PHOENIX – Experts around the country and in Arizona are raising alarms about Arizona's COVID-19 situation because cases and hospitalizations have increased for the past two weeks.
The increase in cases can't solely be attributed to increased testing in Arizona, experts say.
Instead, it looks like the state is trending upward in a way that is concerning and could need another stay-at-home order to curb the spread.
"I would go so far as to say alarming," said Dr. William Hanage, an epidemiology professor at Harvard University's T.H. Chan School of Public Health. "The only sort of crumb of comfort that I can find is that I think, in general, it's sort of easier to social distance in Arizona than it is in some places."
If trajectory continues, state 'may need to gear up for increasing action'
Arizona's largest hospital system warned over the past week that its intensive care units are filling up, ventilator use was on the rise and capacity was reached for extracorporeal membrane oxygenation treatment.
"We have seen a steady climb of COVID-19 cases in Arizona over the last two weeks," Banner Health tweeted Monday. "This trend is concerning to us, and also correlates with a rise in cases that we are seeing in our hospital ICUs."
The state health director sent a letter June 6 to hospitals urging them to "fully activate" their emergency plans.
But Arizona Gov. Doug Ducey and Dr. Cara Christ, the director of the Arizona Department of Health Services, said last week that the rise in cases was expected as Arizona started reopening.
Ducey's office has repeatedly pointed to an increase in testing as the cause of case numbers increasing.
Jessica Rigler, the state health department's assistant director, said the department is trying to spread the message that people can take precautions such as wearing a mask in public and staying home while sick.
"We don't want people to be in crisis mode, thinking that everything is all bad in Arizona with the cases," Rigler said. "We are certainly monitoring what's going on and trying to ensure that people understand where we are with COVID-19 in our communities."
Dr. Kacey Ernst, an infectious disease epidemiologist at the University of Arizona, said all signs seem to point to increasing transmission of the disease. Increased testing could explain increased cases, but not increased hospitalizations, she said. Arizona does appear to be increasing more than other states, she said.
The situation is “very concerning,” she said.
“If we continue on this trajectory and it is not just due to one or two localized outbreaks, then we may need to gear up for increasing action,” Ernst said in an email. “The director of ADHS has declared all hospitals should activate their emergency plans. That should tell us all something.”
Ducey spokesman Patrick Ptak said the governor’s office is working with public health officials and community leaders to provide more guidance on reopening, “ensuring businesses return smarter and work to mitigate the spread.”
Ptak said in an email that the increase in cases was anticipated, and the state is working on ways to increase hospital capacity. The old St. Luke’s hospital is “ready for activation” though not yet needed, he said.
Ptak also pointed to increased testing as a reason cases are increasing, saying testing has doubled since the stay at home order ended May 15.
What national experts see
Across the country, health experts have taken notice of Arizona's trajectory.
"There are 3 state warnings worth issuing today for COVID," Andy Slavitt, a former administrator of the Centers for Medicare and Medicaid Services under President Barack Obama, tweeted Tuesday. "Not panic, but time to consider actions."
Arizona was on the list, along with Arkansas and Utah.
Youyang Gu, a data scientist who created covid19-projections.com, posted a map of how states' cases are changing, considering both population and the rate of increase, he wrote on Twitter.
In that map, Arizona appears bright red, earning the worst score for COVID-19 case changes. Positive scores on the map mean cases are decreasing. States that had early outbreaks, including New York and Michigan, now have positive scores on the map.
Arizona scored -100, the lowest in the country.
Other models projecting the spread of COVID-19 have adjusted their estimates upward for Arizona.
A model from the Institute for Health Metrics and Evaluation at the University of Washington showed in mid-May that Arizona would reach about 2,900 deaths from the disease by August 4. It now predicts more than 4,400 by that date.
During New York Gov. Andrew Cuomo's COVID-19 briefing June 8, he said Arizona and a few other states offered a "cautionary tale."
With an increase like Arizona is seeing, the state needs to be thinking about how to slow the disease down, Hanage said. Reopening does the opposite, because transmission occurs when people come into contact with others, he said.
If states wait too long to act, they're "sitting on a kind of powder keg of transmission chains," Hanage said.
What are numbers showing?
Most indicators in Arizona show an increase in the disease's spread that goes beyond just increased testing, experts say. For example, since the day after the stay-at-home order expired May 16 to Tuesday, cases increased by 108% while testing increased by 100%.
Last week, several days saw more than 1,000 newly reported cases. Prior to the past week's dramatic case increases, new cases reported daily have typically been in the several hundreds.
Hospitalizations have steadily risen. Statewide hospitalizations as of Sunday were at 1,266 inpatients in Arizona with suspected and confirmed COVID-19, which was the second highest number, behind Friday, since the state began reporting the data on April 9. The past eight days have seen inpatient hospitalizations statewide for suspected and confirmed COVID-19 eclipse 1,000.
The percentage of positive tests per week increased from 5% a month ago to 6% three weeks ago to 9% two weeks ago, and 12% last week.
With increasing testing, the percent of positive tests out of all tests would ideally decrease, Hanage said.
Who is being tested, particularly if there are efforts to test those in congregate settings such as nursing homes, can affect this percentage, Hanage said.
Statewide, Arizona didn't see a decrease in COVID-19 at any point, said Dr. Joe Gerald, an associate professor at UA's Mel & Enid Zuckerman College of Public Health. Some places did begin to plateau or level off, he said. But since social distancing restrictions were lifted in early- to mid-May, the disease has taken off, he said.
"When you put these pieces together, they're really worrisome signs that the outbreak has really gained speed and momentum again," Gerald said. "And if we don't do something to turn it around fairly quickly, we could be in real trouble come early July."
Gerald said it looks like, if trends continue, hospital capacity could reach its limit by early July, which could mean trouble for providing high-quality care to people who need it.
What could stop the trend?
It's clear now to experts that the state is in a concerning position. But acting immediately to take measures to curb the spread won't have an immediate effect on case increases because people are already infected and spreading it to their close contacts, they said.
Hanage said if he were advising the governor, he would say the least that can be done is to halt reopening and see if the increase continues.
"Even if you were to be able to take pretty effective measures now, you'd still be having a month or so of difficulty with cases at at least this level, if not somewhat more," Hanage said.
Still, experts say the state needs to act quickly to get the situation under control.
The public needs to continue following public health recommendations, such as physically distancing, wearing masks and washing hands, Ernst, of the University of Arizona, said. It's also important for state leaders to follow these guidelines, she said.
Ducey, for instance, has not worn a mask in public and has been pictured at meetings indoors with groups of unmasked people.
"There needs to be a cultural shift," Ernst said. "So many people still aren’t wearing masks. But people see leaders not taking these precautions and they hear the state is open and they let their guard down. Psychologically, it is hard to keep it going, but it is critical. This will get closer to home to people as more get sick."
Gerald said it's hard to see how the state could avoid another shutdown at the rate cases and hospitalizations are increasing right now.
Will Humble, the executive director of the Arizona Public Health Association, detailed in a blog post several steps the state should take now to stem cases. Those include a focusing on testing and infection control in nursing homes, enhancing contact tracing, allowing cities to put their own mitigation strategies in place and requiring people to wear cloth masks in public.
Those steps could make it so the state doesn't have to institute another stay at home order, Humble said.
"If we don't do anything, we're just going to drive off a cliff," Humble said.
Contributing: Stephanie Innes and Alison Steinbach, Arizona Republic
Follow reporter Rachel Leingang on Twitter.