03.05.21 | Creating an Emergency Response System for Emerging Infectious Diseases: Lessons Learned and Future Directions
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The document outlines a presentation by the UC San Diego Antiviral Research Center regarding lessons learned from the COVID-19 pandemic and future directions for public health. It details major events throughout 2020, the impacts on healthcare and community response, and innovative public health initiatives aimed at addressing the pandemic's challenges, including vaccination efforts and equity considerations. The presentation emphasizes the importance of applying insights gained to combat other infectious diseases and improve public health strategies.
03.05.21 | Creating an Emergency Response System for Emerging Infectious Diseases: Lessons Learned and Future Directions
- 1. HIV & Global Health Rounds The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease and global public health clinicians, physicians, and researchers. The goal of these presentations is to provide the most current research, clinical practices, and trends in HIV, HBV, HCV, TB, and other infectious diseases of global significance. The slides from the HIV & Global Health Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission.
- 2. A YEAR OF COVID-19 IN REVIEW:LESSONS LEARNED AND FUTURE DIRECTION Ankita Kadakia, MD Tuberculosis Control and Refugee Health Branch Chief/Medical Director, HHSA, County of San Diego Tri-Chair, County Covid-19 Vaccine Clinical Advisory Group
- 4. LEARNING OBJECTIVES 4 1. Apply County-specific data to guide decision making and equity 2. Understand innovations in science related to Covid-19 that affect policy decision making 3. Apply how lessons from COVID-19 can be utilized for other infectious diseases 4. Understand how the use of infection control practices in the pandemic can shape policy decisions
- 5. ZOOM CHAT 5 Please put into the chat pod one word that describes the past year of the COVID-19 Pandemic!
- 6. 2020: A YEAR IN REVIEW 6 • Dec 31, 2019- China alerts the WHO of a virus in Wuhan • Jan 21 –First US Coronavirus Case in Washington State • Jan 22 –Trump 1st impeachment trial begins culminating in acquittal Feb 5 • Jan 27 –HHS Declares PH Emergency • Jan 30 –WHO Declares Global Emergency, Mar 11 WHO declares a pandemic • Feb 5 –Wuhan diplomatic evacuees at MCAS Miramar • Feb 11- WHO officially names the novel coronavirus as COVID-19 • Feb 14 –The County declares local emergency & assembles the COVID-19 Incident Command Center
- 7. 2020: A YEAR IN REVIEW 7 •March –The County’s Medical Operations Center starts acquiring PPE and sanitation supplies to distribute to healthcare provider •Mar 8 – Cruise ships arriving in Port of San Diego with COVID positives passengers, The County worked with the CDC to assist with testing and disembarkation plans •Mar 16 –Activated the County of San Diego Emergency Operations Center •Mar 19 –Governor issues Stay-at-Home Order & Implements Watch List •Mar 20- The County went into its 1st lockdown •March- Hoarding of toilet paper, sanitation supplies, and empty grocery store shelves
- 8. 2020: A YEAR IN REVIEW 8 • March – Much of the workforce converted to teleworking • The County opened a 200 bed emergency military hospital at Palomar • The County assembled 2000 Public health hotel rooms for isolation/quarantine • City of San Diego and County of San Diego opened Convention Center for homeless/unsheltered individuals • Hospitals in San Diego County received patients from Mexico and Imperial County as the pandemic filled their hospital beds
- 9. 2020: A YEAR IN REVIEW 9 • April 12- Easter weekend, start to see “holiday surges” 2-3 weeks after a holiday • May 1st – Mask mandate goes into effect in County of San Diego • May 26 –Killing of George Floyd by a white police officer sparked protests and brought forward the Black Lives Matters movement • May 31- Beaches Reopen in San Diego County, beach in Orange county experience crowding • June 12 –Governor allows broader State reopening • June 15-Supreme Court rules employers cannot discriminate on the basis of sexual orientation or gender identity • July 13 –State orders second shutdown
- 10. 2020: A YEAR IN REVIEW 10 • Jul 24 –Baseball Reopens with no fans followed by other sports with empty stadiums • Aug 4 – The County develops COVID-19 Compliance Teams to investigate claims of noncompliance to the health officer’s order • Aug 11- Biden announces Kamala Harris as his running mate making her the first black woman and first Asian woman on a major party’s presidential ticket • Aug 31 – State announces a color tier system for county reopening • Sep 7 –SDSU reopening for on campus classes reports outbreak (1100 cases)
