations be  hit?   At this                                                               
rate, how  could it not, he  stated.  So, the  question is, "What                                                               
do  we need  to do?"   Alaska  needs to  wake up,  he admonished.                                                               
There  is no  vaccine to  slow  this spread,  so that  is not  an                                                               
option.  The  next best option is pretty simple,  he said.  "It's                                                               
doing our  part as individuals.   We need to wear  masks, we need                                                               
to wash  our hands,  and we need  to practice  social distancing.                                                               
It has to happen."                                                                                                              
                                                                                                                                
3:02:39 PM                                                                                                                    
                                                                                                                                
MR. KOSIN  concluded by relating  that the common  question asked                                                               
is, "Should we  cease medical visits and  surgeries and different                                                               
operations like  that to clear  the way for the  impending wave?"                                                               
He said the  answer is, "Absolutely not."  Delay  in medical care                                                               
again  creates a  whole  set  of other  issues  and problems,  he                                                               
advised.   Hospital capacity  is available  and fluid  today, but                                                               
the issue before  Alaska is a prevention issue.   The only chance                                                               
to limit  the impending  harm is to  prevent the  rapidly growing                                                               
case  counts.   Would building  up and  emptying out  hundreds of                                                               
beds tomorrow make a difference?   "The answer is no, not without                                                               
staffing  and not  if these  cases  translate to  hospitalization                                                               
incumbent," he said.   "The only way to change  this situation is                                                               
to  lower  the daily  case  count.   That  is  where  all of  our                                                               
attention must go."                                                                                                             
                                                                                                                                
3:04:23 PM                                                                                                                    
                                                                                                                                
ELLEN  HODGES,   MD,  Chief  of  Staff,   Yukon-Kuskokwim  Health                                                               
Corporation (YKHC),  noted she is  a family medicine  doctor, and                                                               
she has been privileged to  serve the Yukon-Kuskokwim area for 17                                                               
years.   She said the  Yukon-Kuskokwim Health  Corporation serves                                                               
28,000 people in 48 villages and  58 tribes in a large expanse of                                                               
Southwest Alaska without roads to connect any of the villages.                                                                  
                                                                                                                                
DR. HODGES  explained that the  health resources of  rural Alaska                                                               
are limited.   For instance,  she said, YKHC  has no ICU  beds or                                                               
physicians specially  trained in caring  for ICU patients.   Many                                                               
of YKHC's  Alaska Native  patients receive  tertiary care  at the                                                               
Alaska  Native Medical  Center (ANMC)  [in  Anchorage], and  that                                                               
YKHC transfers  any critically ill  patients to ANMC  for further                                                               
treatment,   while   patients   who   are   not   Alaska   Native                                                               
beneficiaries are  transferred to  other hospitals.   She pointed                                                               
out that if the ICU capacity  is exceeded, YKHC does not have the                                                               
resources  or  staffing to  manage  critically  ill patients  for                                                               
extended  periods of  time.   Last  winter,  she continued,  this                                                               
region experienced  the worst  outbreak of  respiratory syncytial                                                               
virus (RSV) seen in over a  decade.  This virus primarily affects                                                               
young  patients  with  respiratory symptoms  that  often  require                                                               
ventilatory support  in the form of  specialized high-flow oxygen                                                               
or even  ventilators.  The region's  babies filled up all  of the                                                               
pediatric ICU  (PICU) beds in  Anchorage and YKHC was  very close                                                               
to  having  to   send  its  patients  directly   to  Seattle  for                                                               
treatment.   Many days  saw multiple  air medical  evacuations to                                                               
Anchorage with babies  to various PICU beds  at various hospitals                                                               
in Anchorage to  receive the support and expert  care they needed                                                               
to recover.   Thankfully, other regions in  Alaska had relatively                                                               
minor  outbreaks of  RSV and  YKHC was  able to  keep all  of its                                                               
babies in state.   She said this was a  sobering reminder "of how                                                               
we are all connected and outbreaks in one region affect us all."                                                                
                                                                                                                                
3:06:28 PM                                                                                                                    
                                                                                                                                
DR.  HODGES  related  that  her  region  has  watched  increasing                                                               
[COVID] cases in Anchorage with  considerable alarm.  Most of the                                                               
cases in  this region are  from travel to Anchorage  or somewhere                                                               
on the road  system.  The interconnectedness of  Alaska is clear,                                                               
and it  is known from  the RSV  outbreak that patients  from this                                                               
region can  overwhelm the resources  of the  Anchorage hospitals.                                                               
If all  the ICU beds  are full  of Anchorage patients  where will                                                               
[YKHC] patients go?                                                                                                             
                                                                                                                                
DR. HODGES noted that the models  used to predict the increase in                                                               
cases  mostly point  to  first an  increase  in community  spread                                                               
followed by  hospital admissions, then ICU  admissions and death.                                                               
Alaska  cannot bank  on having  a different  trajectory than  the                                                               
rest  of this  country, she  said.   The  evidence suggests  that                                                               
mitigation  strategies can  interrupt  this seemingly  inevitable                                                               
sequence.   The  risk to  Alaska's population  could possibly  be                                                               
reduced if enough  Alaskans can be convinced to  wear masks, keep                                                               
their  social  circles  small,  avoid  indoor  gatherings,  limit                                                               
travel, and  isolate immediately if  they are sick.   Identifying                                                               
cases,  isolating sick  people,  and tracking  down contacts  are                                                               
critical.   To  do this,  testing resources  and contact  chasing                                                               
resources are needed.   Community members who  have to quarantine                                                               
need  support.   It  is  clear that  something  must  be done  to                                                               
interrupt the current trajectory.   The choices are not simple or                                                               
easy, Dr.  Hodges said, and  she knows the economic  hardships of                                                               
all  Alaskans are  real and  painful.   But,  she continued,  she                                                               
knows too the sorrow and grief of  a life cut short by a terrible                                                               
virus despite all our efforts to prevent tragedy.                                                                               
                                                                                                                                
3:07:59 PM                                                                                                                    
                                                                                                                                
DR. HODGES  suggested some  tools for  consideration that  may be                                                               
especially useful  for rural Alaska.   She said  a one-size-fits-                                                               
all mask mandate might not work  for the state.  However, an opt-                                                               
out  mask mandate  would allow  municipalities  to opt  out of  a                                                               
statewide mandate  if it weren't appropriate  for that community.                                                               
This  would  allow  communities  such as  hers  to  tailor  their                                                               
approach  to pandemic  control  while  providing the  much-needed                                                               
leadership  and guidance  for the  smallest  and most  vulnerable                                                               
[communities]  that need  the support  from the  state.   Another                                                               
tool  that may  be useful,  Dr.  Hodges continued,  is a  testing                                                               
strategy for smaller communities off  the road system, similar to                                                               
the interstate  travel mandate.   Since  everyone must  arrive in                                                               
rural communities by air, requiring  them to have a negative test                                                               
in  hand may  reduce  the  number of  people  who arrive  already                                                               
infected  with  the virus  into  these  communities with  limited                                                               
resources.  It  would also allow communities like  Bethel to more                                                               
easily  enforce   a  testing   strategy  that   all  disembarking                                                               
passengers get tested  on arrival, given the only  way this virus                                                               
gets  to  her  region  is  on  an  airplane.    Public  education                                                               
strategies  that  are culturally  appropriate  and  aimed at  the                                                               
mitigation  strategies  that  are  known  to  work  may  also  be                                                               
helpful.   Stories are  a powerful  tool in  her region,  and the                                                               
stories of  the region's survivors  could be told so  that others                                                               
can learn and maybe change critical behavior.                                                                                   
                                                                                                                                
3:09:27 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY recalled that the  prior three witnesses testified                                                               
about the importance of staffing  within health systems, not just                                                               
looking  at the  number of  beds  available.   She requested  Dr.                                                               
Hodges to  talk to  the capacity and  morale of  providers within                                                               
the YKHC system who are responding to this pandemic.                                                                            
                                                                                                                                
DR. HODGES  replied YKHC  has a  limited capacity  for healthcare                                                               
workers  off the  road system.   She  said YKHC  understands from                                                               
other  places  with  large  outbreaks  that  about  one-third  of                                                               
medical staff  that support a  hospital can be out  on quarantine                                                               
or with active infections at  any given time, which would greatly                                                               
limit YKHC's response to this  pandemic as YKHC already has razor                                                               
thin staffing  in its  hospital facility.   The morale  of YKHC's                                                               
hospital is  pretty good right  now and people definitely  have a                                                               
community  mind  in  the  hospital,  but  the  strain  of  seeing                                                               
increasing  cases  in Anchorage  and  other  places, as  well  as                                                               
within this  region, is  starting to affect  the people  who live                                                               
and work here.  A large  outbreak that forced staff to quarantine                                                               
or that  infected staff would  drastically affect  YKHC's ability                                                               
to respond to the pandemic.                                                                                                     
                                                                                                                                
3:11:30 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE DRUMMOND  expressed her concern about  the ability                                                               
of  communities in  Dr. Hodges'  region  to maintain  sanitation,                                                               
given the  lack of  running water  and such.   She  requested Dr.                                                               
Hodges to speak to this.                                                                                                        
                                                                                                                                
