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WC CWF Health District Board Minutes - 11/13/2020 WICHITA FALLS-WICHITA COUNTY PUBLIC HEALTH BOARD MINUTES November 13, 2020 Wichita Falls-Wichita County Public Health District 1700 Third Street—Zoom Video Conference Wichita Falls, Texas BOARD MEMBERS PRESENT: David Carlston, Ph.D., Chair Citizen At-Large-County Appointment Keith Williamson, M.D., Vice-Chair Physician -City Appointment Julie Gibson, D.V.M., Secretary Veterinarian -City Appointment Lauren Jansen, Ph.D., R.N. Registered Nurse—City Appointment Melissa Plowman Restaurant Association - City Appointment BOARD MEMBERS ABSENCE: Tonya Egloff, D.D.S. -Excused Dentist- County Appointment Paris Ward, M.A., B.S. - Unexcused Citizen At-Large-City Appointment OTHERS PRESENT: Lou Kreidler, R.N., B.S.N. Director of Health Amy K. Fagan, M.P.A. Assistant Director of Health Michael Smith City Council Liaison Woodrow W. Gossom, Jr. County Judge I. CALL TO ORDER David Carlston, Chair called the meeting to order at 12:03 pm after a quorum of members was attained. II. APPROVAL OF MINUTES AND ABSENCES David Carlston called for the approval of minutes. Lauren Jansen introduced a motion to approve the minutes, Julie Gibson seconded the motion. The motion passed unanimously. III. COVID-19 UPDATE Amy Fagan, Assistant Director stated in the last 30 days there has been an explosive number of cases and deaths. Since the last Board meeting the number of hospitalizations and daily average number of hospital beds occupied with current active cases of COVID-19 increased substantially. The hospital held a Press conference that spoke specifically on critical care beds and concern of the primary hospital and trauma service area being inundated with COVID positive patients and the secondary effects that may have. A basic analysis of 30 days over 30 days was addressed to convey a perspective realization of the increases. In a timeframe from 10/12 to 11/11/2020 of Wichita County residents in the last 30 days, COVID-19 hospitalizations went from an average of 14 people to 65 each day a 364% increase. Total new cases in the last 30 days 2,781 in the 30 days prior 862 a 223% increase. It is heard a lot that there is going to be more cases because more tests are being conducted, while that is true to a degree the new tests or number of increased tests is not correlated with the percent increase in cases. Some of the increase maybe because of more testing, however have seen more test results that are positive then prior. Total new tests in the last 30 days 10,759 in the 30 days prior 6,330 a 70% increase. The positivity rate of those tested positive in the last 30 days 25.8% in the 30 days prior 13.6% a 90% increase. Positivity rate is-what the Centers for Medicare and Medicaid (CMS) services use as an indicator for the burden of disease in a community and associate certain activities with that percentage. Local facilities, nursing homes are now required by CMS to test residents and staff about twice a week because of Wichita County high positivity rate. Deaths of residents with an active case of COVID-19 in the last 30 days 64 in the 30 days prior 8 a 700% increase. Fundamentals of the Public Health process are anyone that tests are required within 24 hours to report test results whether positive or negative, the information is entered into a case list, determination is made whether in or out of jurisdiction, the information is given to case managers hired contact tracers, reports are turned in each day from case managers,Amy reviews each report to determine type of spread, case managers do the exclusion from work/return to work and school/return to school. Community Spread is 33% of cases it is not known how the person contracted COVID no link to anyone else. Travel has decreased substantially. Close Contact is a household contact anyone under one roof. Contact is any other type of contact where there is an index case. Under Investigation is where staff is still actively working to gather information. The following new data is aimed to have people understand what is being dealt with and what can be done to possibly stop or reduce the spread. In the 30-day window of those 2,781 cases Amy took sub-data that was turned into 30 days of Contact, the Contact sub-group Employee is the most type of spread and another the Co-worker. A co-worker is where indicated on the case report worked directly with another person with COVID, confirmed from the Master List the individual worked with the other individual during which individual A was symptomatic a direct cause of link. Employee is where there is not a direct cause of link to a second employee that is documented within that time frame but works in a facility with an active outbreak. Active means 1 or more cases within the time in which someone would have been symptomatic (work back to 2 days prior to symptom onset). A High Consequence Infectious Disease (HCID) is an outbreak that typically constitutes of 2 or more people in a location, but it depends if it is a large manufacturing plant with no one close to each other it is not an outbreak. Not sure why or how it happens but one week it is banks and credit unions, one week churches, last week hair dressers, barber shops and this week fast food locations. Essential care givers and facility residents had a drastic increase in cases in a 30-day time frame. Typically, the residents physically take longer