- 11. 2020: A YEAR IN REVIEW 11 • Sept 18- Supreme Court Justice Ruth Bader Ginsberg dies at age 87 • Oct 1 –President Trump diagnosed with COVID- 19 • Nov 4- The County Registrar of Voters has 4 days of in person voting to accommodate COVID- 19 safe voter protocols • Nov 7- President Biden and VP Kamala Harris are elected • Dec 6 –Regional Stay-at-Home Order goes into effect from the governor • Dec 11- Pfizer receives FDA EUA for their MRNA vaccine and becomes the first COVID-19 vaccine to receive EUA in the US • Dec 14 –First vaccine shipments arrive in San Diego and roll-out begins
- 12. USING SCIENCE TO GUIDE PUBLIC HEALTH POLICY
- 14. • Speed of science and collaboration • Coronavirus was identified quickly and genome made publicly available • Collaboration of science between labs/universities/countries • Academic, private, and government labs started developing testing mechanisms • Vaccine development GENOME SEQUENCING
- 15. TRANSMISSION STUDIES • Morawska published transmission studies prior to this commentary • Challenged the idea of respiratory viruses always being droplet transmission • Debate in scientific community which delayed aerosol and ventilation guidance from WHO, CDC, and public health departments • Adapted indoor business guidelines, mask use during exercise • Mask guidance Clinical Infectious Diseases, Volume 71, Issue 9, 1 November 2020, Pages 2311– 2313, https://doi.org/10.1093/cid/ciaa939
- 16. ASYMPTOMATIC AND PRESYMPTOMATIC SPREAD • Public health guidance changed on testing of SNF/LTCF residents and staff – state requirements for testing • Brought to light even more the severity of disease and outbreaks in SNF/LTCF • SNF/LTCF residents and staff first in vaccine prioritization • Supported physical distancing and hand hygiene measures • Changed quarantine and isolation guidance – updated health officer orders • Supported widespread covid testing – county boosted our testing efforts
- 17. DEVELOPING A FRAMEWORK FOR EMERGENCY OPERATION PROTOCOLS DURING COVID-19 PANDEMIC USING EXPERIENCE FROM OTHER INFECTIOUS DISEASES
- 18. H1N1 INFLUENZA OUTBREAK • First case of swine flu in a 10 year boy in San Diego County • A global pandemic ensued but death toll was much lower than COVID-19 • The County of San Diego used H1N1 experiences for development/improvement of the Incident Command Structure, vaccination protocols during a pandemic, quarantine and isolation procedures, case investigation and contact tracing, infectious disease surveillance
- 19. HEPATITIS A OUTBREAK-MARCH 2017 Top Antivir Med. 2019 Jan; 26(4): 117–121. • CoSD declared a local health emergency 9/2017 • Developed and improved upon CosD Department of Environmental Services sanitation protocols • Developed mass vaccination clinics, mobile clinics, and vaccination using mobile foot teams • Developed partnerships with local healthcare systems for vaccinations
- 20. TUBERCULOSIS • Translated TB infectious transport protocols for COVID use • Translated TB-CDC-CBP protocols for border crossing and transport of COVID patients • Using TB staff for case investigation and contact tracing for COVID • Used TB infection control protocols for congregate housing and applied to Convention Center • HMIS and other homeless shelter collaborative work with TB applied toward COVID- development of screening tool
- 21. USING DATA TO GUIDE PUBLIC HEALTH DECISION MAKING FOR COVID 21
- 22. STATE METRICS DETERMINE TIERS Adjusted case rate = # positive cases confirmed by PCR (rate) per 100,000 population excluding prison cases averaged over 7 days with a 7day lag to account for testing delays Unadjusted test rate does not account for the test rate Excluding federal inmates, ICE facility residents, state hospital inmates, US marshal detainees Testing positivity = # of positive cases/amount tested overall Also excludes testing in prisons CDPH states as counties focus on increased testing in the health equity metric and to support school openings, they are likely to experience an increased number of cases. We want to avoid disincentivizing increased testing, provided that test positivity is low and there is sufficient capacity for contact tracing and isolation. We are therefore increasing the adjustment for higher volume testing. 22
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- 24. CALIFORNIA HEALTHY PLACES INDEX (HPI) -Health Equity Metric based on HPI which uses local factors in a community that affect life expectancy/health outcomes and provides a percentile. -The higher the percentile the healthier the census tract- ( small, relatively permanent, subdivisions in a county) -25 individual indicators across housing, transporation, education, healthcare access, economics, clean environment,neighborhood 24 https://healthyplacesindex.org/
