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Closure of rural hospitals places Alabama at disadvantage in COVID fight

Chip Brownlee | The Trace

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Whether Alabama’s health care system will be able to handle the coronavirus pandemic will depend on its people.

The infectious disease specialist leading the UAB Medicine’s response to the coronavirus outbreak urged Alabamians to take social-distancing measures seriously to blunt the exponential growth of coronavirus cases in the state so as to not overload health care facilities.

An unmitigated spread of the virus—not to be alarmest—could cripple Alabama’s hospitals and leave doctors and other medical workers in horrible situations. Blunting the number of new cases in the near term by limiting social interaction and practicing good hygiene is the only way to prevent a health care crisis, experts warn.

On a call with reporters Monday, Dr. Jeanne Marrazzo from UAB said the closure of rural hospitals, the growth in the number of cases in the state and the potential for a ventilator or ICU bed shortage if the growth curve of COVID-19 cases isn’t blunted is “frightening.”

“In Italy, they don’t have enough,” Marrazzo said. “They are actually having to make decisions about taking people they believe are not going to survive off ventilators to reassign them to people. We do not want to be placed in that excruciating situation. It’s about the worst possible thing I can imagine as a physician, talking to a family about that or dealing with that. I don’t believe there’s any indication we’re going to get there. But again, my assurance is all based on my belief that we can deflect this curve and not be where Italy is right now.”

Marrazzo said UAB has about 300 ventilators ready for use, which should be enough if the number of cases is limited through social-distancing measures.

But there remains a larger question about the state, and whether the state as a whole has enough ventilators and ICU beds to deal with the COVID-19 epidemic.

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“We well know that many rural hospitals have been closing, right,” Marrazzo said. “We’ve been losing a lot of our smaller hospitals. Even those that have remained open may not have a deep staff to take care of critically ill patients. That’s when things do get frightening, and you do need to think about expanding your capacity at a place like UAB or a central place. We have contingency plans that we have been discussing. So this is basic disaster preparedness that people are actively pursuing. But I want to reassure people, we’re definitely not there. And we will be keeping very close, close track of this and updating you all as it comes on.”

Earlier Monday, Alabama Department of Public Health state health officer Scott Harris and Emergency Management Agency director Bill Hastings urged the state to take extra precautions to avoid spreading the disease any further.

“This is a human disease that is going to require a human response, which is going to require a whole of government response, which will require a whole of society response,” Hastings said. “A mobilization of all Alabamians, all U.S. citizens to reduce and slow the transmission of COVID-19. So it stays at or below or around the max capacity of our health care system. That is the fight that we’re in right now.”

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The Department of Public Health is monitoring the total number of intensive care beds available and ventilators available for use in the state. Hospitals are required to report their numbers to the ADPH daily—sometimes more often. That number is not publicly available, but some estimates have placed the ICU bed capacity in Alabama’s hospitals at between 1,000 and 1,600. In total, there are about 16,000 hospital beds in Alabama. Most of those are already at use today, and a growing outbreak of coronavirus will undoubtedly put a strain on Alabama’s hospital system.

Just how bad that strain will get is not yet known. Experts have said that more than 50 percent of the population could become infected with COVID-19—some have placed that number higher at 70 percent. Research out of China indicates that about 15 percent of people who are infected require hospitalization and about five percent require intensive care. Alabama has a population of 4.8 million. So at some point, 120,000 could require intensive care in the state and 360,000 could require hospitalization.

Of course, all of those cases won’t happen at once, but the number illustrates the importance of reducing the rate at which cases multiply across the state.

Harris, during the press conference on Monday, said there is no reason to be worried yet.

“Do we have enough beds and ventilators? Yes, we have been tracking the number of our bed capacity and our ventilators for about a week now using the Alabama Incident Management System,” Harris said. “At this time, we do not have any hospitals that are having issues with surge capacity that we’re aware of. And we track that daily. So we don’t think that’s an issue at the moment. Clearly, that’s always a concern when you’re dealing with a respiratory illness like this, and so we’ll continue to monitor that.”

This story will be updated.


Transcript of the Q&A

Q: This is Chip Brownlee with the Alabama Political Reporter. Dr. Marrazzo, I was wondering if you were—how you feel about the way that the state has handled this so far. And also, what’s your read on the preparedness level in terms of ventilators? I know you just talked about that. But do have any concerns, for Alabama in particular, that we’ll have enough ICU beds and ventilators to handle the cases?