to recover those with symptoms are an active case for longer than the 14 days or 10 days asymptomatic. Friends is where a friend came over to their house, went to do laundry at a friend's house, or went out spent time together, it is documented the friend had COVID within a time frame, all links are checked and confirmed. Family Close Contact is where most families contract COVID from one another that is where there is family outside the home. Church has been less in the last 30 days because it was outside the outbreak about 5 weeks ago with 8 Churches total. Relationships is girlfriend/boyfriend. Car Ride for some reason being in a car with someone seems to increase the probability to contract COVID from someone. Sports is challenging received a call today, a WFISD sporting team had one of the students not feeling well but did not want to let the team down so traveled on the bus and all have to quarantine. Often hear from the parents and students alike was not feeling quite right but had a sport to play and a team to support, especially when it seems like allergies. Extra- curricular sports such as gymnastics, soccer, those type of things school age children play outside the school environment. Medical where there is a positive link between a patient and provider or vice versa. Number of students in the School Districts or Universities with COVID is where there is a causal link between a student to student. Bars is where someone would be in a bar with an identified person that has COVID within their symptomatic period. A lot of activity captured in the community spread category are funerals, hair salons, barbers, weddings, adult sports, school sports and sports outside the extra-curricular. Councilor Smith said Dr. Von Gray had some projections of the future, did any of his work show the current surge. Amy Fagan replied that the models Dr. Gray came up with did not pan out for this community. It had been very low and done so well compared to other Communities through about September then things blew up. The rate of incline is substantial compared to other Cities just makes you wonder if having done such a great job as a community in the summer that everybody went we are not affected and it went crazy. The University of Texas Austin came out with a report titled, Texas Trauma Service Area (TSA) COVID-19 transmission estimates and healthcare projections: Oct 20 update, our area was associated with one of the higher in the State of Texas, a 78% chance in an increasing phase of COVID, that was right. Some time lines were set for a time by which the hospital capacity would be exceeded a 30% probability within 3 weeks, kind of the same thought process Dr. Gray put out initially. At that time El Paso had an 85% probability to be exceeded, next Wichita Falls at 30%, Lubbock at 29%then Amarillo at 28%. Statistical data provides a foundation by which to plan, their projective COVID hospital census did not necessarily pan out but did give the indication of a challenging predicament. Those models still do not give great indications of how it is going to be in the next 30 days, it cannot be as accurate as seen in terms of outcome because it is people, their behaviors can often change that. The State determines the hospitalization rate based on all Trauma Service Areas(TSA's) is the number of available beds, type of bed and percent of use. About a month ago the Governors order said if a TSA hit 15% or higher the State could or would deploy assets to that region, as in El Paso because their hospitalization rate was incredibly high. Here it had steadily maintained around 4%then jumped to 9%with an increase of 70 hospitalizations. Councilor Smith asked if the SAFB students here temporarily going home for Thanksgiving and/or Christmas, with them going home and returning what would be the effect on others. Amy Fagan said she works closely with SAFB every day, Operation Thanksgiving was cancelled, going home for the holidays has not been discussed but when she finds out will let him know. Lou Kreidler stated the same situation is around Midwestern with the students and asked Dr. Williamson if he would like to address that. Dr. Keith Williamson responded since September 1st had 148 positive cases on campus and currently 34 still in isolation. The plan at the beginning of the semester was to shorten the semester after the Thanksgiving break with only two weeks of classes left they would be done entirely on line, encouraged students to move out Thanksgiving then telecommute to finish up the week and last week finals. In actuality discovered in talking to students many of them still plan to go home and return to their dorm rooms being more in a college environment can focus better in their dorm rooms than at home, so indeed may have some traveling to other parts of Texas and Oklahoma and returning here. Most of the international students will stay and not go home for the holidays as their concerns of not getting back into the Country. His anticipation for the spring semester is they are going to have to redo things in the way they do contact tracing and tracking. He thinks they have been very successful in the endeavor a large part support from the Health 2 Department. Also had a very aggressive quarantine policy for all the students who live on campus in dormitories because those are fairly close living circumstances. Amy Fagan said consistently over time seen the highest group with