DR.  HODGES responded  that several  studies in  the region  have                                                               
shown that  the households with  either inadequate or  no running                                                               
water have much  higher rates of hospitalization  of children and                                                               
adults for pneumonia as well as  skin infections.  She said there                                                               
is no reason  to believe that COVID will  affect these households                                                               
any  differently.   She is  highly concerned  for the  households                                                               
without  running water  with regard  to basic  sanitation of  the                                                               
house,  overcrowding, and  inter-generational nature  of many  of                                                               
the households that leads to  the virus spreading rapidly in some                                                               
of the rural areas.                                                                                                             
                                                                                                                                
3:13:12 PM                                                                                                                    
                                                                                                                                
ROBERT ONDERS,  MD, Acting Hospital Administrator,  Alaska Native                                                               
Medical  Center (ANMC),  Alaska Native  Tribal Health  Consortium                                                               
(ANTHC), noted he  is a family physician.  He  said the testimony                                                               
heard so far makes it easy  to identify the direction that Alaska                                                               
is going,  and the challenges before  the state.  He  thanked the                                                               
State of Alaska,  Governor Dunleavy, Chief of  Staff Ben Stevens,                                                               
Commissioner Adam  Crum, Dr. Anne  Zink, Dr. Joe  McLaughlin, and                                                               
the  unified command  for  working well  with  the tribal  health                                                               
system  and keeping  communication  open.   Their willingness  to                                                               
listen  to  people   in  the  tribal  health   system  about  the                                                               
challenges and  concerns is  appreciated.  The  issue at  hand is                                                               
about what's going on, not about necessarily individuals.                                                                       
                                                                                                                                
DR.  ONDERS  said  the previous  testifiers  have  provided  very                                                               
similar information  to what he had  prepared to speak on,  so he                                                               
has modified  his presentation to  touch on three things  that he                                                               
believes would  be beneficial for  the committee to be  aware of.                                                               
He stated  he still believes  Alaska is  in a unique  position in                                                               
that its geography  still affords the chance to  have a different                                                               
outcome than  the rest  of the  U.S.   Particularly in  the rural                                                               
areas,  he continued,  that  geography is  an  advantage.   Also,                                                               
Alaska  has come  into  this  pandemic a  little  bit later  than                                                               
everyone else,  and being  able to watch  what works  and doesn't                                                               
work in  the rest of the  country puts Alaska in  an advantageous                                                               
position.  However, he cautioned,  what he isn't seeing right now                                                               
is that Alaska  is acting upon what isn't working  in the rest of                                                               
the  U.S.  and currently  Alaska  is  looking  to have  the  same                                                               
trajectory as the rest of the U.S.                                                                                              
                                                                                                                                
DR.  ONDERS specified  that of  critical potential  in Alaska  is                                                               
health  equity.   He related  that COVID  has exacerbated  health                                                               
equity differences across the U.S.   African Americans and Native                                                               
Americans  are experiencing  the highest  rates of  morbidity and                                                               
mortality from  COVID-19.   This pattern is  similar to  what was                                                               
seen in  2008 and 2009  with the  H1N1 [novel influenza  A virus]                                                               
pandemic.  He  noted that Dr. Hennessy was one  of the authors of                                                               
an  article  that  showed  that  H1N1  brought  higher  rates  of                                                               
hospitalization, intensive care unit  admissions, and a mortality                                                               
rate four  times higher to  American Indians and  Alaska Natives.                                                               
If Alaska  continues on  the current  course, he  anticipates the                                                               
exact same outcome  in Alaska with this pandemic as  seen in 1918                                                               
and  2008/2009    there will  be a  disproportional effect.   For                                                               
Alaska  to have  equitable outcomes,  he advised,  there must  be                                                               
disproportional  protections related  to resources.   Dr.  Hodges                                                               
touched  on  the  need  for testing  in  rural  communities,  and                                                               
policies.   Alaska needs  to have a  different approach  than the                                                               
rest of the  U.S. if it wants to have  equitable outcomes.  Right                                                               
now Alaska's approach  is similar to the rest of  the U.S. and he                                                               
would anticipate inequitable outcomes  and Alaska Natives to bear                                                               
a disproportionate burden of death  and morbidity related to this                                                               
pandemic.  Truly it's the  outcomes that matter, he stressed, and                                                               
Alaska is at  a critical time where decisions need  to be made to                                                               
change course, as emphasized by the previous testifiers.                                                                        
                                                                                                                                
3:17:18 PM                                                                                                                    
                                                                                                                                
DR. ONDERS  stated that "good intentions  only go so far,  and we                                                               
will be measured at  the end of this by the  outcomes, not by our                                                               
intent."    Making key  decisions  to  impact those  outcomes  is                                                               
needed now,  he emphasized.  He  said the staff at  Alaska Native                                                               
Medical  Center  is  working  incredibly  hard  -  ANMC  had  bed                                                               
shortages before COVID  and right now it  has staffing shortages.                                                               
When he  came to  work this  morning, ANMC had  one bed  open and                                                               
seven people  in the emergency  room looking for seven  beds post                                                               
operating  room  procedures.   Additionally,  he  continued,  the                                                               
critical care unit (CCU) is always  short of nursing.  He related                                                               
that ANMC is  looking to open an alternate care  site because all                                                               
the numbers predict  that many more beds are going  to be needed.                                                               
More room is  needed so that physicians like Dr.  Hodges can send                                                               
their  patients here.   He  said  he is  really sad  to see  that                                                               
Alaska has lost the advantage it  had, and that ANMC is having to                                                               
actively build out  another 30 beds for overflow  because that is                                                               
what ANMC anticipates is coming.                                                                                                
                                                                                                                                
3:19:19 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY asked  what  the decisions  look  like to  change                                                               
course.                                                                                                                         
                                                                                                                                
DR. ONDERS  replied that high-risk activities  must be mitigated,                                                               
which  Dr.  Hennessy   touched  on  very  clearly.     There  are                                                               
activities  that are  at  risk  for COVID  spread  and there  are                                                               
activities that  aren't at  risk.   Alaska needs  to be  open for                                                               
activities  that aren't  at risk,  he  said.   Instead of  having                                                               
full-blown  activities, Alaska  can  be smart  and reflective  in                                                               
mitigating the  risk in  activities where  COVID can  spread, and                                                               
what Dr.  Hennessy spoke to  would make  sense.  As  mentioned by                                                               
Dr. Hodges,  he continued,  there is a  challenge locally  to get                                                               
all these implemented.   It has been seen in the  Lower 48 that a                                                               
patchwork  component  of  regulations   does  not  prevent  COVID                                                               
spread.  Since a patchwork  regulatory process doesn't work well,                                                               
Alaska should learn from what is being seen in other states.                                                                    
                                                                                                                                
CHAIR ZULKOSKY  requested Dr. Onders to  clarify what regulations                                                               
would look like in the state of Alaska that aren't a patchwork.                                                                 
                                                                                                                                
DR.  ONDERS responded  that statewide-related  policies would  be                                                               
beneficial  with the  potential to  opt out  of that,  similar to                                                               
what Dr. Hodges said,  but to at least set a  minimum of where it                                                               
is thought  that those high-risk  activities are.   Public health                                                               
is about keeping  people out of the hospital,  not about watching                                                               
hospital  capacity.   All kinds  of  measures are  in place,  the                                                               
minimum that  is thought needed  to prevent spread, he  said, and                                                               
statewide those need to be in place.                                                                                            
                                                                                                                                
3:21:45 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY  invited  the   Department  of  Health  &  Social                                                               
Services  to  begin  its  presentation.   She  thanked  DHSS  for                                                               
providing  updates  to  the  legislature  as  it  works  hard  at                                                               
responding to this pandemic.                                                                                                    
                                                                                                                                
3:22:31 PM                                                                                                                    
                                                                                                                                
ADAM CRUM,  Commissioner, Department of Health  & Social Services                                                               
(DHSS), stated that  DHSS has done many items  to protect Alaska,                                                               
such as  putting forth social distancing  mandates and restaurant                                                               
business closures.   He  said the  department has  worked towards                                                               
reopening because  there are other  effects, such as  making sure                                                               
people have  the chance to  move around, and DHSS  is encouraging                                                               
Alaskans to go  outside.  The department has put  forward all the                                                               
best  information  from  the  Centers  for  Disease  Control  and                                                               
Prevention  (CDC), including  workplace guidance,  HVAC guidance,                                                               
and airport  testing.  He pointed  out that Alaska was  the first                                                               
state in  the U.S. to  put forward  a robust plan  for passengers                                                               
and people traveling to Alaska,  including residents returning to                                                               
the  state,  to come  in  and  to make  sure  that  the state  is                                                               
protected.                                                                                                                      
                                                                                                                                
COMMISSIONER  CRUM related  that the  department has  worked with                                                               
communities around  the state  and put  forward and  built robust                                                               
plans  for  fish  processing  that  are  protecting  those  rural                                                               
communities  while thousands  of individuals  come in,  and still                                                               
have industry  that brings incredibly valuable  property taxes to                                                               
those communities.  In looking at  what can be done, he said DHSS                                                               
has worked with  the Department of Law (DOL) and  studied some of                                                               
the statutory authority  that communities can do.   Over the last                                                               
two weeks DHSS has been  meeting with the Alaska Municipal League                                                               
and  mayors across  Alaska  and informing  them  that first-  and                                                               
second-class cities,  and first- and second-class  boroughs, have                                                               
the  authorities  to  enact  quite a  few  public  health  powers                                                               
themselves and  restrictions.  The department  has informed these                                                               
communities  that   they  can  enact   these  items   to  protect                                                               
themselves as they see fit.   The department will be working with                                                               
them providing them  this guidance and showing  them the toolkits                                                               
that are available for them to use moving forward.                                                                              
                                                                                                                                