Marrazzo: Sure. Great, great questions. I think that the governor has taken it very seriously. She’s convened a task force of which I’m a member and Dr. Harris is the leader. We’ve met several times in the last several days and I have a call actually, at one o’clock today. They have been—the leadership has been incredibly receptive to our suggestions and our feedback. So I think based on the state of emergency that was declared last Friday, the administration has been very responsive. I do think that as you’ll hear more emphasis particularly, particularly from local health departments like Jefferson County, on some of the more aggressive social-distancing measures, that the state government is going to need to amplify those messages.

You know, you saw all the pictures of people partying this weekend for St. Patrick’s Day, all the invulnerable people out there at the bars. I’m happy for them. But I’m very worried for us. I really don’t think people should be out doing that right now. And we all have to give a little bit to protect our community. So that’s a really important message. And I think the governor will be very on board with that, given the data.

Your second question about ventilators is a great one. We have, for example, at UAB hospital, I think it’s about 300 ventilators. So we have a lot. Is that going to be enough? In Italy, they don’t have enough. They are actually having to make decisions about taking people they believe are not going to survive off ventilators to reassign them to people. We do not want to be placed in that excruciating situation. It’s about the worst possible thing I can imagine as a physician talking to a family about that or dealing with that. I don’t believe there’s any indication we’re going to get there.

But again, my assurance is all based on my belief that we can deflect this curve and not be where Italy is right now. There are I like your question about the rest of the state though because we well know that many rural hospitals have been closing, right. We’ve been losing a lot of our smaller hospitals, even those that have remained open, may not have a deep staff to take care of critically ill patients. That’s when things do get frightening, and you do need to think about expanding your capacity at a place like UAB or a central place. We have contingency plans that we have been discussing. So this is basic disaster preparedness that people are actively pursuing. But I want to reassure people, we’re definitely not there. And we will be keeping very close, close track of this and updating you all as it comes on.

Q: This is Chip again, I’m wondering what you think about—some people have suggested that some of the hospitals across the state that have closed might need to be reopened. I’m wondering, given your experience, how likely you think that would be to happen, like, what would, what would those places have to do to reopen to deal with this?

Marrazzo: Yeah, I mean, it’s a great question and I think anything’s on the table right now. If we come to that point, and again, we should have much more data in hand over the next week, I would say. If we come to that point, you know, what that means is we’re looking at capacity beyond our immediate medical systems. That means either repurposing existing facilities or creating temporary new facilities, which is also a pretty heavy lift. What would have to happen is you’d have to obviously make sure the infrastructures were capable. And you’d have to more importantly, almost staff them up with people who are capable and willing to do that. So that’s a pretty big step people are, I know, in active discussions about that contingency planning as part of the disaster preparedness response. It’s really no different than thinking about a mass casualty like you might have with a hurricane or an earthquake or something like that. Unfortunately, you have an infectious disease, so it’s a little bit more dynamic and ongoing than either of those things. But I do know that people are talking about it and we will be updating you all as those discussions proceed and if they do proceed to anything more concrete.

Chip Brownlee is a former political reporter, online content manager and webmaster at the Alabama Political Reporter. He is now a reporter at The Trace, a non-profit newsroom covering guns in America.

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Coronavirus task force’s Dr. Deborah Birx says Alabama should extend statewide mask order

Eddie Burkhalter

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Dr. Deborah Birx, coordinator of the White House’s coronavirus task force, met with Gov. Kay Ivey and State Health Officer Dr. Scott Harris Thursday.

Dr. Deborah Birx, coordinator of the White House’s coronavirus task force, said Thursday that Gov. Kay Ivey should extend her statewide mask order, set to expire on Oct. 2. She also responded to a CNN report that cited those close to her as saying she’s “distressed” with the direction the White House coronavirus task force is taking and is unhappy with what she sees as her diminished role in the group. 

Birx, speaking at Auburn University, said she met with Ivey and Alabama State Health Officer Dr. Scott Harris earlier in the day to discuss COVID-19 and how the state is responding.

“So we really talked about the importance of continuing mitigation,” Birx said of her talk with Ivey and state officials earlier on Thursday, adding that Ivey was one of the first governors in the South to enact a statewide mask mandate, which she said clearly decreased the spread of the disease.

Birx pointed to numbers, such as the test positivity rate, that have improved since July, but said “we’ve got to do even more.” Asked if the statewide mask mandate was one of the mitigation efforts she suggests continuing into the fall, Birx said she does. “Because if you look at what happened within two weeks of the mask mandate you can see the dramatic decline in cases here in Alabama,” Birx said. 