COVID are the 20-29 year olds, the CDC said basically they take it home to parents and grandparents. The 0-5 year olds decreased over time as a percentage, 6- 10 years remain consistent, 11-19 years consistently gone down since the beginning of school. The week of the uptick in church cases was also the week with a substantial increase in the 30-39 and 50-59 with the 60-69 years a significant change. Deaths in the 60+ category from the beginning went from 2 to 5 to 8 and now 9, in the 80+ chances are not engaging in risky behavior but being exposed to those with a higher probability of the disease then contract it. Over and over hear people do not understand the symptoms of COVID and those have changed over time. In the last month seen symptoms that look and feels like pink eye but it is not aneye infection, also tingling on the tip of the nose. Still get the do not have a fever, not an elevated temp, none of those things, get people with just a headache, less than 50% of cases have a fever, people surprised that the runny, stuffy nose is still a big component of COVID something to be aware of. The SAFB contact sent a response for Councilor Smith that airmen cannot go home for Thanksgiving they are going to be on the base, they are going to be released for Exodus as tradition that will be in December. This is merely information from the contact not an official SAFB statement. Lauren Jansen asked if anyone can elaborate on new treatments or what has helped with COVID as far as medications. Dr. McBroom replied there are newer treatments but they are only effective after infection has already taken place. So what is desperately needed is to ramp up our reference for pre-exposure protection which will be of course the vaccine program, evidently the vaccines have fairly high effective immune value. In addition to that the only other thing desperately needed would be oral medication for outpatient treatment to be used as pre-exposure and post-exposure prophylaxis to minimize the spread, unaware of any of those or any currently being investigated for use. Based on his observations and interacting with a Rheumatologist in town there have been very few cases of immunosuppressed individuals already on Hydroxychloroquine in normal therapeutic doses being admitted, only very mild disease or not caught it. That would have been a good possible pre-exposure and post-exposure prophylaxis agent, it has not been tested in that capacity only tested in severely ill patients, evidently the toxicities were what threw it out. It has not been adequately studied and does not see it to be considered to be brought back on the table at this time. What we have is what we have already been doing with the masks, the other hygienic and contact precautions put in place. Education is another thing to keep doing, still a lot of people a little loose in their distancing and behaviors that put everybody at risk,feeling their symptoms are allergies go about their business, subclinical is the greatest danger most likely to spread to other individuals who are unprotected. Councilor Smith asked Dr. McBroom if he knew the new drugs name the FDA was looking into for use as a treatment. Dr. McBroom thinks it is Bamlanivimab a monoclonal antibody a treatment agent antibody that binds to the spike proteins of the virus an infusion to target cells. They have ramped up the effort to get it at United Regional. He understands it is a very good drug but only for outpatients it is not indicated for inpatients, so that would be good for post-exposure maybe even for post-exposure prophylaxis. At this time, it is only indicated for people with mild disease going to be treated as an outpatient that has to be given IV. United Regional has a policy right now they are trying to work through in regards to try to obtain it and give it IV without exposing unnecessarily to the risk of infection to the hospital employees or the other outpatients that come to the infusion center. Probably going to need to try to work with other Community Physicians, he knows Dr. Nagra the other Infectious Disease Specialist in town is trying to look into being able to use that at her infusion center. It is still investigational because it is only released on Emergency Use Authorization however he thinks emergency use is probably going to be a bit lax. There are several other agents out there available on Emergency Use Authorization that look good, those might be looked into as well, a lot of them are very similar,will take them as they are released and work with them one by one. He is still looking for the drug company that can produce a considerable prophylaxis agent because that is going to give the best protection, that and the vaccines if they perform as the pharmaceutical companies say with 90% protection will have to see how it works out. Councilor Smith stated it was said one of the problems with Bamlanivimab once FDA approval there will not be a lot of doses, even by the end of the year only a couple million doses plus it was hard to produce. Dr. McBroom said it belongs to classifications called monoclonal antibodies or biological therapy some of the ones you may be familiar with go by the name Enbrel or Humira. All are used in some capacity in the Rheumatologic diseases both are difficult to produce and like everything else even water can be toxic. All biologic therapies have toxicities, side effects that have to be monitored closely, nothing is absolutely safe but overall they are probably safer than risking complications from COVID. They are going to try it and see if it can improve the outcome of some of the hospitalized cases to get them home sooner and ease the surge. Lauren Jansen asked if the hospital is using Remdesivir? 