3:25:03 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  recalled that the commissioner  also testified in                                                               
late  June  about  the  delegated authority  that  the  state  is                                                               
providing, particularly  to communities off the  road system, for                                                               
enacting local health  mandates.  She related that  she has heard                                                               
concern from communities and second-class  cities in her district                                                               
that there  is confusion and  extremely shaky legal  grounds that                                                               
did not  offer clearly delegated  authority from the  governor or                                                               
within Alaska  statute.  If that  is the case, she  asked whether                                                               
the governor  or the department  would consider issuing  a health                                                               
or  legal  mandate that  clearly  states  second-class cities  or                                                               
communities  in  unorganized  parts  of  Alaska  have  the  legal                                                               
authority to implement more stringent mandates.                                                                                 
                                                                                                                                
COMMISSIONER CRUM replied that DHSS  has been answering questions                                                               
as it goes through  this.  He said the Department  of Law has put                                                               
together a  group.   Also, the Alaska  Municipal League  has been                                                               
organized  in specific  groups;  for example  today  there was  a                                                               
phone call  for answering the  concerns of  second-class boroughs                                                               
and  whether  they   can  be  addressed  in   either  statute  or                                                               
constitutional available powers.   The department, he added, will                                                               
be meeting  with other cities  and second-class cities.   He said                                                               
the chair's suggestion is an  interesting option and he will make                                                               
sure the governor and attorney general are aware of them.                                                                       
                                                                                                                                
3:26:42 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  recalled that  the epidemiologists  and providers                                                               
who testified  earlier today pointed out  the sobering conditions                                                               
and  the need  to  act and  respond  now.   She  asked about  the                                                               
timeframe  by  which  the  state expects  to  put  forward  legal                                                               
guidance  and  authority  to   small  communities  if  additional                                                               
statewide health mandates are not going to be issued.                                                                           
                                                                                                                                
COMMISSIONER  CRUM responded  that  he  understands from  talking                                                               
with DOL that  communities have this authority right  now and can                                                               
move  on   it,  and  DHSS   has  shared  this  with   mayors  and                                                               
communities.   He said  DHSS is working  on walking  them through                                                               
their individual  municipal codes and has  had conversations with                                                               
cities around the state that  have actually enacted some of this.                                                               
He said DHSS  recognizes that the high daily COVID  case count is                                                               
something the  department needs to make  sure that municipalities                                                               
understand how  they can address  and protect their  local areas,                                                               
and DHSS will continue to press this.                                                                                           
                                                                                                                                
3:27:59 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY posed  a scenario  in  which the  City of  Bethel                                                               
enacted  requirements for  arriving  passengers to  be tested  or                                                               
provided  a mask  mandate within  the community  of Bethel.   She                                                               
further posed  in the scenario  that those mandates  were legally                                                               
challenged, and  that the  department had not  yet come  out with                                                               
clear legal precedent.  She  asked whether, in this scenario, the                                                               
State  of Alaska  would support  municipalities and  stand behind                                                               
them  stating   that  the   municipalities  acted   with  clearly                                                               
delegated  authority as  authorized  by the  governor under  this                                                               
public health emergency.                                                                                                        
                                                                                                                                
COMMISSIONER  CRUM answered  that he  cannot offer  legal advice.                                                               
He noted  that that  was part of  the conversations  and concerns                                                               
that the mayors  had brought up.  He offered  his belief that DOL                                                               
came up with  a solution, and [DHSS] will make  sure that that is                                                               
clearly articulated.                                                                                                            
                                                                                                                                
CHAIR  ZULKOSKY noted  that this  evening the  City of  Bethel is                                                               
considering some  community mandates, but  that the city  had not                                                               
yet  received any  additional legal  guidance from  the state  in                                                               
order to respond in providing  more localized mandates.  She said                                                               
she knows that timeliness would  be appreciated, especially given                                                               
the magnitude of the cliff that is being approached.                                                                            
                                                                                                                                
3:29:46 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ  related that small business  owners and                                                               
communities across  the state  are being put  in the  position of                                                               
making  what are  public health  decisions  for their  employees.                                                               
She asked what  the department is doing to  help small businesses                                                               
understand how they  can make their workplaces  and businesses as                                                               
safe as possible during COVID-19.                                                                                               
                                                                                                                                
COMMISSIONER  CRUM  replied that  throughout  this  DHSS has  put                                                               
forward all  the CDC guidance  and recommendations,  the business                                                               
toolkit  that allowed  employees  to know,  and  a reopen  Alaska                                                               
plan.  The  department put forward the best guidance  that it had                                                               
at  the  time  of  each  phase for  businesses  to  reopen,  safe                                                               
practices for  their employees, and  the department  continues to                                                               
communicate.   He  noted  that  each week  DHSS  holds calls  for                                                               
different  industries,  calls  comprised   of  a  couple  hundred                                                               
people,  to address  specific concerns.   Additionally,  DHSS has                                                               
created  list  serves for  immediately  posting  and sharing  new                                                               
information when it comes out from federal partners.                                                                            
                                                                                                                                
3:31:04 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ  said  members   have  heard  that  the                                                               
business  toolkit has  been helpful  for  some small  businesses.                                                               
However, she  continued, other businesses  feel that  just having                                                               
guidance  and  suggestions  from  the  state  puts  them  in  the                                                               
position of being  police and policing public health.   She asked                                                               
why the department would not just  go ahead and issue a statewide                                                               
mask mandate as  a measure to take the onus  off small businesses                                                               
to protect  public health and  also to  make it easier  to ensure                                                               
that Alaska's economy continues to stay open.                                                                                   
                                                                                                                                
COMMISSIONER CRUM responded that  many small businesses and large                                                               
businesses have  put forward  their own  mask mandates  for their                                                               
patients  and  their employees  throughout  this.   As  they  put                                                               
forward, there  is the guidance  to look at what  the responsible                                                               
action is for all of Alaska    covering mandates across the board                                                               
or  providing  local  powers  so   they  can  protect  their  own                                                               
communities through  the public  health process.   The department                                                               
has put  forward guidance  as it sees  fit, shared  guidance from                                                               
its  federal partners,  and  provided  consistent messaging  that                                                               
DHSS encourages the  use of masks.  The  department will continue                                                               
to push this information, he said.                                                                                              
                                                                                                                                
3:32:45 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ inquired  whether there  is any  reason                                                               
why the department wouldn't institute a statewide mask mandate.                                                                 
                                                                                                                                
COMMISSIONER CRUM answered that that has  to do with what he just                                                               
said    it has to  do with what is  appropriate at what  point in                                                               
time.  Some groups are willing to  do this and others are not, so                                                               
the  department  is  sharing  the information  for  how  to  keep                                                               
themselves and others safe.                                                                                                     
                                                                                                                                
3:33:26 PM                                                                                                                    
                                                                                                                                
ANNE  ZINK,  MD, FACEP,  Chief  Medical  Officer, Office  of  the                                                               
Commissioner,    co-provided    the    department's    PowerPoint                                                               
presentation  titled "COVID-19  in Alaska,"  dated 7/28/20.   She                                                               
drew attention to  the graph on slide 3 and  pointed out that the                                                               
U.S. had  its initial curve, then  it started to slow  down, then                                                               
it started to pick up, and now  an easing of that second curve is                                                               
starting to  be seen.   She moved to  slide 4 and  discussed show                                                               
where  Alaska stands  compared  to  the rest  of  the  U.S.   She                                                               
explained that  the graph depicts  the number of  confirmed cases                                                               
normalized by population.   She noted that  Louisiana and Florida                                                               
have had an acceleration phase  and that Alaska has been climbing                                                               
and is above some other states when looking at cases per capita.                                                                
                                                                                                                                
Dr. ZINK addressed the graph on  slide 5 depicting case counts by                                                               
date for  communities in Alaska.   She  said that next  week DHSS                                                               
would be moving and significantly  changing its dashboard to show                                                               
better (indisc.) on both the  current as well as residency. These                                                               
are epidemic curves  ("epi curves"), she explained,  so the dates                                                               
change as each  individual case is investigated in  order to find                                                               
out  when the  patient's  symptoms initially  began  or when  the                                                               
patient first tested positive.                                                                                                  
                                                                                                                                
3:35:04 PM                                                                                                                    
                                                                                                                                
DR. ZINK  turned to slide  6 and  specified that [as  of 7/27/20]                                                               
overall Alaska has had 2,622  residents and 817 nonresidents test                                                               
positive.   The majority of  those nonresidents, she  noted, have                                                               
been in the  seafood industry and have been  in quarantine during                                                               
their test positive  range, but not all.   Total hospitalizations                                                               
are at 116, total deaths at  21, and total recovered patients are                                                               
at 817.  She explained that  recovered patients is a way for DHSS                                                               
to categorize when someone is  no longer thought to be infectious                                                               
and  to no  longer require  isolation.   Their overall  long-term                                                               
health,  she  added, is  a  much  more  complex story  that  DHSS                                                               
continues to watch the data and learn from.                                                                                     
                                                                                                                                