- 25. HEALTH EQUITY METRIC (HEM) • -Health equity metric = only applies to counties with population > 106K • -Due to the limited number of census tracts, test positivity cannot be reliably calculated by quartile for smaller counties • -HEM for county census tracts divided into quartiles • -Health Equity Quartile Test Positivity Rate Must Meet Specified Threshold for Less Restrictive Tier. 25
- 27. 27 • CoSD rotates testing sites per zip code data using the HPI • Focused no appointment testing and increased testing sites in lower HPI areas https://sdcounty.maps.arcgis.com/apps/opsdashboard/index.html#/e09887e8e65d4 fda847aa04c480dc73f
- 31. INNOVATIVE PUBLIC HEALTH INITIATIVES DURING COVID • -Convention center for homeless • -Public health hotel/temporary lodging • -HOT teams and hygiene kits • -Registrar of Voters - election -Vaccination Super Stations 31
- 32. OPERATION SHELTER TO HOME -Collaborative effort between the City of San Diego and County of San Diego to shelter 1500 individuals - Infection Control protocols for mass amount of migratory individuals in a massive space -Collaboration with FQHCs for onsite medical/telehealth care/mental health and SUD -PH physicians and PH nurses onsite daily and weekends -EMS onsite -Screening tool adapted from asylum seeker shelter for COVID -Protocols for isolation/quarantine and public health hotel -Lessons learned: elopement, criteria for hotel
- 33. INNOVATIVE PUBLIC HEALTH INITIATIVES DURING COVID • -Convention center for homeless • -Public health hotel/temporary lodging • -HOT teams and hygiene kits • --Registrar of Voters - election -Vaccination Super Stations 33
- 34. PUBLIC HEALTH HOTELS - 2000 rooms commandeered for public health use - Care and Shelter branch of EOC - Infection control protocols -PH physicians and PH Nurses onsite daily to provide medical care -Lessons learned: mental health, EMS, elopement
- 35. INNOVATIVE PUBLIC HEALTH INITIATIVES DURING COVID • -Convention center for homeless • -Public health hotel/temporary lodging • -HOT teams and hygiene kits • -Registrar of Voters - election -Vaccination Super Stations 35
- 36. HOMELESS OUTREACH TEAMS -9 teams paired with PHN, police officer, homeless outreach worker -Screening tool for COVID-19 -Developed protocols for care, isolation, shelter at hotel/CC -9-10K hygiene kits distributed -Lessions learned: HOT and PHN partnerships, refusal of care/isolation -Next step is vaccination
- 37. INNOVATIVE PUBLIC HEALTH INITIATIVES DURING COVID • -Convention center for homeless • -Public health hotel/temporary lodging • -HOT teams and hygiene kits • -Registrar of Voters - election -Vaccination Super Stations 37
- 38. ROV-PRESIDENTIAL ELECTION -6 months of planning between PH and ROV - Infection control protocols for in person voting, electoral candidates, observation, ballet counting - mass scale up of 1000 temporary staff including training, 235 polling sites -the intersection of election laws with public health/infection control -political parties and their views on masking,social distancing -PH physician/ROV/HR on call for 4 days of presidential election -Lessons learned: refusal to mask but allowed to vote- acommodations
- 39. INNOVATIVE PUBLIC HEALTH INITIATIVES DURING COVID • -Convention center for homeless • -Public health hotel/temporary lodging • -HOT teams and hygiene kits • -Registrar of Voters - election -Vaccination Super Stations 39
- 41. In a 1988 essay on pandemics Joshua Lederberg, Nobel laureate and president of The Rockefeller University, reminded the medical community that when it comes to infectious disease, the laws of Darwin are as important as the vaccines of Pasteur. 41 The New York Times, “The Virus Won’t Stop Evolving”, Nov 27,2020
- 42. COVID-19 Vaccine Goal: The Numbers *Estimated 250,000 vaccinations to be completed by end of January. 3,515,088 doses from Feb 1 – July 1, 2021 (150 days) = 23,434 vaccine/Day San Diego County Population: 3,370,418 residents San Diego County Population age 16 and older: 2,689,348 residents Goal to vaccinate at least 70% San Diego County Population age 16 and older by July 1, 2021: 1,882,544 residents 3,765,088 doses of vaccine (first and second dose) 23,434 vaccines/Day*
- 43. COSD COVID-19 VACCINE OPERATIONS COVID Vaccine Operations Standing up and staffing vaccination sites including superstations Operation Collaboration/CALFIRE/Paramedics/EMTs COVID Vaccine Distribution/ MOC Logistics Protocols for handling vaccine Cold-chain distribution (ULT freezers) Ancillary supplies ( PPE, syringes/needles etc) Volunteer vaccinator coordinatiion COVID Vaccine Clinical Vaccine Clinical Advisory Group – determining fair and equitable allocation recommendations Clinical operations of county vaccine administration- nursing workforce, training, clinical decision making Communications- educational materials, speakers bureau, vaccine hesitancy External stakeholder partnerships 43
