By MARY SELL, Alabama Daily News
On Saturday, I spoke with Alabama Public Health Officer Dr. Scott Harris about the state’s response to the coronavirus, its expected peak and the recent stay-home order.
Harris is an infectious disease specialist who now finds himself leading Alabama’s efforts to combat the most deadly pandemic in a century. We spoke at length about his experiences over the last several weeks, how the Department of Public Health is dealing with the unique challenges of COVID-19 and what led to the recent decision to order Alabamians to stay home except for essential needs.
Below is our conversation, with minor edits for brevity.
Mary Sell: Friday, you said the state has a surge team working and you expect the coronavirus cases to peak in two to three weeks. What sort of numbers is your surge team predicting? What will that peak look like?
Dr. Scott Harris: I think the numbers are all over the board, depending on which model you use, I think that the IHME (Institute for Health Metrics and Evaluation) site is probably the best known one. And we have relied on that one pretty extensively, especially for the timeline.
… I think we just take it with a grain of salt. I mean, it’s all predictions.
Sell: So what numbers are you using? Or do you have any numbers that you can use?
Harris: We would say worst-case scenario would be about 10% of the population getting infected. And, you know, if we had a 1% mortality of that 10%, then that takes you, you can do the math on that. And so, that would be thousands of deaths.
(ADN note: There are about 4.9 million people in Alabama. If 10% got COVID-19, that’d be 490,000 people. If 1% of those people died, it’d be 4,900 deaths. As of Sunday morning, ADPH was reporting nearly 1,700 confirmed cases and 31 deaths. The department has also added the number of hospitalizations for confirmed cases to its online dashboard. As of Sunday morning, that number was 231.)
Harris said ADPH soon plans to release information, includes ages, about Alabamians who die from COVID-19 on its dashboard soon. Harris did share some more specific data with ADN. Of 26* confirmed deaths as of Saturday morning:
- They ranged in age from 33 to 86. The median age was 67.
- Nine were women, 17 were men.
- Fourteen were black, 10 were white and two were Asian.
- One was a health care worker, two were long-term care facility residents, one was a visitor to a long-term care facility.
*Twelve of the 26 killed had diabetes, 12 had cardiovascular disease, seven had chronic lung disease. Ten had multiple underlying medical conditions.
The death totals have increased. For the latest information from ADHP, click here.
Harris: We certainly hope that social distancing measures will improve those numbers quite a bit. And it certainly is true, I think, that Alabama is not New York City. You know, New York City has something like a 10% transmission rate, and obviously the population density is so much different there. So, we think that maybe helps, you know, small town, rural Alabama.
…So what we’ve done is ask hospitals to give us information about what their bed status is and what their ventilator status is, and we’ve tried to look at these numbers, and we’ve worked with the National Guard planning folks and the Army Corps of Engineers and we’re just trying to have sites available, alternative care sites. In the meantime, our strategy just has to do with making sure we utilize all of our available capacity. We have a lot of small rural hospitals, for example, that are probably not going to take care of a lot of seriously ill people, but they might be able to offload less ill people from the (larger metro hospitals) so that those places can take care of more seriously ill people.
The governor’s declaration of emergency allowed these hospitals to activate their emergency operation plans and start using their crisis standards of care. And that frees them up a lot to kind of create alternative spaces. I know, for example, East Alabama Medical Center, which is really at the center of the crisis right now, they’ve been able to add some ICU capacity just by simply adding beds and spaces or converting beds and spaces to ICU beds.
And, you know, I think I mentioned yesterday, we’ve claimed some veterinary ventilators and some anesthesia machines from out-patient surgery centers and we’re trying to use all those available things. And, and even the out-patient surgery centers themselves can be surge locations.
And then really, what you do last after you’ve done all those things, is when you go to an alternative care site.
Sell: Are there any priority areas for the alternative care sites? Any we could see created before others?
Harris: There’s always controversy about where they go because we’re such a big rural state, but the alternative care sites, at the moment, have been explored in the larger population centers because that’s where most of the demand would be. And at the same time, we’re trying to make sure that we still have the ability to get people out of rural areas and transported as needed. But Birmingham, Mobile and Huntsville are the ones who probably have done the most extensive planning and preparation so far. But Montgomery, Auburn and Tuscaloosa are also going through the same process. And then we’re still working on a way to make sure that we take care of the rural parts of our state.
Sell: You mentioned East Alabama Medical Center, what happened there to make that such a hot spot early on?
Harris: What we believe is that it was related to a church homecoming in Chambers County around the first week of March. And there are a number of cases that have been associated with that group.
