Last Updated: 7:14 p.m.
As confirmed Flagler County Covid-19 cases reach 28 Friday evening and Florida’s exceed 10,000, jumping by more than 1,200 in the last 24 hours, with 170 deaths, local health officials are now stopping short of using reassuring language, saying the worst is yet to come, while various shifts point to the increasing severity of the coronavirus pandemic even locally.
Nevertheless they stress that for now Flagler County’s hospital–AdventHealth Palm Coast–is “in good shape,” with 15 ventilators, while readying to expand ICU capacity threefold in case of a surge, from 18 rooms to 66. The hospital is also exploring using anesthesia equipment to supplement its ventilators.
In yet another escalation of apprehension over the extent of infections, local department of health officials now echo the Centers for Disease Control’s new directive that wearing masks in public is recommended. In another shift, local officials also now acknowledge that more detailed information about where people are infected, down to zip codes and neighborhoods, is necessary, but not yet available.
Testing remains woefully low in the county, with just 290 tests conducted as of this morning, according to Department of Health figures, suggesting that Flagler County’s true extent of the contagion is far higher than the figures posted by the department. But rapid tests promised with much fanfare since last week by President Trump, Gov. Ron DeSantios and even Bob Snyder, chief of the Flagler County Health Department, are not arriving any time soon. Federal officials had promised that they would start arriving at the end of this week. That’s not happening.
The hospital’s ICU plans were detailed by Chief Operating Officer Wally de Aquino in his latest appearance on WNZF’s daily morning update on the coronavirus emergency.
“Regarding capacity, We have certain wings of our hospitals [where] we can make necessary changes to make those rooms identical to an ICU room, de Aquino said. “So the hospital has 18 officially licensed ICU rooms. Well, that would not help us if we get a surge, right? So we identified at least three other wings, each wing has 16 rooms, that we can actually overflow and use as an ICU, which would give us plenty of ICU-like rooms, and I’m using the word ‘like’ because obviously they’re not licensed. But we will be allowed to use them. Some of them we’ll be making some minor modifications and we’ll be looking into that, but thankfully some of those wings already had the proper hookups behind the walls so we can utilize it as a proper ICU room. If we don’t get a surge here, we most likely will be able to help other areas where they don’t have enough beds.”
Today Advent Health’s bed capacity was at 33 percent, according to the state Agency for Health Care Administration.
DeAquino said the hospital currently has just 15 ventilators. He would not specify how many are in use (he said he would do so in subsequent days), but said “we’re not even close to using half” of them. “But there are other ways for us to also work with our anesthesia equipment to make them ventilators as well,” de Aquino said, “so we’re looking into that to see how many we can actually change them from being an anesthesia equipment to a ventilator.” The hospital is also in touch with the Advent command center to seek additional help, if it becomes necessary.
Asked if single ventilators have been adapted to be used for two patients, de Aquino said the Palm Coast hospital isn’t doing that, but other hospitals in the Advent system are testing the approach, which has been used successfully in New York.
According to Florida Department of Health data, four Flagler residents are hospitalized for Covid-19. It’s not clear if that figure includes the Flagler Beach resident who died on Wednesday, and who was hospitalized in Daytona Beach. Because she was a Flagler Beach resident, she was counted as such, even though she was hospitalized elsewhere. There have been numerous, ongoing problems with clarity of data from the health department’s state dashboard.
De Aquino spoke very cautiously about being too optimistic despite the county’s relative fortunes so far.
“Where we need to be cautious is, when we talk about a surge, what is that? What does that mean?” he said. “So, we are in good shape right now, we are in good shape to expect, if we have a surge, if numbers double, two, three times, we’ll be fine here. What does the surge mean–that’s the question to answer: we don’t know.” He said the hospital can be helped to remain in good condition if residents respect social distancing rules and limit infections.
“Obviously we haven’t seen the surge that we’re expecting yet, but overall the employees are doing well and they are actually very responsive to all the changes that we have to do,” de Aquino said. In an acknowledgment of the strains the Covid-19 emergency is placing on family relations, especially when patient visits are either severely restricted or disallowed, the hospital is working with longer-term patients to have virtual visitations, providing devices to them if they don’t have any, thus essentially diminishing the effects of the in-person visitation restrictions. Physicians are also consulting with patients who are Covid-19 positive, or who are under investigation for Covid-19, through telehealth.