- 44. COVID-19 Vaccine Ecosystem: Health Equity, Accessibility, & Convenience County Hosted Vaccine Events Vaccination Super Station Sites Mobile Vaccination Teams Hospital-based Vaccination Sites Clinic-based Vaccination Sites City Partnership Vaccination Sites Military & Veteran Administration Pharmacies
- 45. COVID-19 RATE BY HHSA REGION 45
- 46. COUNTY OF SAN DIEGO COVID-19 VACCINE CLINICAL ADVISORY GROUP TRI-CHAIRS COUNTY CLINICAL REPRESENTATIVES COMMUNITY CLINICAL REPRESENTATIVES Dr. Rodney Hood Founder & CEO, Multicultural Health Foundation Physician, San Ysidro Health Center Member, CA Governor’s COVID-19 Vaccine Task Force Chair, San Diego County COVID-19 Equity Task Force Dr. Ankita Kadakia Medical Director, Public Health Services, Health & Human Services Agency, County of San Diego Dr. Gail Knight Chief Medical Officer, Rady Children’s Hospital Co-Chair, Hospital CMO COVID-19 Advisory Group Objective: Determining fair and equitable vaccine allocation for San Diego County residents
- 48. PROJECT SAVE The pilot program is now operating in the southern region of the county and is managed by nine community groups who have access to reserve appointments at four vaccination sites. The sites are: •South Region Live Well Center – Chula Vista •Martin Luther King Community Center – National City •Mar Vista High School – Imperial Beach •Southwestern College – San Ysidro The reserved appointments will be filled through outreach by community health workers or promotoras who are contacting people 65 and older at locations that include grocery stores, faith centers, food distribution sites and housing complexes in the South Bay.
- 49. 211 ASSISTANCE FOR VACCINE APPOINTMENTS 211 FOR 65 AND OLDER WHO DO NOT HAVE ACCESS TO COMPUTER OR SOMEONE TO ASSIST WITH VACCINE APPOINTMENTS • 211 helping homebound seniors access vaccination • 211 is assisting with transportation for seniors to vaccine appointments
- 50. MTS PROVIDING FREE RIDES TO VACCINE NEED TO BRING PROOF OF VACCINE APPOINTMENT
- 51. SPANISH LANGUAGE VACCINE APPOINTMENT SCHEDULING CAN SEARCH IN SPANISH BY MAP OR CALENDAR
- 52. REGIONAL VACCINATION SITES • 5 Regional Vaccine Super Stations in partnership with the County: Chula Vista, La Mesa, San Marcos, Downtown/Petco Park, Del Mar Fairgrounds • San Marcos/211/West Pace/Gary and Mary West Foundation POD for seniors – access through 211 • Rotating pods in harder to reach communities i.e. Malcolm X Library vaccine site with SDFD • Project Safe • Majority of vaccination sites are in hardest hit Covid areas –East County and South Bay
- 53. LESSONS LEARNED AND FUTURE DIRECTION PANDEMIC PLANNING IN PUBLIC HEALTH Innovation Partnership Science
Editor's Notes
- #32: Driver of public health innovation is partnership
- #36: HOT teams made of police officer, PHN, and shelter outreach worker, 9-10K kits distributed, covid screening tool developed for CC to screen unsheltered and get them into care or public health hotel or CC
- #38: HOT teams made of police officer, PHN, and shelter outreach worker, 9-10K kits distributed, covid screening tool developed for CC to screen unsheltered and get them into care or public health hotel or CC
- #40: HOT teams made of police officer, PHN, and shelter outreach worker, 9-10K kits distributed, covid screening tool developed for CC to screen unsheltered and get them into care or public health hotel or CC
- #47: The COVID -19 Vaccine Clinical Advisory group is tri chaired by Dr. Gail Knight, Chief Medical Officer at Rady Children’s hospital and Co-chair of the Hospital CMO Covid-19 advisory group. Dr. Ankita Kadakia, Medical Director of the County of San Diego Health & Human Services Agency, Public Health Services. And Dr. Rodney Hood, Founder & CEO, Multicultural Health Foundation and a member of the Governor’s COVID-19 Vaccine Task Force. This group is made of collaborative clinical leaders from the County and Community- indivduals who work with vulnerable and underrepresented populations. We are collaborating to provide guidance to allocation of vaccine using health equity. I will now turn it over to Supervisor Cox. NEXT SLIDE
- #49: Removing barriers to vaccination
- #50: 211 is keeping a list of homebound seniors who call and will provide that info to the county as we figure out how to vaccinate them.
- #53: Limiting factor for vaccination is the supply. Despite having multiple sites open we are limited by how much vaccine is being allocated to the county.