Riverside County Supervisors expected to rescind local health orders

The Riverside County Board of Supervisors is expected to rescind local health orders. "Because of the efforts that we’ve been able to accomplish over these past couple of months, we are in the position to align ourselves once again and be consistent with the governor’s orders," said V. Manuel Perez, a supervisor for Riverside County in the 4th district. The motion would end restriction on schools, short term lodging, golf courses, face coverings and social distancing, all set to expire on June 19th, and place them under state orders. "I’m not saying that by us doing this that we’re ready to open the economy tomorrow. We know that we still need to work hard to ensure that in case there’s a surge we have enough hospital beds and equipment," said Perez. Since the announcement, Coachella Valley Health Experts wrote an open letter to the board saying, "It’ is imperative that we continue to implement the orders to prevent a second wave of infections." Representatives from different parts of the desert agree. "Riverside County has the second largest number of cases in the state and this isn’t a good time to rescind any orders if it’s not based on public health justifications and experts," said Christy Holstege, Mayor Pro Tem for Palm Springs. "The health and safety is the biggest concern, when we start talking about lifting restrictions, most of us think this is a little too much too fast," said Joe Duffle, president of the UFCW 1167. And both experts point to the county health officials as the main resource for the desert. "Cities don’t have doctors on staff, we don’t have public health experts To make the decisions about interpreting the state order and how to apply public health to each of our different industries, that’s the job of the county, that’s their fundamental job right now, and we need the county to do their job," said Holstege. You can read the full open letter here: Email covid19.student.taskforce@gmail.com, or text 9163181376 to sign or for more information. Open letter to the Riverside County Board of Supervisors Summary On Tuesday, May 5, 2020 the Riverside County Board of Supervisors will vote on a motion proposed by the Economic Recovery Task Force to rescind the following public health orders: a) April 1, 2020, Amended Order of the Health Officer Closing All Schools, Community Colleges, Colleges, and Universities from March 16, 2020 through June 19, 2020; and, b) April 2, 2020, Amended Order of the Health Officer Related to Short Term Lodging Facilities through June 19, 2020; and, c) April 29, 2020, Amended Order of the Health Officer for the County of Riverside and the Director of Emergency Services Placing Restrictions on Golf Course Use; and, d) April 29, 2020, Amended Order of the Health Officer for the County of Riverside and the Director of Emergency Services requiring the use of face coverings and practice of social distancing. We, as a collective group of physicians, practitioners of public health and community organizations, strongly urge the Riverside County Board of Supervisors to oppose the motion to rescind the public health orders currently in place. Rescinding these orders prematurely will lead to unnecessary illness and deaths in Riverside County and, ultimately, lead to a delayed economic recovery for the region. Background Riverside County is the second-hardest hit county in California with 4,164 cases and 161 deaths, thus far. We have seen that the above public health orders, which were developed based on our current scientific understanding of COVID-19, have aided in flattening the curve. According to estimates from the World Health Organization and the Johns Hopkins School of Public Health, each person infected with COVID-19 will transmit the virus to two or three individuals. Thus, a small number of cases is capable of quickly multiplying at an exponential level, as was seen in New York, which now has approximately 25% of all confirmed cases in the United States. In order to prevent Riverside County from becoming an epicenter of COVID-19 on par with New York or Los Angeles County, it is imperative that we continue to implement the orders to prevent a second wave of infections. Facts about COVID-19: The virus spreads via three routes: hand to mouth/face, aerosol transmission, and via feces. Research on the COVID-19 virus suggests it spreads more efficiently than influenza, and spreads easily and sustainably between people. Many people are asymptomatic carriers and do not know they have the virus and, therefore, contribute to further spread. Main strategies to prevent further spread: Social distancing: The largest portion of