DR.  ZINK discussed  the graph  on  slide 7  regarding the  time-                                                               
varying reproductive number  (Rt).  She said  Alaska continues to                                                               
see a  steady Rt value  of about 1.2, but  that there is  quite a                                                               
bit of variability within the state  as a whole with that number,                                                               
given Alaska's large  geographic area and small  population.  The                                                               
department  continues to  look at  both resident  and nonresident                                                               
cases in  a reproductive  number as a  whole, she  continued, and                                                               
this information is  also reported back to DHSS from  the CDC and                                                               
the White House in comparing to other states across the country.                                                                
                                                                                                                                
3:36:20 PM                                                                                                                    
                                                                                                                                
DR.  ZINK  displayed  slide 8  depicting  hospital  capacity  for                                                               
inpatient  beds,   ICU  beds,  and  ventilator   capacity.    She                                                               
referenced  the earlier  testimony  regarding  the challenges  of                                                               
staffed  beds, not  staffed  beds, and  total  bed capacity,  and                                                               
stated  that DHSS  gets this  information from  the Alaska  State                                                               
Hospital and Nursing Home Association.   She offered appreciation                                                               
to the  association for its  partnership in  providing dashboards                                                               
and information to  the department on what those  beds look like.                                                               
From a state  perspective it's hard to know what  are staffed and                                                               
not staffed, so the state relies on that partnership.                                                                           
                                                                                                                                
3:37:09 PM                                                                                                                    
                                                                                                                                
DR. ZINK  focused on slide 9  depicting the risk alert  levels by                                                               
behavioral  health region  in Alaska.   She  explained that  DHSS                                                               
talks with  national and  international partners  as well  as its                                                               
team   internally   to  try   to   help   give  good   tools   to                                                               
municipalities, local  authorities, and to  the state as  a whole                                                               
to understand  what really is  the risk  of COVID spreading  in a                                                               
particular community.   This is  challenging, she  noted, because                                                               
there could  be people  in quarantine  that are  not mixing  or a                                                               
large outbreak,  which will fluctuate  the numbers.   She related                                                               
that the  department looked at  3-day, 7-day, 20-day,  and 28-day                                                               
chunks to decide  what made the most sense to  be able to provide                                                               
the  most  timely,  accurate  information for  the  state.    The                                                               
department  ultimately went  with the  behavioral health  regions                                                               
shown  on  the map,  she  said,  because each  behavioral  health                                                               
region  had  at  least  20,000  people in  the  region  and  also                                                               
represented  where people  move for  their health  care, although                                                               
it's  definitely not  perfect.   From  there  she continued,  the                                                               
department broke  it down  into three categories:   [a  low alert                                                               
level is]  less than  5 new  cases per  100,000 averaged  over 14                                                               
days;  [an  intermediate  alert  level is]  5-10  new  cases  per                                                               
100,000 averaged over  14 days; and [a high alert  level is] more                                                               
than 10  new cases per 100,000  averaged over 14 days.   She said                                                               
it's important to note that  this may lag slightly, and therefore                                                               
a big  outbreak in cases that  happens quickly will take  a while                                                               
to show up in the data.   She explained that the idea behind this                                                               
larger  chunk of  time and  larger population  is to  average out                                                               
these  outbreaks and  give  a better  sense  of what's  happening                                                               
overall  in a  community.   While  not a  perfect  tool, DHSS  is                                                               
providing  additional tools  to  the public  and local  decision-                                                               
makers on what the current COVID risk is in communities.                                                                        
                                                                                                                                
DR. ZINK  concluded her portion  of the presentation.   She noted                                                               
that there are more tools and  dashboards that she would be happy                                                               
to provide as the committee follows this pandemic.                                                                              
                                                                                                                                
3:39:04 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON inquired about  the ventilator capacity in                                                               
Anchorage.    She further  inquired  about  whether the  homeless                                                               
population is disproportionately affected.                                                                                      
                                                                                                                                
DR. ZINK replied  she would get back to the  committee in writing                                                               
about the ventilator  capacity in Anchorage.   She explained that                                                               
the Alaska  State Hospital and Nursing  Home Association provides                                                               
this  information.    Regarding   the  homeless  population,  she                                                               
deferred to Dr. McLaughlin to answer the question.                                                                              
                                                                                                                                
3:40:37 PM                                                                                                                    
                                                                                                                                
JOE  MCLAUGHLIN,  MD,  State Epidemiologist,  Chief,  Section  of                                                               
Epidemiology, Division  of Public Health, Department  of Health &                                                               
Social  Services (DHSS),  responding to  Representative Jackson's                                                               
question, stated  that DHSS hasn't identified  any large outbreak                                                               
yet in the  homeless population, but qualified  that that doesn't                                                               
mean it  hasn't happened.   Sometimes  there can  be a  very high                                                               
rate of asymptomatic  infection, he explained.  It  has been seen                                                               
in  some  states,  whether in  homeless  or  prison  populations,                                                               
upwards of  50-70 percent of  the people who become  infected are                                                               
asymptomatic for reasons that aren't  clear.  So, while no large-                                                               
scale outbreaks  have been detected  in the  [Anchorage] homeless                                                               
population,  it's  possible that  COVID  is  circulating in  that                                                               
population but has not been detected yet.                                                                                       
                                                                                                                                
3:41:43 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  recalled the testimony  about the ability  of the                                                               
COVID virus  to grow  exponentially.   She further  recalled that                                                               
the  medical providers  testified  that  continuing forward  with                                                               
"business as usual" is likely to  push Alaska to the brink of its                                                               
capacity.  She  requested Commissioner Crum or Dr.  Zink to speak                                                               
to what  the state's existing  mitigation strategy is  to revisit                                                               
new or  revised statewide mandates  that would seek  to stabilize                                                               
or  decrease the  rates of  infection, recognizing  that some  of                                                               
these  lagging indicators  could suggest  continued increases  in                                                               
critical patients and pushing hospital capacity to the limit.                                                                   
                                                                                                                                
COMMISSIONER  CRUM  answered that  DHSS  works  closely with  its                                                               
partners in the hospitals to make  sure the department has a good                                                               
understanding on the staffing and  bed capacity at the hospitals.                                                               
For example,  he related,  34 people  are hospitalized  today and                                                               
there were  35 on  Friday, so it's  at a bit  of a  steady point.                                                               
How  this  virus  behaves  and how  it  gets  individuals  really                                                               
depends upon  the populations  and the clusters.   The  state has                                                               
done a  very good  job in protecting  its congregate  settings at                                                               
assisted  living homes  and corrections.    As far  as any  other                                                               
further mitigation strategies, he said  the governor is holding a                                                               
press conference tonight to discuss those items.                                                                                
                                                                                                                                
DR. ZINK noted  that DHSS has some additional  information on its                                                               
dashboard that talks  about projected doubling times,  as well as                                                               
the Rt  value.   The projected doubling  time is  currently 18.08                                                               
days, she specified,  so in 18 days it is  expected there will be                                                               
about  twice  as  many  cases.   Alaska's  Rt  has  been  holding                                                               
steadily at about  1.2, meaning if one person has  the virus that                                                               
person gives  it, on average, to  1.2 people, which can  get into                                                               
an exponential climb,  but it just takes a bit  longer.  She said                                                               
DHSS is  also working on  an internal dashboard.   The department                                                               
is working closely  with Dr. Hennessy and his team.   The CDC has                                                               
a surge tool, and the  DHSS team is developing an Alaska-specific                                                               
surge tool  to better  take into  account the  variability within                                                               
Alaska, and the hope is to have it on the dashboard shortly.                                                                    
                                                                                                                                
3:44:43 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  clarified her  question by  noting that  at least                                                               
three  of  the  earlier  testifiers said  that  statewide  health                                                               
mandates would be  helpful in pushing Alaska's Rt  value below 1,                                                               
the  value needed  to  contain  or mitigate  spread.   She  asked                                                               
whether  there  is not  an  existing  strategy  at this  time  to                                                               
revisit  Alaska's reopening  plans  at the  statewide level  with                                                               
additional mandates.                                                                                                            
                                                                                                                                
COMMISSIONER  CRUM  reiterated  that  members  should  watch  the                                                               
governor's press conference this  evening where the governor will                                                               
be discussing this.                                                                                                             
                                                                                                                                
3:45:24 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY  requested Dr.  Hennessy  and  Dr. Papacostas  to                                                               
describe what  they think is  the timeline by which  Alaska would                                                               
need to  take action  on the  response recommendations  that were                                                               
made today.                                                                                                                     
                                                                                                                                