Meanwhile, the incompleteness of data, and not even knowing the true extent of the contagion locally, makes any forecasting of a downturn in the grimmest numbers very difficult.
“In terms of the war we’re fighting,” said Steven Bickel, a physician and the medical director for the Flagler and Volusia health departments, “the key component that every country has focused on that we’re going to need to focus on is, when can you start bending the curve. That’s where all the action is. If it’s still a steep, upward slope, and it’s near this exponential spread, you’re in trouble. When you can start diminishing the spread, even if it’s increasing but increasing at a lower rate, then you’re starting to make headway.”
Those are the numbers that dictate what strategies that need to be in place, and whether the strategies need to be intensified. “It’s kind of a shifting background there,” Bickel said, “because you’re looking at spread in the community, and then the measures you do change the rate of spread and you’re trying to extrapolate from that what that means for the population, and the data are not clear. There’s a range for all this stuff. It’s pretty tricky stuff, that’s why people will do these models and then plug in different numbers.”
Until now, and under command from the state department of health, local officials have been resistant to detailing any information about the whereabouts of people with Covid-19 or people under investigation. That may change.
“We would really benefit from knowing the number of positive cases by zip code and by neighborhood,” Snyder, who’s had long and frequent conversations with local reporters about the data, said. “I’m going to do my best as health officer here to push my colleagues in Tallahassee to please consider this. I think something like this would be very important. However, like other health and medical professionals, we just cannot share detailed information about patients, positive cases, persons under investigation, not only because of HIPAA,” he said of the federal health-record privacy law, but doing so would violate Florida law. The department doesn’t comment on current or past epidemiological investigations, he said, “and the medical community regards that information as sacrosanct.”
Still, he said, zip code and neighborhood data tied to Covid-19 “will give us an indication of the community spread, because so many of the people in our community, they do not have symptoms, yet they could be carrying the virus. So this is why this is so important. I’m on it, and I’ll do my best as one person to get things changed as best I can.”
Shortages continue, with both personal protection equipment and tests. While there are a half dozen places where people can get tested, among them the Health Department, AdventHealth Palm Coast and two urgent care facilities, the Health Department is still at the same 100-test-kit capacity as it was last week, and does not expect to have more capacity any time soon, Snyder said. “It’s sufficient for now, we have ordered more, we expect delivery soon,” Snyder said. But he cannot tell when.
Attention had focused on a company’s pledge late last week that it would provide 50,000 rapid tests a day, with results from the tests available in minutes.
“That’s a whole new ballgame,” Trump said in a Rose Garden news conference this week. “I want to thank Abbott Labs for the incredible work they’ve done. They’ve been working around-the-clock.”
Snyder, too, was essentially deceived.
“We are very, very excited about hearing about Abbot labs who are producing 50,000 test kits a day,” Snyder said as recently as Monday, “and it takes 15 minutes for the test results to surface. We would be interested as soon as possible to start some kind of more broad-based surveillance testing. We look forward to that day.”
Yet a document circulated among officials at the Department of Health and Human Services and the Federal Emergency Management Agency this week shows that state and local public health labs were set to receive a total of only 5,500 coronavirus tests from the giant manufacturer of medical devices, diagnostics and drugs, according to emails obtained by Kaiser Health News.
That number falls well short of the “about 500,000 capacity of Abbott tests that” Dr. Deborah Birx, the White House coronavirus response coordinator, said were in the states and were “not being utilized.” Although it is unclear whether she was referring to just the quick test or combining it with another test — one with slower results — that Abbott previously received authorization to sell.
Millions of tests are urgently needed as the virus keeps communities across the country in lockdown and hospitals are overwhelmed with patients.
Labs in all 50 states were set to receive roughly the same number of Abbott’s test cartridges and the devices on which they run ― 100 tests and 10 or 15 devices — the document shows, regardless of how many confirmed COVID-19 cases officials had reported in each state.\
Abbott Labs spokesperson Darcy Ross on Thursday said the company had shipped tests to customers in 18 states but did not elaborate on how many were public clients or governments as opposed to private health care facilities. Ross also said the document circulated among federal officials showed an “intended purchase by HHS and FEMA” of tests and related instruments.