COVID-19 cases have been related to mass gatherings, religious activities, workplaces, and hospitals. The risk of indoor exposures shows the necessity for social distancing measures. One recent study out of South Korea, identified 94 out of 216 employees on one floor has tested positive for COVID-19. This results in an attack rate of 43.5% (2). This outbreak shows alarmingly that COVID-19 can be exceptionally contagious in indoor settings; such as schools, businesses, and restaurants. A high-density work environment can become a high-risk site for the spread of COVID-19 and potentially a source of further transmission. Face coverings: A primary route of transmission of COVID-19 is through small respiratory droplets that can be spread by coughing, sneezing, and even talking. These droplets are known to be transmissible from asymptomatic and presymptomatic individuals, so limiting contact via physical distancing and reducing probability of spread and/or acquisition per contact by wearing face coverings. Public mask wearing is most effective at stopping the spread of COVID-19 when compliance among a given population is high (6, 9). Mass testing and tracing: We need to be able to have mass testing to know what communities are affected. Riverside County has been working on expanding testing centers; however, more testing centers are still needed. Especially in underserved communities. In addition, the county needs to start working on contact tracing (10). According to a report by the WHO, the city of Wuhan required 9,000 trained full-time individuals in order to perform contact tracing and follow up regularly with cases and contacts. Scaled to the population of Riverside county, such an effort would require approximately 2,000 individuals as well as complex infrastructure, neither of which are in place. Without scaling up testing and contact tracing, we should not be thinking about lessening social distancing measures. A summary of events in Riverside County thus far: April 4: Riverside County Public Health Office Dr. Cameron Kaiser released orders to wear face coverings and ban non-family gatherings with the exception of essential services. This decision was taken as the most scientifically sound measure to mitigate spread in communities and lower likelihood of exposure. April 29th: Dr. Kaiser extended his order requiring residents to wear face coverings when outside and practice social distancing through June 19th. In hopes of decreasing transmission of COVID-19 and relieve strain upon the health care system. What the projections were and what they are now Projections: March 31st: Riverside County projected 1000 COVID-19 related deaths in early May. However, as of May 3, 2020, there are 161 COVID-19 deaths. This significant decrease is an astounding testament to the efficacy of the public health orders put in place thus far. To rescind the aforementioned orders at this time would put our community in jeopardy. March projections showed greater than 65,000 cases and 1,200 deaths in early May for Riverside County. After the statewide stay-at-home order and Dr. Kaiser’s face covering order on April 4, 2020, real-time projections from the week of April 13 lowered those projected numbers to 13,000 cases and 289 deaths by early May (5). As of May 3, 2020, there are 4,180 cases and 161 deaths. This significant decrease is an astounding testament to the efficacy of the public health orders put in place thus far. To rescind the aforementioned orders at this time would put our community in jeopardy. On March 31, 2020 Riverside County had an infection doubling rate of 4.7 days. With social distancing, stay-at-home, and face covering measures, the curve has been effectively flattening with doubling rates now greater than 7 days (5). While this slowing of infection rates is promising, cases and deaths are still rising and warrant the maintenance of those measures which have decreased the strain on our health care system. Concerns with Motion Our concerns with this motion are a resurgence of cases and increased death toll if these measures are lifted prematurely, especially in the most impacted regions of Riverside County such as the Coachella Valley. The Coachella Valley currently stands at 767 confirmed cases and 25 deaths. The deaths in this area account for 15% of COVID-19 deaths in Riverside County. The rate of cases in the Eastern Coachella Valley, where testing has been more sparse and patients have lower access to care, has already exceeded the rates in the initial outbreak areas in the West. The pandemic is disproportionately affecting more vulnerable communities, including the unhoused, socioeconomically disadvantaged, undocumented, frontline