DR.  HENNESSY replied  that it  is difficult  to answer  how soon                                                               
Alaska must act to  avert a problem.  He said  that if the models                                                               
are  correct and  Alaska  is heading  toward  ICU capacity  being                                                               
exceeded around  9/20/20, it  is known  that those  actions taken                                                               
today even  to completely curtail  transmission might  be delayed                                                               
for   two   weeks   in   terms  of   producing   an   impact   on                                                               
hospitalization.  So,  ideally, it should be backed up  as far as                                                               
possible to  prevent the kind  of overflow in hospitals  that was                                                               
mentioned in the  other testimony today.  The  longer [the state]                                                               
waits the  worse it  will get.   The sooner  action is  taken the                                                               
more  cases  and  hospitalizations  are prevented  and  the  more                                                               
suffering that is  prevented.  He continued:  "I  think we are at                                                               
a point now  where we can see  just over the horizon  a time when                                                               
we would exceed  our intensive care capacity and a  lot of people                                                               
would suffer .... The time to act is now."                                                                                      
                                                                                                                                
3:46:55 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY asked  what it  will look  like if  it gets  to a                                                               
point  where Alaska  has  exceeded its  capacity,  and what  that                                                               
would mean in terms of impacts to Alaskans.                                                                                     
                                                                                                                                
DR. HENNESSY  responded that Alaska  could look to  other states,                                                               
such as  Florida, Texas, Arizona, and  California, where hospital                                                               
beds are full  in some locations and physician  providers have to                                                               
make choices about who gets a  ventilator and who gets to go into                                                               
an intensive care  unit.  He explained that there  is a spillover                                                               
effect into other  medical conditions that should be  or could be                                                               
treated in  the hospital system,  but capacity is  overwhelmed by                                                               
COVID cases.  So, [in Alaska]  a ripple effect could be seen onto                                                               
other  health conditions  and emergencies.   He  deferred to  Dr.                                                               
Papacostas and Mr.  Kosin to speak to the  anticipated impacts to                                                               
the healthcare system.                                                                                                          
                                                                                                                                
3:48:18 PM                                                                                                                    
                                                                                                                                
MR. KOSIN stated  that the picture is awful    the story has been                                                               
written  before,  such  as  the catastrophe  in  Italy.    Alaska                                                               
hospitals will step up and change  operations, he said.  "We will                                                               
start to  repurpose the  way we  look and the  way we  operate to                                                               
meet the surge  and the challenge," he stated,  "but that doesn't                                                               
take  away those  hard  decisions that  Dr.  Hennessy alluded  to                                                               
concerning  who gets  the bed,  who gets  the ventilator,  and it                                                               
puts us  in the situation that  is awful."  Action  is needed now                                                               
for Alaska's  hospitals and nursing  homes, he stressed,  and for                                                               
doing  something in  the way  of  how individuals  are acting  in                                                               
terms of masking  and taking responsible steps as a  society.  If                                                               
this isn't done it's going to be a very bad picture, he warned.                                                                 
                                                                                                                                
3:49:39 PM                                                                                                                    
                                                                                                                                
DR. ONDERS  advised that the  longer there  is a delay,  the more                                                               
severe the shutdown needs to be  to slow things.  He related that                                                               
during the month  of June ANMC had the  highest orthopedic volume                                                               
for surgeries it had had all  year because of the pent-up demand.                                                               
There is  plenty of health care  that needs to be  addressed on a                                                               
routine basis.   Significant  life-altering procedures  are being                                                               
delayed,  he  continued, because  they  can  be delayed  or  were                                                               
delayed earlier, and he fears that  those will have to be stopped                                                               
again if action  isn't taken soon enough.  To  keep the health of                                                               
Alaska's  population  ongoing,  the   spread  of  COVID  must  be                                                               
mitigated and  actions taken  about unsafe  activities -  and the                                                               
earlier the  better.  Four weeks  ago he would have  said to take                                                               
those actions now, he noted, but he wasn't asked then.                                                                          
                                                                                                                                
3:50:56 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  LEBON inquired  whether the  presenters have  any                                                               
insights  on how  best to  reopen schools.   He  further inquired                                                               
about  the   percentage  of  positive   tests  for   children  in                                                               
kindergarten through grade 12.                                                                                                  
                                                                                                                                
DR. ZINK  responded that DHSS  has been working closely  with the                                                               
Department  of  Education  & Early  Development  (DEED)  and  has                                                               
established  a  core team  to  support  schools that  includes  a                                                               
physician,  a  family medicine  physician,  a  school nurse,  and                                                               
backup lead  from the DHSS  team.  She  noted that DHSS  met with                                                               
superintendents today regarding  updated guidelines for reopening                                                               
schools  with   additional  details   now  that  DHSS   has  more                                                               
information and CDC guidelines came  out [on 7/23/20].  Regarding                                                               
what  percent of  children  are testing  positive,  she said  she                                                               
doesn't have that information because  DHSS has been breaking out                                                               
by region  more than  percent of children  positive.   She stated                                                               
she would get back to the committee with that information.                                                                      
                                                                                                                                
3:52:53 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE LEBON related he has  been hearing from parents in                                                               
the Fairbanks area regarding schools  reopening.  He said parents                                                               
are telling him  that they "are caught between a  rock and a hard                                                               
spot" in the  sense that they are  trying to go back  to work and                                                               
employers  are  trying to  make  workplaces  safe.   Parents  are                                                               
trying  to juggle  a daycare  facility,  many of  which have  not                                                               
reopened, plus  they are  juggling homeschooling  their children,                                                               
so the stress  level is going way up.   He asked whether children                                                               
are carriers and  likely to pass the coronavirus on.   He further                                                               
asked what the  risk would be of sending children  back to school                                                               
if the schools are able to reopen.                                                                                              
                                                                                                                                
DR. ZINK answered  that DHSS continues to follow  the science and                                                               
data closely  regarding children and their  risk of transmission.                                                               
She said the department also  follows what that overall community                                                               
risk  looks like     how  many cases  are  circulating through  a                                                               
community at this  time.  In the new DEED  guidelines, DHSS talks                                                               
about how to use the risk  alert levels and put that into context                                                               
when thinking  about opening schools.   She said  DHSS definitely                                                               
hears [the  public] with how stressful  this has been in  so many                                                               
different  ways   for  teachers,  families,  kids,   and  working                                                               
individuals in trying to balance  lots of different things all at                                                               
the  same  time.    The  department wants  to  provide  a  steady                                                               
constant guidance and information, but  also be responsive to the                                                               
information.   She  advised that  there is  movement in  the data                                                               
that looks like  children under the age of 10  may be less likely                                                               
to transmit  the disease.   It  is known  that children  are less                                                               
likely to be significantly affected  by the disease.  Children of                                                               
all age  groups are able to  potentially have COVID and  some can                                                               
get very sick.   Generally the younger the child  the better they                                                               
do and  the less  likely they are  to have  significant symptoms.                                                               
While  the  department  did  provide  information  to  the  House                                                               
Education Standing  Committee about this,  she said she  is happy                                                               
to provide  this separately  [to this  committee] and  to include                                                               
the most recent information and DEED guidelines.                                                                                
                                                                                                                                
3:56:07 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY returned attention to the DHSS presentation.                                                                     
                                                                                                                                
3:56:25 PM                                                                                                                    
                                                                                                                                
DR. MCLAUGHLIN resumed the department's  presentation.  He showed                                                               
slide 10 and  said Alaska's current situation  begs the question,                                                               
"What are the  current drivers of the increased  case counts here                                                               
in Alaska?"   He explained that  there are a number  of different                                                               
drivers; it is  multi-factorial.  First, a  much higher incidence                                                               
is being seen in young adults  than in any other age demographic.                                                               
He  advised that  while  not 100  percent  clear, some  potential                                                               
reasons for  why COVID-19  is disproportionately  affecting young                                                               
adults  could  be  because  they   may  be  less  compliant  with                                                               
interventions  like social  distancing, mask  use, hand  washing,                                                               
and potentially  even self-quarantining if they've  been exposed.                                                               
They  may be  more  likely  to congregate  at  parties and  other                                                               
social venues and they may be  more likely to go in physically to                                                               
work  than  their  older  counterparts.    This  disproportionate                                                               
effect  on young  adults  is  being seen  in  Alaska  as well  as                                                               
nationally.                                                                                                                     
                                                                                                                                
DR.  MCLAUGHLIN  specified  that  the  second  issue  is  seafood                                                               
processing facility  outbreaks.  He  related that Alaska  has had                                                               
four large-scale outbreaks in  seafood processing facilities this                                                               
month, with three  of them reported within about  a five-day time                                                               
period.  The  American Triumph outbreak was  all nonresidents and                                                               
the  other three  did involve  some  Alaska residents.   He  said                                                               
these outbreaks are analogous to  the meat packing outbreaks seen                                                               
in  the Lower  48.    Any time  there  is  a congregate  setting,                                                               
whether a work or living  setting, the risk of COVID transmission                                                               
is really increased.                                                                                                            
                                                                                                                                
3:58:46 PM                                                                                                                    
                                                                                                                                
DR.  MCLAUGHLIN   said  the  third  issue   is  widespread  COVID                                                               
activity; all regions  of the state have now  had COVID activity.                                                               
The likelihood of further transmission,  he advised, is increased                                                               
with more cases and the more widely distributed those cases.                                                                    
                                                                                                                                