Birx said that when she last visited Alabama in July, the state was suffering from too many new cases of COVID-19. 

“I think when I was last here at the beginning of July, it was a very difficult time in general for Alabama. We saw nearly 95 to 100 percent of every county in Alabama, rural or urban, that had more than 10 percent test positivity to COVID-19,” Birx said, adding that today, around 20 percent of the state’s counties have positivity rates above 10 percent. 

Public health experts believe positivity rates above 5 percent mean that there isn’t enough COVID-19 testing being done and cases are likely going undetected. 

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In a statement to APR on Thursday, a spokeswoman for Ivey said Ivey and Dr. Scott Harris would provide an update on the statewide mask order ahead of its Oct. 2 expiration date. 

“It is evident that Alabamians are doing considerably well in modifying their behaviors to take the COVID-19 pandemic seriously, and we all remain optimistic that a successful vaccine will be coming soon,” said Gina Maiola, Ivey’s press secretary, in a statement to APR on Thursday. “Our state’s success is largely in part to Alabamians stepping up to the plate when it comes to cooperating with the mask ordinance.” 

Maiola said Ivey is leading the way on several fronts “including getting students and teachers back in the classroom, college students returning to campus and businesses remaining open — in fact, Alabama has one of the country’s lowest unemployment rates.” 

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“This success is a reality because Alabamians are wearing their masks and maintaining social distancing precautions. Governor Ivey and Dr. Scott Harris will continue closely monitoring our progress and provide an update ahead of the October 2nd expiration,” Maiola continued. 

Speaking to reporters at Auburn, Birx was also asked about a CNN report on Wednesday that cited sources close to Birx as saying she is unhappy with what she sees as her diminished role on the White House coronavirus task force, that she’s not certain how long she can serve in her position and that she is “distressed” with the direction the task force is taking. 

CNN also reported that Birx, who is no longer a fixture at White House coronavirus briefings, views Dr. Scott Atlas, a recent addition to the task force, as an unhealthy influence on President Donald Trump.

Atlas, a neuroradiologist with little experience in public health or epidemiology, has expressed support for the so-called herd immunity “strategy,” which infectious disease expert roundly dismiss as unattainable and a move that would cost millions more lives.  

Instead of being a regular presence at White House coronavirus briefings, Birx has spent recent months traveling the country and speaking with governors and university administrators about coronavirus. 

Asked Thursday about CNN’s reporting, Birx pushed back. 

“Because they wrote that without even speaking to me,” Birx said. “Do I look like a person that’s diminished?” 

CNN reported Wednesday that Birx had not responded to requests for comment on the story. 

“Yes, I have been on the road. I’ve been on the road not as a spokesperson, but on the road to really understand what’s happening across the country, to be in deep dialogue with mayors, with communities, with governors, with administration school and faculty,” Birx said. 

“I’m asked here because I am supposed to be here,” Birx said. “I haven’t been in Washington, and nor was I asked about that, but I’ve actually never been called diminished.” 

Asked if she was planning to leave the task force, Birx said, “I have strong tenacity, and I’m very resilient, and we’re in the middle of a pandemic that’s affecting Americans, and as an American, I think I can do the best service to my country right now by serving in this role, working across the agencies, because that’s the experience that I have.” 

Asked to clarify whether she planned to step down from the task force, Birx said “no.” 

Asked if she was distressed about the direction the task force is taking, Birx said, “well that would be on me, if I was distressed, right, because I’m supposed to be coordinating the groups.” 

“So that would be an indication that I’m not doing my job, and I believe that I do my job pretty well every day. I can always learn to do better,” Birx said.

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Health

UAB doctor urges public get flu vaccine as COVID-19 continues to spread

Eddie Burkhalter

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Dr. Erin DeLaney, assistant professor in the department of family and community medicine at UAB’s School of Medicine, speaking to reporters on Thursday. 

As the flu season nears, Alabama health care providers are encouraging the public to get flu vaccines to prevent stressing hospitals, which continue to care for COVID-19 patients. 

“We just are really encouraging everyone to go ahead and get vaccinated,” said Dr. Erin DeLaney, assistant professor in the department of family and community medicine at UAB’s School of Medicine, speaking to reporters on Thursday. 

DeLaney said physicians are encouraging flu vaccinations, regular hand washing and social distancing because they’re not sure what flu and COVID could look like together.

“We know that there are other respiratory pathogens that together, combined with the influenza virus, can have poor outcomes,” DeLaney said. “And we know that the flu and COVID separately can have poor outcomes, so we’re hoping to protect as many people as we can.” 