workers, elderly, communities of color, and those exposed to environmental toxicity. These factors are especially acute in Riverside County, and lifting restrictions would cause further spread amongst the most vulnerable and least able to access care. For example, Georgia has witnessed a surge in cases after the lifting of restrictions, as predicted by modeling from Harvard Medical School (1,3). A careful and meticulous economic recovery plan is vital but it is imperative that Riverside County’s economic recovery plan include mass, large scale testing of symptomatic and asymptomatic patients, such as the infrastructure seen in Los Angeles County, prior to reopening. The county does not have the capacity in terms of health infrastructure and number of providers to withstand the sort of resurgence seen in other areas which have opened. This would be translated to significant stress to the system and potentially greater losses than witnessed elsewhere. Furthermore, the public health orders in place were imperative to prevent overwhelming our health care system at the onset of this crisis. The fact still remains that our current health infrastructure cannot handle a surge of the nature projected in early March, when these measures were not established. Reopening society without substantial planning and protections for our healthcare system would be a disservice to our healthcare providers and community at large. Recommendation Given the clear risk to our community, we strongly discourage the Board of Supervisors from passing this motion and rescinding the existing public health orders. Sources Abusaid, S. (2020, May). Georgia’s COVID-19 death toll increases up to 1,174; cases top 28.3K. The Atlanta Journal-Constitution. "Early Release – Coronavirus Disease Outbreak in Call Center, South Korea – Volume 26, Number 8-August 2020 – Emerging Infectious Diseases Journal – CDC." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, wwwnc.cdc.gov/eid/article/26/8/20-1274_article. "Georgia: a case study." (2020). COVID-19 Simulator. MGH Institute for Technology Assessment. Horseman, J. (2020, April). Riverside County coronavirus projections improving; fewer cases, deaths predicted. The Press Enterprise. Horseman, J. and Johnson, N. (2020, April). 5 things we’ve learned about coronavirus in Riverside County. The Press Enterprise. Howard, J.; Huang, A.; Li, Z.; Tufekci, Z.; Zdimal, V.; van der Westhuizen, H.; von Delft, A.; Price, A.; Fridman, L.; Tang, L.; Tang, V.; Watson, G.L.; Bax, C.E.; Shaikh, R.; Questier, F.; Hernandez, D.; Chu, L.F.; Ramirez, C.M.; Rimoin, A.W. Face Masks Against COVID-19: An Evidence Review. Preprints 2020, 2020040203 (doi: 10.20944/preprints202004.0203.v1). Johnson, George. "AMENDED ORDER OF THE HEALTH OFFICER FOR THE COUNTY OF RIVERSIDE AND OF THE COUNTY EXECUTIVE OFFICER AS DIRECTOR OF EMERGENCY SERVICES." Https://Rivcoph.org/, 6 Apr. 2020, rivcoph.org/Portals/0/Documents/CoronaVirus/April/PHOrders/Riv-EOC_20200406_090004.pdf?ver=2020-04-06-102528-423×tamp=158619393518. SUPERVISOR V. MANUEL PEREZ AND SUPERVISOR KAREN SPIEGEL: Rescission of Local Public Health Orders – Riverside County, California, 2020, riversidecountyca.iqm2.com/Citizens/Detail_LegiFile.aspx?Frame&MeetingID=2279&MediaPosition&ID=12515&CssClass&fbclid=IwAR3eDPfCN04wWlGWxr17GneFazkIwYEMCvvpbkWUORJcIcuQ_KDuDQpjq4o. Tufekci, Z., Howard, J., Greenlagh, T. (2020). The real reason to wear a mask. The Atlantic. www.theatlantic.com/health/archive/2020/04/dont-wear-mask-yourself/610336/. Watson, J., Cicero, A., Blumenstock, J., Fraser, M. (2020). A National Plan to Enable Comprehensive COVID-19Case Finding and Contact Tracing in the US. Center for Health Security. Johns Hopkins Bloomberg School of Public Health. Baltimore, MD. Signed, IE Medical Student COVID-19 Student Taskforce UCRSOM Organized Medicine UCRSOM Street Medicine UCRSOM Medical Students for Immigrant Justice UCRSOM Muslim Student Association UCRSOM American Medical Women’s Association UCRSOM LGBT+ Health Interest Group UCRSOM Emergency Medicine Interest Group Riverside Free Clinic LULAC of Riverside 3190 California Partnership TODEC Legal Center Coachella Valley Immigrant Dignity Coalition Inland Coalition for Immigrant Justice Providers: Roula Younes, DNP Infectious Diseases Nurse Practitioner Bachir Younes, MD, MPH Board Certified Infectious Diseases Ignacio Borensztejn, MD Resident Physician Internal Medicine Eisenhower Health Richard A Loftus MD -Associate Program Director, Internal Medicine Residency Program Eisenhower Health Rancho Mirage CA -Principal Investigator Palmtree Clinical Research Palm Springs CA Troy Kurtz, MD Resident Physician Psychiatry UCR SOM Psychiatry and Neuroscience