DR. MCLAUGHLIN stated that the  fourth issue is group gatherings.                                                               
He  said lots  of  people report  that they  were  at a  wedding,                                                               
funeral,  backyard  barbeque,  bar, nightclub,  or  other  social                                                               
gathering.   The likelihood of  transmission is  really increased                                                               
any time people  get together, especially if they  are not social                                                               
distancing by keeping  six feet apart and if  they're not wearing                                                               
face  coverings.    He  related  that early  in  the  epidemic  a                                                               
principal  author in  the CDC's  morbidity  and mortality  weekly                                                               
report wrote that there are four  main drivers of COVID:  travel-                                                               
associated   importations,  large-group   gatherings,  congregate                                                               
living settings, and cryptic  transmission, which is asymptomatic                                                               
or mildly  symptomatic transmission.  Dr.  McLaughlin stated that                                                               
the  group   gatherings  and  the  seafood   processing  facility                                                               
outbreaks are examples of one of those modes of acceleration.                                                                   
                                                                                                                                
4:00:25 PM                                                                                                                    
                                                                                                                                
DR. MCLAUGHLIN spoke to the  fifth issue, household transmission.                                                               
He specified  that the people who  are at highest risk  for COVID                                                               
infection  are  those  who  live  with  someone  who  has  COVID.                                                               
Household  transmission  is  playing   a  big  role  in  Alaska's                                                               
increased case counts, he noted.                                                                                                
                                                                                                                                
DR. MCLAUGHLIN identified  the last issue as  being breakdowns in                                                               
adherence  to  social  distancing,   masking,  and  hand  washing                                                               
guidance.   He said he  thinks this is  probably disproportionate                                                               
in that some  factors of society are following  the guidance very                                                               
closely.  Anybody  who is at higher risk for  illness is probably                                                               
more likely to be following  social distancing, masking, and hand                                                               
washing  guidance.   "The  extent  that  we  are able  to  really                                                               
promote adherence  to these three basic  intervention measures is                                                               
really going to help us curb this epidemic," he concluded.                                                                      
                                                                                                                                
4:01:39 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY offered  her understanding  that  the risk  alert                                                               
levels are  case rates per  population of 100,000.   She inquired                                                               
whether  that was  normalized  for different  areas  that are  in                                                               
smaller population  hubs and the  impact that current  cases have                                                               
in terms of percentages of impact.                                                                                              
                                                                                                                                
DR.  MCLAUGHLIN   replied  that  these  are   rates  per  100,000                                                               
population; so,  they are normalized  in that way.   He explained                                                               
that basically  a rate calculation is  done per day and  then for                                                               
the alert level those rates are averaged over a 14-day period.                                                                  
                                                                                                                                
CHAIR ZULKOSKY asked  what the age range is for  the young adults                                                               
referred to in slide 10.                                                                                                        
                                                                                                                                
DR.  MCLAUGHLIN responded  that  the highest  case  count by  age                                                               
demographic is  in people in  their twenties, the  second highest                                                               
is  people in  their thirties,  the  third highest  is people  in                                                               
their  forties, and  then people  in their  fifties, and  then it                                                               
goes  down from  there, so  a stepwise  progression.   He further                                                               
advised that  an incidence  increase is being  seen in  teens, so                                                               
DHSS is also watching that demographic.                                                                                         
                                                                                                                                
4:03:26 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY  asked what information  is being used by  DHSS to                                                               
make  data-informed decisions  about  remaining  open in  Alaska.                                                               
Given that  group gatherings are  contributing to an  increase in                                                               
case counts,  she said  she would be  interested in  hearing what                                                               
data is  being evaluated every day  to determine what is  open in                                                               
Alaska, considered, and re-evaluated.                                                                                           
                                                                                                                                
DR. ZINK responded  by reviewing the big categories  of data that                                                               
DHSS  looks  at  every  day  and shares  with  the  governor  and                                                               
communities.   She noted  that there  is some  nuance to  this as                                                               
there may be  an outbreak and that changes the  way DHSS looks at                                                               
certain  data.     She  said   DHSS  has  been  looking   at  the                                                               
epidemiology,  the  overall  healthcare  capacity,  testing,  and                                                               
contact  tracing.    Within  epidemiology  DHSS  is  looking  at:                                                               
community transmission  level; risk alert levels;  the overall Rt                                                               
value;  the nature  of the  outbreaks, such  as whether  they are                                                               
discreet,   small,  isolated,   easily  contained,   or  multiple                                                               
outbreaks  involving  multiple  communities   that  are  hard  to                                                               
contain  or involve  high  risk  populations; percent  positivity                                                               
rate as  an early indicator  of disease progression in  any area,                                                               
and whether it  is less that 2 percent, between  2 and 5 percent,                                                               
or greater  than 5 percent,  and DHSS  is looking at  that across                                                               
regions;  new case  rate  over  seven days,  which  is a  shorter                                                               
timeframe that  will help DHSS to  better look at what  is coming                                                               
up down  the pipeline, what DHSS  needs to be thinking  about and                                                               
projecting  for  each  community,  and how  DHSS  needs  to  move                                                               
resources to respond,  and for that reason using  cutoffs of less                                                               
than 5  per 100,000,  5-10, or  greater than  10 per  100,000 for                                                               
each  of those  behavioral health  regions.   Dr. Zink  said that                                                               
also  in  the  epidemiology,  DHSS  is  looking  at  the  overall                                                               
(indisc.)  data,  which  looks  at  COVID-like  illness  such  as                                                               
pneumonia and what  is being seen in the  hospitals and emergency                                                               
departments.   She stated  that DHSS  has looked  at that  in the                                                               
past and  is continuing to follow  that moving forward to  see if                                                               
that is at average, below average, or above average and rising.                                                                 
                                                                                                                                
4:05:48 PM                                                                                                                    
                                                                                                                                
DR.  ZINK continued  her response.   She  advised that  in public                                                               
health capacity  and testing,  DHSS is  looking at  whether broad                                                               
testing can be  done, making sure that a minimum  of 2 percent of                                                               
the population is  tested per month.  Alaska continues  to be the                                                               
third most  tested state per capita  and continues to try  to get                                                               
testing  in  every  region  of  the state,  she  reported.    The                                                               
department looks  at the  testing environment as  a whole  to see                                                               
such things  as whether  there are  region shortages  and whether                                                               
the  ability to  do testing  is being  limited.   Right now  some                                                               
shortages are  being seen,  as well as  a community's  ability to                                                               
test,   that  alternatives   are   available   versus  at   times                                                               
alternatives  are not  available, and  looking at  the turnaround                                                               
time at the state labs, hospital labs, and commercial labs.                                                                     
                                                                                                                                
DR. ZINK  explained that for  contact tracing DHSS is  looking at                                                               
two  major  things:    how   many  cases  per  contact  and  what                                                               
percentage of the new cases  are [the department] able to contact                                                               
within 24 hours as it brings  on additional capacity.  She stated                                                               
that this information would be shared at the press conference.                                                                  
                                                                                                                                
CHAIR  ZULKOSKY noted  she hasn't  seen  any details  or a  press                                                               
release.  She  inquired where and when Alaskans could  tune in to                                                               
the governor's press conference.                                                                                                
                                                                                                                                
DR.  ZINK answered  that the  press  conference is  at 5:00  p.m.                                                               
tonight.                                                                                                                        
                                                                                                                                
4:08:09 PM                                                                                                                    
                                                                                                                                
COLEMAN  CUTCHINS,  PharmD,   BCPS,  COVID  Testing  Coordinator,                                                               
Office of Substance Misuse &  Addiction Prevention, Department of                                                               
Health   &  Social   Services,   resumed   the  DHSS   PowerPoint                                                               
presentation.   He  turned to  slide  12 and  reviewed the  COVID                                                               
testing process.   He  explained that  it is  a medical  test and                                                               
therefore requires an order, the  patient to register, the sample                                                               
to be  collected, the  sample to  be packaged,  the sample  to be                                                               
transported, the sample  to be processed at the  lab, the results                                                               
to be interpreted at  the lab, the result data to  go back to the                                                               
provider,  the result  data entered  into the  provider's record,                                                               
and the result to  the patient.  He pointed out  that only two of                                                               
those nine  steps in the process  actually happen at the  lab and                                                               
within the state lab's control.   Movements have been made within                                                               
the  state lab  and in  other systems  to make  as many  of these                                                               
steps digital and  adapted to an online platform  as possible, he                                                               
related.   The process goes  a lot  faster when people  and paper                                                               
don't have  to handle  certain steps  and technology  and digital                                                               
can take over.                                                                                                                  
                                                                                                                                
4:09:18 PM                                                                                                                    
                                                                                                                                
DR.  CUTCHINS moved  to slide  13  and elaborated  on testing  in                                                               
Alaska.  He  explained that the testing is a  molecular test that                                                               
looks for  and detects the  viral genetic material, which  is the                                                               
most sensitive and specific of all  the tests to detect an active                                                               
infection.  Most  of the testing is done at  Alaska's state labs,                                                               
which  have massive  capacity compared  with  most other  states.                                                               
While  the  state  labs  of  most  other  states  have  very  low                                                               
capacity, they  have large  commercial labs  in state  and Alaska                                                               
doesn't.   He related  that rapid tests  are available  to detect                                                               
the genetic material, but their  limiting factor is that they are                                                               
extremely low volume.   Rapid tests work very well  when there is                                                               
only one or  two or a handful  of people that need  to be tested;                                                               
for example, when admitting someone  to the hospital and it needs                                                               
to be known right away if  the patient is positive.  Rapid tests,                                                               
he  continued, have  been very  beneficial  in small  communities                                                               
with  only a  few people,  as well  as in  cases of  outbreaks in                                                               
congregate living facilities or fish processing plants.                                                                         
                                                                                                                                