… I know there have been a number of cases directly admitted to East Alabama that were associated with that event, as well as some health care workers who have worked in health care facilities and have been infected who are associated with that.
… I looked at the information this morning, they have 30 ventilator patients. And that’s because they have 30 ventilators in that facility. We’ve been working with them night and day to secure additional ventilators from other folks here in the state. They’re obviously facing personal protection equipment shortages and had some health care workers infected. And so it’s just a really difficult time for now.
Sell: In an interview with CBS 8/ABC 32 earlier in the week, you said Alabama had requested 500 additional ventilators and 200 of them were urgently needed. Where does that request stand and where does need stand?
Harris: The request was denied by (U.S. Department of Health and Human Services). They are prioritizing the other hotspots in the country like New York City and indicated that when Alabama is facing a surge, within about 72 hours of that expected peak, that we might be able to get some relief at that point. So we do not have anything coming from the Strategic National Stockpile at this point. We continue to try to source our own ventilators. I signed off on an order earlier this week to purchase 250 from a company that makes them, but we don’t know how quickly they can get here.
…As you know, we’re bidding against other states, and sometimes even other facilities within our own state, for the same resources. But the federal government has also sort of commandeered supplies of parts that go into ventilators to send them to Ford and GE who are going to start making ventilators, so even the people who are already in business are having trouble getting parts to make them because of what the federal government’s done.
Sell: The confirmed cases, can you talk a little bit about the percentages that need hospitalization, ICU beds and ventilators? Has that been pretty consistent? And do you expect those percentages to stay the same as we get toward the surge?
Harris: We started tracking ventilator capacity back in early March, so we’ve been fairly consistently having around 50 to 60% of our vents reportedly available. That’s statewide, every vent, everywhere. But what’s remarkable about that is, at the time we started counting, not necessarily every hospital was reporting. So in some cases, we’re just not sure we had all the available data, but we’ve gone from a report of around 700 or 800 ventilators statewide, which I think is not true, I think we just didn’t capture them all, now to as high as 1,600 or close to 1,700 ventilators reported. Yet the capacity, the availability, has been about the same or gone down. Even though we’ve added ventilators, getting these veterinary ventilators in and recovering some from out-patient surgery centers, the percentage available to us has not really changed that much, because they’re in use, they’re being used. And so as of this morning, again, I’m not positive that every facility reported on this report, but as of this morning, we supposedly have 850 ventilators still available in the state and have a capacity of 1,469. But I’m not sure we’ve got all the numbers there.
Our ICU bed capacity is about 30% of ICU beds are available. But you know, that certainly doesn’t apply to Jefferson County, for example. I’m not positive, but I doubt Huntsville or Mobile have that kind of capacity.
Sell: You said Friday that more than 200 health care workers have tested positive. One of the things we’ve seen in other places is when health care workers test positive, it’s not just them, but co-workers they were in contact with who have to be quarantined as well. Are we seeing that in Alabama?
Harris: Yeah, absolutely. The close contacts of active cases are isolated for 14 days unless they develop symptoms and get tested and become cases themselves, but, yeah, that’s absolutely the case. And we’ve had a number of nursing homes and hospitals report that they had an infected worker that resulted in a number of other people being quarantined also.
Sell: I know that as of a few weeks ago, the Alabama Board of Nursing Board and Board of Medical Examiners were relaxing rules to make it easier for retirees to come back to work or let medical professionals whose licenses had lapsed come back to work. Where do we stand on any potential workforce shortages or efforts to get more frontline medical personnel in the state?
Harris: I know (the Board of Medical Examiners) has been working on that. Obviously, workforce is part of what our surge folks have worked on. They’re polling our hospitals every day, they’re measuring not just beds but staffed beds as well. We have heard that at the moment we have, since we’re not doing a lot of elective procedures, we have health care workers that are being recruited to go out of state, and that’s really unfortunate at this time.
I know that hospitals in Jefferson County, in particular, are really working hard to try to make sure they can keep their folks working in some way.
If you have, for example, an alternative care site, you need an additional workforce that’s not already working somewhere. … And so, we have to come up with just from scratch a brand new set of people and that would be, we would think, those people who are not working in the out-patient setting at the moment or outpatient surgery centers or clinics or offices that aren’t seeing patients right now.
Sell: As of early afternoon Saturday, there are more than 1,500 confirmed COVID-19 cases reported, according to the ADPH website. What do you think a more accurate number might be?