3 Dr, McBroom replied yes, using it very expensively. The good news is when Remdesivir was received and used it in cases there was a threshold of initiation, unfortunately set to high by the manufacturers who control the drug study. Now with an ample supply of Remdesivir have used it earlier before people start to show signs of progression to severe disease and organ failure. Like everything else he has found that these medications work much better,more reliable when initiated earlier in the course of the disease rather than later. This is a learning curve it took 35 years to learn how to use ACT with AiDS and longer to determine that people would probably do better if started right after diagnosis instead of waiting until their immune system is about to crash. So results are a tremendous success with HIV but in the early days not knowing how to use it probably hurt more people than helped and that Is the same process going on here. They do not know how to use these medications he thinks Hydroxychioroquine was not given a good chance it was started out to late in the course,not used prophylactically,not studied at any meaningful way, but that is the way science is and progress Is. The biggest benefit is there are some good candidate vaccines to prevent and hopefully some good medications, like Remdesivir that seems to be working better having lowered the threshold to begin treatment with hospitalized patients. A whole lot more medications are needed available for outpatient use. The biologic Bamlanivimab Is going to be a good therapeutic agent on an outpatient basis, delivery is going to be difficult because it is.IV but he thinks they have a plan in place to get that started. Never the less a good oral therapy for outpatient treatment and for pre-exposure prophylaxis would be as good as well. Lauren Jansen asked if Hydroxychloroquine was not able to be used at all. Dr. McBroom said social media has pretty much killed it, he still uses it every now and then, he had at least as good success with it as he did Remdesivir when it came available. It has toxicities that is all history like ACT in the 80's, 10 times the amount was given because they did not know how it was used turned out very little was needed to do an efficient job to kill the HIV virus which is a RNA virus just like Coronavirus, had hoped to try some of the HIV meds. There have been no good studies none of the literature supports much of anything because of too hastily done,with time will get infection under control will get some medications to stop the progression and improve outcomes,hopefully prevent infection all together but it takes time. Yes, Hydroxychloroqulne may have been a good agent even prophylactically it just got too much bad press. A lot of rheumatoid, lupus and other patients with rheumatologic diseases on smaller doses of Hydroxychloroquine, have not seen a great number of patients either contracted or had significant complications from COVID. The hospital epidemiologist April Little is going over the data on that so we can see and compare just how significant the Hydroxychloroqulne factor may be. He discussed with Dr.Wagler and Dr. Shiner,two excellent Rheumatologist in town what their situation has been with their patients on Hydroxychloroqulne, not a great number of their patients have been infected. Do not make any conclusions about that it is purely antidotal and physicians conversation about their experience, certainly no statistical analysis would be possible. He read one article that suggested that Hydroxychloroqulne could be protective based on the patients in the Rheumatoid arthritis populations whom do not seem to be severely affected. Personally he would like to bring back Hydroxychloroquine if there was not so much bad press but now is not the time. Lou Kreidler thanked everyone who agreed to serve another term it is nice to have the same board in the midst of a pandemic and your willingness to serve the community and Health District is appreciative. They are to meet with the ' . State not a great deal is known about which vaccines will be out, looking at vaccine storage capacity and meeting with Community Partners. The outreach team is aggressively reaching out to all Wichita County medical facilities to get them to sign up on the DSHS website to be COVID-19 vaccine providers. The more individuals getting the vaccine in the community the better off the community will be. There are plans in place, meeting actively and working with the community partners to insure that when there is a vaccine will be ready to go. Melissa Plowman would like to thank Lou,Amy and the Department,our county has been blessed with their leadership, appreciative for all that they have done. Melissa Plowman called for a motion to adjourn. Julie Gibson introduced a motion to adjourn, Keith Williamson seconded the motion and the meeting adjourned. • IV. NEXT MEETING DATE Friday January 8,2021 was noted as the next meeting date. V. ADJOURN • Melissa Plowman adjourned the meeting at 1:07 pm. gnature // al of 4f Print Name-Davl'd Certston,PhD, Chair, Keith Williamson,MD, Vice-Chair,Julie Gibson,DVM, Secretary 4