DR. CUTCHINS continued  his discussion of slide 13.   He said the                                                               
use of  out-of-state commercial labs  has recently  been expanded                                                               
for those  communities that have  good shipping logistics.   More                                                               
of  the   out-of-state  commercial   labs  are   expanding  their                                                               
"emergency use," he  noted, which is the FDA  approval process to                                                               
allow  for longer  durations for  the  sample to  be in  transit.                                                               
Early on  in the epidemic,  many of the  labs only had  a 24-hour                                                               
emergency use  and it  was very hard  to consistently  get things                                                               
out of Alaska  in 24 hours.   He said another new  thing that has                                                               
been beneficial  in terms of  looking at a multi-strategy  is the                                                               
"direct to consumer" COVID test  where the consumer orders a test                                                               
online, the test is shipped in  a box with instructions on how to                                                               
swab  one's self,  and then  the swab  is sent  back to  the lab.                                                               
Alaskans have had some impressive  turnaround times with of three                                                               
to four  days from the  time of clicking  on the Internet  to the                                                               
time the results come back.   But, he cautioned, things are fluid                                                               
and as demand  ramps up in other parts of  the country things can                                                               
go up and down in terms of turnaround times.                                                                                    
                                                                                                                                
4:12:14 PM                                                                                                                    
                                                                                                                                
DR. CUTCHINS reviewed antigen testing  and serology as he further                                                               
discussed slide  13.   He explained  that molecular  tests detect                                                               
the viral  genetic material, while  antigen tests  detect surface                                                               
proteins on the virus.  Antigen  tests are not quite as sensitive                                                               
and  specific, he  noted, which  means they  have a  higher false                                                               
negative  rate  and  a  higher   false  positive  rate  than  the                                                               
molecular  test.   The advantage  of antigen  tests is  that they                                                               
will  likely  become much  less  expensive  as they  become  more                                                               
readily  available.   Some are  now available  on the  market, he                                                               
continued,  but  given  the current  limitations  they  are  more                                                               
applicable  to  determine if  someone  is  positive if  they  are                                                               
symptomatic.  Antigen tests require  a higher level of the virus,                                                               
so even if someone tests  negative it is considered a presumptive                                                               
negative because the test has  a much higher false negative rate.                                                               
He explained  that serology  is about  looking for  antibodies in                                                               
someone who  has had exposure  to COVID.   The CDC, he  noted, is                                                               
very clear on its recommendations  that serology only be used for                                                               
epidemiologic  survey because  it's unknown  clinically how  long                                                               
immunity will last.   An increasing number of  studies show there                                                               
is significant  reduction in  antibodies after  90 days,  even in                                                               
those who have been infected.                                                                                                   
                                                                                                                                
DR. CUTCHINS continued on slide 13.   He reported that the number                                                               
of  testing locations  is being  expanded  throughout the  state,                                                               
with locations  of the testing sites  shown on the map  of Alaska                                                               
on slide  14.   He said  the state  has distributed  about 30,000                                                               
test  kits for  commercial fishing  and about  25,000 rapid  test                                                               
kits to support  commercial fishing in small  communities.  Also,                                                               
the Alaska  Native Tribal Health Consortium  has distributed lots                                                               
of  rapid testing  to  small  communities and  has  done lots  of                                                               
testing.  He  pointed out that testing has been  done in Alaska's                                                               
airports,  with a  little  over 100,000  passengers  from out  of                                                               
state  screened in  about the  first seven  weeks.   Of those,  a                                                               
little over  50,000 arrived with  a negative test result  in hand                                                               
from prior to travel and a  little over 40,000 were tested in one                                                               
of Alaska's  airports.   Testing is being  done for  travelers to                                                               
keep Alaska's borders open.                                                                                                     
                                                                                                                                
DR. CUTCHINS  noted that the  time it  takes to get  test results                                                               
varies  because  of  Alaska's   complex  shipping  logistics  for                                                               
shipments going  to the state's  high-throughput labs  located in                                                               
Anchorage and Fairbanks.   He further noted  that [variability is                                                               
also due  to] the  availability of  materials and  reagents given                                                               
there  is some  dependency  on things  happening  outside of  the                                                               
state, although swabs and media are produced in state.                                                                          
                                                                                                                                
4:15:02 PM                                                                                                                    
                                                                                                                                
DR. CUTCHINS addressed the topic of  testing in rural Alaska.  He                                                               
drew  attention to  the  map  on slide  14  of  testing sites  in                                                               
Alaska.   He said there  are testing locations across  the state,                                                               
with the locations  shown in green accepting  travel vouchers and                                                               
the locations  shown in  orange not  accepting vouchers.   People                                                               
with travel vouchers  can still be tested at  the locations shown                                                               
in orange, he  continued, but it may be a  different process than                                                               
for those locations shown in green.                                                                                             
                                                                                                                                
DR. CUTCHINS spoke  to the graph on slide  15 depicting statewide                                                               
cumulative  tests by  day.    Early in  the  pandemic the  public                                                               
health  lab  carried   the  bulk  of  testing   in  Alaska,  then                                                               
commercial labs  took over,  and in  mid-May hospitals  and other                                                               
point of  care places  took over,  but all  the while  the public                                                               
health lab has  carried a lot of the testing.   Out-of-state labs                                                               
and shipping  are now starting  to open  up so that  Alaska isn't                                                               
reliant on any one of the three options.                                                                                        
                                                                                                                                
DR. CUTCHINS  turned to the  graph on slide  16.  He  pointed out                                                               
that  in early  April Alaska's  daily  test positivity  was at  4                                                               
percent, and  that since late  June it has been  creeping upward.                                                               
He displayed  slide 17  and reported  that the  last time  he was                                                               
before the committee Alaska was  the seventh most tested state in                                                               
terms of  population and  now Alaska  is third  most tested.   He                                                               
recalled a statement by Dr.  McLaughlin that Alaska will not test                                                               
its way out of COVID.   Testing, while extremely helpful in terms                                                               
of  early  identifying  of  outbreaks and  figuring  out  who  is                                                               
infected, won't be the sole reason  that will negate risk of this                                                               
disease.                                                                                                                        
                                                                                                                                
4:18:14 PM                                                                                                                    
                                                                                                                                
TARI  O'CONNOR,  Deputy  Director,  Division  of  Public  Health,                                                               
Department  of Health  & Social  Services  (DHSS), continued  the                                                               
DHSS PowerPoint presentation.   She addressed the  topic of surge                                                               
capacity  for  contact  tracing.    She  explained  that  contact                                                               
tracing is  an essential element  of the department's  efforts to                                                               
test,  isolate, find,  and quarantine  to prevent  the spread  of                                                               
COVID-19.                                                                                                                       
                                                                                                                                
MS.  O'CONNOR brought  attention to  slide 19  and discussed  the                                                               
five  priorities for  contact  tracing:   coordination,  quality,                                                               
confidentiality  and  privacy,  scalability, and  build  capacity                                                               
Alaska can use for future  responses.  In regard to coordination,                                                               
she said  the priority  is being  able to  coordinate assignments                                                               
for a statewide  workforce, being able to flex  that workforce to                                                               
provide  capacity where  it is  needed, and  being able  to share                                                               
information among that workforce so  the work on individual cases                                                               
and contacts is coordinated and  people can pick up where someone                                                               
else left  off.  She stated  that the priority of  quality speaks                                                               
to a high level of training  in health and public health that the                                                               
contact  tracers  have.    She specified  that  the  priority  of                                                               
confidentiality  and privacy  is  related to  complying with  the                                                               
Health Insurance Portability and  Accounting Act of 1996 (HIPAA),                                                               
and speaks to  how DHSS structures its  agreements with partners.                                                               
Regarding scalability, Ms. O'Connor said  DHSS is trying to build                                                               
this workforce in  a way to be  able to respond to  needs so that                                                               
when the  need is  low DHSS is  able to not  have as  many people                                                               
engaged, but  to be able to  add workforce if needed.   In regard                                                               
to the fifth  priority, she explained that while the  focus is on                                                               
the  current response,  the  department is  trying  to build  the                                                               
capacity  in a  way that  Alaska  can use  for future  responses.                                                               
This  is  being  done,  she continued,  by  working  with  Alaska                                                               
institutions and  Alaskans who will  be here the next  time there                                                               
is a response.                                                                                                                  
                                                                                                                                