DeLaney also discussed what will likely be the challenge for the public in attempting to determine whether they have the flu or COVID-19, which would prompt them to seek coronavirus testing.  

“Unfortunately, coronavirus and influenza, they will share a lot of the same symptoms,” DeLaney said. “The only thing that’s going to be completely different would be the loss of sense of taste and smell, is specific to COVID.” 

DeLaney said the medical community will have to rely on testing to determine between a case of influenza or COVID-19, and recommended that if a person isn’t able to get a coronavirus test they should assume they have COVID-19 and self-quarantine for 14 days. 

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Taking a clue from areas of the world that have already seen the start of the flu season, DeLaney said it appears that the spread of flu in those areas has been lighter this year, most likely because of what’s being done to protect people from COVID-19, including the wearing of masks, social distancing and regularly washing hands. 

“We are hopeful that would also be our same experience as we enter our flu season — that if people are vigilant with COVID that it would protect us from not only the flu but other respiratory pathogens as well,” DeLaney said. 

Speaking about the upcoming Halloween holiday, DeLaney said if families decide to go door-to-door with their children, eager for candy, masks should be worn. Masks that come with costumes do not provide protection, however, and DeLaney said they don’t recommend placing cloth masks over costume masks either. Medical providers are encouraging kids to wear Halloween-themed cloth masks instead. 

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The Centers for Disease Control and Prevention encourages families giving out candy on Halloween not to put the candy in a bowl for children to reach into, but instead suggest placing candy into separate bags and to place the bags outside the home.

She also recommended other outdoor activities in lieu of door-to-door candy gathering. 

“So an outdoor pumpkin carving. Playing some Halloween music outside or having different types of activities where people are not going to be gathering closely, or not all touching the same things, would be ideal,” DeLaney said.

There have been 148,206 confirmed cases of COVID-19 in Alabama as of Thursday, when the state added 1,052 new cases, according to the Alabama Department of Public Health. As of Thursday, 2,506 people have died in Alabama from COVID-19, 18 of which were added on Thursday.

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Education

Alabama declines to release COVID-19 data associated with child care centers

APR has asked for that data and whether ADPH was aware of the number of cases associated with child care centers statewide.

Eddie Burkhalter

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(STOCK PHOTO)

It was unclear Tuesday the number of confirmed cases of COVID-19 there have been among staff, children and relatives associated with child care facilities in Alabama, because the Alabama Department of Public Health declined to release that data.

“All cases of COVID-19 are required to be reported to the Alabama Department of Public Health under notifiable disease laws. ADPH is aware of cases in entities such as child care but does not report separately from other data,” said Dr. Karen Landers, assistant state health officer, in a message to APR on Tuesday.

APR has asked for that data and whether ADPH was aware of the number of cases associated with child care centers statewide.

Landers noted that ADPH does provide the percentage of cases among age ranges, however. There had been approximately 2,628 confirmed COVID-19 cases among Alabama children 4-years-old and younger as of Monday, according to ADPH’s dashboard, but the department doesn’t specify which of those cases are associated with child care centers, and it was unclear how many cases there have been among relatives or workers connected to child care centers.

While children 10-years-old and older can efficiently transmit COVID-19 to others, the Centers for Disease Control and Prevention in a recent report note that “limited data are available on SARS-CoV-2 transmission from young children, particularly in child care settings.”

The Sept, 18 CDC report looked at three COVID-19 outbreaks in child care facilities in Salt Lake County, Utah, during April 1 through July 10, and found that the 12 children who contracted the disease spread it to at least 12 others outside the centers, and one parent was hospitalized with coronavirus.

In one facility, researchers confirmed five cases among workers and two among children. One of those children, aged 8 months, transmitted COVID-19 to both parents, the report notes. Many of the children had mild symptoms or none at all, researchers found.

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“COVID-19 is less severe in children than it is in adults, but children can still play a role in transmission,” the report reads. “The infected children exposed at these three facilities had mild to no symptoms. Two of three asymptomatic children likely transmitted SARS-CoV-2 to their parents and possibly to their teachers.”

While Alabama’s Department of Public Health isn’t releasing data on cases associated with child care centers, many other states are, including Texas, South Carolina, North Carolina, California, Minnesota and Massachusetts.

There have been 332 confirmed cases, two deaths and 14 separate outbreaks associated with child care centers in North Carolina, according to the North Carolina Department of Health and Human Services.