Harris: We don’t have a way to say for sure in Alabama, I can just say that around the world, public health experts have claimed, and this is totally an estimate, but they claim five or 10 undetected cases for every one that’s confirmed. So, obviously, the more you test, the more likely you are to pick up on those. We certainly recognized that we’re not testing as widely as say South Korea did. I would not be shocked at all to have thousands of other cases that we just haven’t detected. You know, (Centers for Disease Control and Prevention Director Dr. Robert Redfield) this week said maybe as many as 25% of cases are asymptomatic. But I think in the Singapore study that just got published, they were seeing 6 or 7% of their outbreak were linked to asymptomatic people. And there’s been another study from somewhere in Asia, I don’t recall exactly where, that was about 12 or 13%. So clearly, there’s a lot of people out there who were probably infected and probably infecting others that we would never even pick up on unless we just were doing widespread testing of even asymptomatic people.
Sell: Hence the stay-at-home order?
Harris: Right. And so the point of this order is to say, ‘Hey, everybody, you’re all at risk, and maybe you’ve all even been exposed and just don’t know it.’
…Given that this is a disease with no treatment and no cure, the test results, honestly, aren’t as important as just staying home. Particularly if you have symptoms, if you have coughing and sneezing and fever, it doesn’t really matter what your test result is, you need to go home and be away from other people, because maybe you just have influenza, or maybe you have COVID-19. Or maybe you have something else, but whatever it is, you don’t need to be around other people. A negative test, to me, is not all that reassuring. I mean, it just means we didn’t detect it, it doesn’t mean it’s not there.
… So, I certainly understand why a lot of people want to be tested, I support continuing to test because it gives us a lot of good information about the epidemic itself. And I know that people take certain kinds of reassurance from negative tests, but it really doesn’t affect the individual management of a given patient.
Sell: Would more testing earlier on, more testing three or four weeks ago, would that have changed the situation we’re in now?
Harris: I think it would have made the public aware that it was in Alabama. I mean, there’s no question this has been going on for weeks. And we’ve barely been testing for three weeks. And by the time we got our first positive test, places like East Alabama and UAB already knew they were seeing it, we just didn’t have testing widely available. And so yeah, I think it would have it would have helped us to be able to convince the public that this really is an issue in Alabama.
Sell: Are we in a crisis situation now, or will the crisis be in two or three weeks?
Harris: I guess you’d have to define that word for me. But, I would say we clearly have health care facilities that are in a crisis. I would say, obviously, we’ve taken an extraordinary public action to tell people to stay at home. And so we wouldn’t do that if we weren’t in a crisis situation. But I think in two or three weeks, our hospital capacity is going to be really tested even more. I guess I’m not sure what defines the scale of crisis – we’re going to be at something worse than we are now.
Sell: With the stay-at-home order, as of two weeks ago, I was hearing from some state leaders who were very concerned about the economy and the impact on businesses of some of these orders. Have you gotten pressure from the business community as far as shaping policy? What has that been like?
Harris: You know, Mary, I’m not sure what the right word is. I would say, many different people who are concerned about the economic impact of public health orders have been in touch with me to express their concerns. And I certainly understand that and completely recognize the effect that we’re having on people’s livelihoods when we issue orders that limit social interactions. But we have worked very closely with Gov. Ivey and her staff to give them the best possible public health options in dealing with a pandemic situation and at the same time, I realize she has many more things to consider than I do, so I know she’s very well aware of all those concerns as well. And so we’ve simply tried to present to her the best data we can and the best science that we have. And then obviously, those are considerations that she has to make before we ultimately decide how to respond.
Sell: When we’re on the downside of the curve, what will that look like? What will you be asking of Alabamians? This isn’t going to go away overnight, right?
Harris: Right. I think we’re still trying to figure that out for ourselves. And, you know, it’s not clear when we pass the peak what the response is. I think we haven’t seen examples of that yet anywhere else in the country. And so we’re kind of waiting to see from those places that are ahead of us. You know, for example, does everything go away and you’re back to normal one day later? Or do you ease up on social distancing guidelines and have some restrictions for awhile gradually. I think we really just don’t know that and we’re looking to see what is working in other places.
Sell: What are Alabama’s biggest needs right now?
Harris: Personal protective equipment, ventilators, specimen collection kits for testing and maintaining a healthy workforce. And I guess, this is not a concrete answer to what you asked, but what we really need is for people to stay at home. I mean, that’s Alabama’s biggest need: We need people not to be in contact with other people.
Sell: What is your biggest concern right now? What is your biggest worry?
Harris: That in two or three weeks, our hospitals won’t have the capacity to care for all the patients we have.