The Federal Emergency Management Administration referred questions to HHS, whose spokesperson Mia Heck said, “We do not comment on any allegedly leaked documents.”
“We can confirm that the federal government is looking to make the initial purchase of a rapid point-of-care test to increase COVID-19 testing capacity in the United States,” she said. “Initially, each state will receive 15 point-of-care instruments, and then they will be able to resupply through the commercial market.”
Accuracy has been a broad problem in the testing for the novel coronavirus. Abbott Labs declined to address specifics on the clinical accuracy of its tests, which was fast-tracked through the Food and Drug Administration’s review process, saying that accuracy data and other performance characteristics will continue to be collected in the field.
State officials are scrambling to obtain Abbott’s highly touted machines after it said they could detect the novel coronavirus in as little as five minutes, or give a negative test result in about 13 minutes. That compares with at least 45 minutes to several days to get results from most of the other types of COVID-19 tests being used.
In announcing the test March 27, Abbott said it was “ramping up production to deliver 50,000 ID NOW COVID-19 tests per day” starting this week to the U.S. health care system.
The price of Abbott’s stock has jumped 26.5% since March 23.
The document circulated among HHS and FEMA officials March 30 and obtained by Kaiser Health News said 5,500 cartridges ― which translates to 5,500 tests — and 780 devices would be shipped to 55 state and local public health labs all over the U.S. An additional 1,200 tests would go to the Pacific territories. Smaller numbers would be sent to the CDC’s lab in Atlanta and the HHS’ Strategic National Stockpile. Abbott has said the company is “working with the administration to deploy the tests to areas where they can have the greatest impact.”
But contrary to the document’s contents, distribution has been far from even. For example, within days of Abbott’s announcing it would ship its rapid test around the country, Detroit Mayor Mike Duggan said he had secured a commitment for five machines and 5,000 tests from the company, making it among the first cities to receive them. The city planned to immediately use them to test police officers and other first responders. A spokesperson for the city didn’t respond to questions Thursday about whether Detroit had the tests in hand.
DeSantis last Saturday said he’d secured just 2,000 such tests. “I think this is really really significant because the problem with the testing we have now is these private labs are overrun. Ideally, they would want to turn it around in 24 to 48 hours but in fact, a lot of people have to wait three, four or five days to be able to get test results,” he said. “I think it also gives a lot of people peace of mind because they at least know what the result is.”
Yet providers have reported rampant problems with COVID-19 tests giving false negatives, in which the virus is not detected even in an infected person. Few medical tests are 100% accurate. Any test can have false negatives or false positives. The problem isn’t unique to COVID-19 tests.
“False-negative test results — tests that indicate you are not infected, when you are — seem to be uncomfortably common,” Dr. Harlan Krumholz, director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, wrote in a New York Times piece April 1. “Increasingly, and disturbingly, I hear a growing number of anecdotal stories from my fellow doctors of patients testing negative for coronavirus and then testing positive — or people who are almost certainly infected who are testing negative.”
Reasons for this can vary. The test itself might not be so good at picking out true cases from false ones. Or maybe it wasn’t the test at all, but how the sample was taken or how long it had been since the patient began showing symptoms. Doctors and patients should always consider that a result might not be accurate.
That may be especially true now because the COVID-19 test kits from manufacturers and clinical labs became available under emergency use rules.
Under those rules, manufacturers and labs have to submit documentation to the FDA but don’t have to provide as much information as they would under a regular approval process.
Part of the requirement is they show the FDA just how much ― or little — of the virus must exist in the samples before their test can detect it, said Joeffrey Chahine, technical director for the molecular pathology division at MedStar Georgetown University Hospital in Washington, D.C. They also must show how well the tests specifically pick out the coronavirus, not confusing it with another virus, he said.
By relaxing some of the other information normally required, such as correlating results with the status of actual patients, the test kits could get onto the market sooner. And that’s the trade-off.
“This is the downside to loosening the FDA restrictions in that the tests weren’t required to go through the same level of quality assurance, the testing of the test, that we would normally see before they go on the market,” said Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials. “But I don’t think that was a bad decision. This is an emergency.”
–FlaglerLive and Kaiser Health News