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Health officials in California’s Sonoma County traced 30 cases of coronavirus to one child at a child-care center in the county, where 16 students, 11 relatives and three workers tested positive, according to The Los Angeles Times. In addition to that outbreak, there have been 62 other cases at 13 child-care facilities in the county, including 27 family members, 10 workers and 25 students, with 381 cases of children younger than 17 still under investigation, the newspaper reported on Sept. 21.

Reopening child care centers can be done safely, according to an Aug. 28 report by the Centers for Disease Control and Prevention, which that found that in Rhode Island, which reopened child care centers on June 1, there were just 52 confirmed and probable cases among staff, children and relatives across 29 centers between June 1 and July 31.

The report noted that Rhode Island at first limited centers to 12 or fewer students, required staff and students to not move between groups in centers and “universal use of masks for adults, daily symptom screening of adults and children, and enhanced cleaning and disinfection according to CDC guidelines.”

Alabama State Health Officer Dr. Scott Harris on March 19 issued an order closing child care centers through April 5, with exceptions for facilities that provided services to first responders and other workers deemed essential. Harris on March 27 issued a supplemental order allowing centers that cared for 11 or fewer children to reopen.

The Alabama Department of Public Health on Monday published a press release touting the number of open child care centers across Alabama. According to the department, 76 percent of all child care facilities in Alabama are open.

“Alabama is well on our way to reopening the necessary number of child care facilities to enable parents to return to work and resume a more normal schedule,” said Alabama DHR commissioner Nancy Buckner, in a statement. “This is the sixth survey we have conducted and each one has shown tremendous growth in the numbers of open facilities. We have worked hard to encourage child care providers to open by providing support in the form of grants and supplies.”

Asked whether the department is aware of the number of COVID-19 cases among children, staff or relatives associated with child care centers, a DHR spokesperson responded in a message to APR on Monday that “We don’t track that.”

While child care plays a critical role for working parents across the country, the pandemic and subsequent shutdowns have put a strain on the businesses, according to a July 13 study by the National Association for the Education of Young Children, which surveyed more than 5,000 child care facilities in every state.

Among the child care centers surveyed, two out of five said they would have to close without more public assistance, while half of the minority-owned centers said they have to close without more aid, according to the report. A quarter of child care workers said they’d applied for or received unemployment benefits, and 73 percent of centers said they have or will begin laying off workers and/or make pay cuts.

An Aug. 26 study by the Washington D.C.-based nonprofit Bipartisan Policy Center found that 32 percent of parents polled said their child care centers were closed, 14 percent of them permanently, and 22 percent of the parents said they could not return to work in person without childcare.

Even when child care is available to parents, many are worried about sending their children back while COVID-19 continues to spread. Of those asked, 77 percent of parents said they were concerned that sending their kids back would increase the risk of exposing their family to COVID-19.

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Crime

SPLC report: Despite COVID-19 deaths, Alabama isn’t releasing older, at-risk inmates

Eddie Burkhalter

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(STOCK PHOTO)

A report by the Southern Poverty Law Center published Tuesday found that almost 200 older state inmates, at greater risk from COVID-19, were eligible for parole, but either had no hearing or were denied parole over the summer. 

Alabama’s three-member Board of Pardons and Paroles denied parole for 44 people who were 65 and older over the summer, SPLC’s report states, and a dozen of the more than 1,100 older inmates identified in a previous SPLC report have since died, either from COVID-19 or other illnesses. 

“Despite confirming the deaths, it remains unclear whether the cause could have been COVID-19 as ADOC would not provide information about those individuals in response to a public records request, citing ongoing internal investigations,” the report reads. 

The SPLC and several other criminal justice reform groups urged the Alabama Department of Corrections and the Alabama Bureau of Pardons and Paroles to take steps to release at-risk inmates as the coronavirus pandemic began, through medical parole, medical furloughs and judicial sentence reviews, but to date, no such larger push to release inmates has taken place. 

According to ADOC, 22 inmates have died after testing positive for COVID-19.

SPLC’s report notes that many of the inmates who died had underlying health conditions, which were well known to prison officials. 

The Parole Board denied parole to more than three dozen inmates 65 or older since restarting parole hearings in May, according to the report. 

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“The BPP stopped paroles starting in March, against the demands of activists and legislators who pointed out that hearings could be done virtually. Hundreds of scheduled parole hearings were cancelled. After its hiatus, the BPP scheduled relatively few hearings throughout the summer compared to years past,” authors of the report wrote.

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