Legislature(2019 - 2020)BETHEL
07/28/2020 02:30 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
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| Presentation: Covid-19 in Alaska: a Mid-summer Update on Pandemic Response & Containment Strategies | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
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
[email protected] and questions regarding data can be
emailed to [email protected].
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 |