4:20:44 PM                                                                                                                    
                                                                                                                                
MS. O'CONNOR  stated that slide  20 shows "where we've  been, and                                                               
where we  are today,  and where  we hope  to go."   Prior  to the                                                               
start  of the  COVID  response,  she said,  there  were about  75                                                               
contact  tracers working  statewide  within the  DHSS Section  of                                                               
Public  Health Nursing,  the DHSS  Section  of Epidemiology,  the                                                               
Anchorage Health  Department, the  Maniilaq Association,  and the                                                               
North Slope Borough.  The workforce  has now been expanded to 190                                                               
contact tracers.   To do this,  she explained, DHSS had  to build                                                               
some  systems that  are different  than  the infrastructure  that                                                               
supported  the  initial  group of  individuals.    This  expanded                                                               
number  of contact  tracers represents  additional hiring  within                                                               
the  DHSS Section  of Public  Health Nursing,  as well  as adding                                                               
partnerships with the Anchorage  School District, Yukon Kuskokwim                                                               
Health   Corporation,   ANTHC  Epidemiology   Center,   Fairbanks                                                               
Memorial  Hospital,  CDC  Arctic Investigations  Program,  Alaska                                                               
National  Guard/Air  National   Guard,  Kenai  Peninsula  Borough                                                               
School  District,  and  University  of  Alaska  Anchorage.    Ms.                                                               
O'Connor related that the goal  is 500 contact tracers statewide,                                                               
which is  based on some national  projections for Alaska.   To do                                                               
this,  more  tracers will  be  added  through the  University  of                                                               
Alaska Anchorage, as well as  through the Juneau School District,                                                               
Fairbanks North  Star Borough School District,  Matanuska Susitna                                                               
Borough School  District, and community  health centers/federally                                                               
qualified health centers/tribal health organization.                                                                            
                                                                                                                                
4:23:33 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ remarked that  she is pleased the number                                                               
of contact  tracers is up  to 190, but  she pointed out  that 500                                                               
tracers  has been  the  target  for some  time  now.   Given  the                                                               
significant surge,  she asked whether  anything could be  done to                                                               
speed up the onboarding of new contact tracers.                                                                                 
                                                                                                                                
MS. O'CONNOR replied  that to go from several dozen  tracers in a                                                               
few organizations to this much  larger workforce, DHSS has had to                                                               
do  some work  around  building the  systems and  infrastructures                                                               
that would allow this larger  workforce.  She explained that this                                                               
has required the  building of an entire new training  system.  To                                                               
do this, DHSS  partnered with the University  of Alaska Anchorage                                                               
College of  Health, and  now it is  a statewide  virtual training                                                               
system.   She further  explained that  DHSS also  had to  build a                                                               
data management  system, so the  department brought  the CommCare                                                               
Case  and Contact  Management  System online.    This new  system                                                               
allows  DHSS  to manage  all  of  the information  on  individual                                                               
contacts  and  cases,  and  also  allows  coordination  of  staff                                                               
assignments among the workforce shown on  slide 20.  She said the                                                               
last piece that DHSS had to build  in order to bring on this much                                                               
larger  workforce was  a security  and privacy  infrastructure to                                                               
ensure  everything is  HIPAA  compliant.   These  three things  -                                                               
technology, training,  and security  and privacy -  required DHSS                                                               
to build  a lot  of infrastructure before  it could  bring anyone                                                               
on.  That infrastructure is now  built, she said, so DHSS expects                                                               
workforce additions to be much  faster from hereon.  For example,                                                               
50 tracers  have been  brought on  since DHSS  last spoke  to the                                                               
committee  and the  department  anticipates  bringing on  roughly                                                               
that same number in the next week or so.                                                                                        
                                                                                                                                
4:27:06 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ stated  she is happy to hear  this.  She                                                               
related  that she  recently  heard that  contact  tracers in  the                                                               
Anchorage  area  are  required  to  be in  one  place,  which  is                                                               
concerning.    She asked  whether  there  is  a way  for  contact                                                               
tracers to  be distributed  throughout the  state, so  they don't                                                               
have to congregate.                                                                                                             
                                                                                                                                
MS. O'CONNOR responded  that DHSS is in the process  this week of                                                               
onboarding  the Anchorage  Health  Department  into the  CommCare                                                               
system.  An  advantage of the new CommCare system  is that it can                                                               
be accessed  from either the  workplace or a personal  device, so                                                               
people can work  remotely.  The partners of DHSS  will make their                                                               
own decisions as  to where they want staff to  work, but this new                                                               
system will enable staff to work remotely in new ways.                                                                          
                                                                                                                                
4:29:14 PM                                                                                                                    
                                                                                                                                
MS. O'CONNOR  displayed slide  21 and  summarized her  portion of                                                               
the presentation.   She reiterated  that contact tracing  is part                                                               
of  the   department's  effort  to   test,  isolate,   find,  and                                                               
quarantine to  prevent the spread  of COVID-19.  She  stated that                                                               
the department  doesn't currently have enough  workforce capacity                                                               
to implement  all of the steps  of contact tracing that  it would                                                               
normally do.   So, the  department is currently  prioritizing the                                                               
higher risk cases and the  higher risk contacts and will continue                                                               
to  assess this  as  it  adds new  capacity.    About 50  contact                                                               
tracers have been  added within the last month  and an additional                                                               
238  have  completed training  within  the  University of  Alaska                                                               
Anchorage's workforce.  She added  that the department's partners                                                               
are now  using the CommCare  case and contact  management system.                                                               
The department  is looking at  streamlining the process  to train                                                               
and  onboard  staff,  such  that  the  process  this  week  looks                                                               
different  than the  process used  last week.   Further,  DHSS is                                                               
focusing  on lessons  learned, team  structure, and  coordinating                                                               
assignments  to maximize  efficiency.   Ms. O'Connor  stated that                                                               
quality  assurance and  quality improvement  are challenges  that                                                               
DHSS is meeting by having the  new CommCare system and being able                                                               
to understand the  data closer to real time.   She explained that                                                               
quality  assurance looks  back at  the training,  technology, and                                                               
security environment that support  the department's commitment to                                                               
quality.                                                                                                                        
                                                                                                                                
4:33:16 PM                                                                                                                    
                                                                                                                                
HEIDI HEDBERG,  Director, Division  of Public  Health, Department                                                               
of Health  & Social Services  (DHSS), provided the  final portion                                                               
of the  department's PowerPoint presentation.   She recalled that                                                               
at the  beginning of  the pandemic  there was  lots focus  on not                                                               
having  sufficient  resources at  Alaska's  hospitals  or in  the                                                               
communities to respond  effectively to the pandemic.   She showed                                                               
slide  23 and  discussed  the statistics  of  the medical  supply                                                               
shipments  as of  7/27/20.    She said  DHSS  has received  1,028                                                               
resource requests  at the state  emergency operation  center, and                                                               
of those  requests the department  is serving 62  communities and                                                               
269 individual  organizations, and  has shipped out  numerous key                                                               
resources,  [gloves,  surgical  masks, N95  masks,  gowns,  TYVEK                                                               
suits, face shields, and swabs].   The supply chain is continuing                                                               
to open  up, she related,  although it  is slow in  some specific                                                               
areas  such as  caps,  gowns,  and shoe  covers.    A variety  of                                                               
vendors are  being worked with to  ensure that DHSS has  stock so                                                               
that if  a community or  hospital is  unable to procure  then the                                                               
department is able to meet that need.                                                                                           
                                                                                                                                
MS. HEDBERG  brought attention to the  bar graph on slide  24 and                                                               
said DHSS  values the  partnership of  the Alaska  State Hospital                                                               
and  Nursing Home  Association.   She explained  that DHSS  works                                                               
with the association  on a daily basis.   The association surveys                                                               
all of  the hospitals and  asks where  the hospitals are  at with                                                               
their supplies.  The department  is then able to review, monitor,                                                               
and understand  what are the  hot commodities, what  is difficult                                                               
to procure, and how can DHSS  leverage at the state level some of                                                               
these procurement  contracts.  She  noted that yellow on  the bar                                                               
graph means  a supply  wasn't provided,  blue means  it's greater                                                               
than 60  days, green  denotes 30-60 days,  and grey  denotes less                                                               
than  30 days.   She  indicated that  overall the  hospitals have                                                               
sufficient stock on hand.                                                                                                       
                                                                                                                                
MS. HEDBERG  moved to  slide 25  depicting a  graph of  the total                                                               
hospitalized  positive COVID  patients in  Alaska as  of 7/27/20.                                                               
She  credited   the  Alaska  State  Hospital   and  Nursing  Home                                                               
Association  for  providing  these  statistics.   She  said  DHSS                                                               
monitors these hospitalization numbers very closely.                                                                            
                                                                                                                                
MS. HEDBERG  displayed slide 26  and concluded  the presentation.                                                               
She stated  that DHSS wants  to ensure it is  getting information                                                               
out and has  therefore centralized its communications.   She said                                                               
committee members  are welcome to  share with  their constituents                                                               
that  questions  regarding  COVID  can  be  emailed  to  DHSS  at                                                               
covidquestions@alaska.gov  and questions  regarding  data can  be                                                               
emailed to data.coronavirus@alaska.gov.                                                                                         
                                                                                                                                
4:37:22 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY thanked  the presenters,  Commissioner Crum,  and                                                               
Dr. Zink.  She further thanks  all the physicians from around the                                                               
state who  have contacted  the committee.   She said  the message                                                               
has come through loud and clear that the time to act is now.                                                                    
                                                                                                                                
4:38:28 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at 4:39 p.m.                                                                                                          
                                                                                                                                

Document Name Date/Time Subjects
07.28.2020 - HHSS Update Final.pdf HHSS 7/28/2020 2:30:00 PM
DHSS COVID-19 Update 7.28.2020