Earlier this month, Ohio’s Public Health Advisory System was unveiled to take a county-by-county approach of attacking COVID-19.
During the Thursday, July 16 press conference, Governor Mike DeWine introduced Andrew Thomas, M.D., Chief Clinical Officer at OSU Wexner Medical Center, who has been advising DeWine and his team throughout the pandemic. Since Thomas was involved in helping develop the color-coded public health advisory system, he was asked to discuss the system for the audience viewing the conference.
DeWine indicated that the Ohio map will most likely be updated every Thursday. First, he asked Thomas to explain how the system works. There are four alert levels, as follows:
Alert Level 1 Public Emergency (Yellow): Baseline level. County has met zero or one indicator. Active exposure and spread. Follow all health orders.
Alert Level 2 Public Emergency (Orange): County has met two or three indicators. Increased exposure and spread. Exercise high degree of caution. Follow all current health orders.
Alert Level 3 Public Emergency (Red): County has met four or five indicators. Very high exposure and spread. Limit Activities as much as possible. Follow all current health orders.
Alert Level 4 Public Emergency (Purple): County has met six or seven indicators. Severe exposure and spread. Only leave home for supplies and services. Follow all current health orders.
Counties that are approaching Alert Level 4 are indicated with a star.
A county’s alert level is determined by seven data indicators, including: 1. New Cases Per Capita; 2. Sustained Increase in New Cases; 3. Proportion of Cases that Are Not Congregate Cases; 4. Sustained Increase in Emergency Room Visits; 5. Sustained Increase in Outpatient Visits; 6. Sustained Increase in New COVID-19 Hospital Admissions; 7. Intensive Care Unit (ICU) Bed Occupancy.
Thomas explained that the group of metrics as a whole are responsible for the weekly alerts.
“When you look at the trajectory of each and every metric, you see a trend that will provide an early warning that there are issues related to COVID-19 that need get the attention of local health care providers, local businesses, schools and really the population in general,” said Thomas. “It is not meant to be a grade, or anything beyond a warning — like a weather forecast of a storm coming in the future. It doesn’t do much good to get a weather forecast when you can already see it raining outside. What this system is to designed to do is to look forward.”
According to Thomas, the ability to look forward can give officials an idea of what steps to take before the COVID-19 outbreak becomes worse in an area.
“Any one metric might be imperfect,” said Thomas. “But if you have three, four or five metrics all trending in a worsening direction, it helps make sure you are giving accurate information out to a region of the state. It is meant to be an early warning.”
Of the seven indicators, Thomas said there are five that he would call leading indicators, which will show where the virus is going in a community.
“The first (indicator) and probably most important, although they are weighed equally, is new cases per capita. What per capita means is normalizing the number of new cases based on the population size of the area. What this metric does is take the total number of new cases over the past two weeks and it looks at what is that rate per 1,000,000 citizens,” said Thomas. “That allows us to normalize for a large county like Franklin, a medium county like Stark or a small county like Athens to determine what is an equivalent rate for that county.
“Based on CDC guidelines, anything above 50 cases in 1,000,0000 in the past two weeks would be considered moderately high incidences of new cases. If your county is less than 10 cases per 100,000, no matter what any of the other metrics say, your county is going to be yellow, because the incidence is so low. If you are a above 50, then you will trigger the metric.”
According to Thomas, three other metrics that are also considered leading indicators deal with trends of worsening data over a five-day period. Two of those relate to symptoms patients describe when they either go to the emergency department or their provider’s office. The other metric, also a leading indicator, is about sustained increase in new cases.
“The last one that I would call a leading indicator relates to congregate settings. What we want to measure with this alert system is what is going on in the community, not particularly in a congregate setting, although we care very much about what is going on in local nursing facility, local jail or local prison,” said Thomas.
“To some degree that may not have a lot of impact on what is going on in the rest of the community. This metric is designed not to flag if greater than 50 percent of the cases over the past three weeks have just been in congregate settings. If in any week greater than 50 percent of the new cases are in the community, it will flag.”
Thomas said the two lagging indicators are based on hospitalizations. One relates to COVID-19 hospitalizations. It looks for a sustained five-day increase in the seven-day rolling average for new admissions to the hospital for patients with COVID-19.
“We know based on data that has been published from the time that someone contracts COVID-19, they typically don’t end up being admitted to the hospital the next day,” said Thomas. “They are typically sick or symptomatic often seven to 14 days before presenting for hospitalizations.”
The other is related to ICU-bed occupancy for a hospital for all patients, not just COVID-19 patients, and it includes an entire region. Thomas said hospitals want to make sure they have capacity for all patients in their ICU units.
“The state separated in eight emergency management regions. We have managed this illness based on those eight regions whether it is supplies, testing and hospitalized patients,” said Thomas. “We look at those eight regions and if any of those regions have had three of the last seven days with more than 80 percent of their ICU beds occupied, that will flag the metric.”
Thomas said that none of the counties are labeled as green.
“The reason none of the counties are green is no matter what county you live in, you are at risk to contract COVID-19. There is activity to some degree across the entire state,” said Thomas. “Until we have a vaccine or a pharmacological medication treatment that is known to stop the incidence or spread of the disease, no county will be anything less than yellow. No matter where you live, you are at risk for this.”
Pike County remains yellow at this time, which is the lowest on the tier of alerts. The Pike County General Health District is making a push to keep it that way.
“If your county triggers zero or one of the metrics, you are yellow or if you are less than 10 per 100,000 over the past two weeks. If you have two or three metrics, you are orange. If you have four or five, you are red, and if you have six or seven you are purple,” said Thomas.
“I think one of the key things that individuals can do is wear a face mask. It is what we call source control. Some small percentage of patients who have COVID-19 are asymptomatic or pre-symptomatic. Up to 48 hours prior to developing symptoms, you could potentially infect other people. If you have no symptoms, you could be spreading the disease.”
Thomas added, “There’s a reason surgeons have worn masks in surgery for 100 years. We know when the surgeon or nurses breathe, they can breathing out bacteria. I wish people would wear face masks in the yellow or orange counties without needing to be ordered to do so. I think that is one of the most effective ways for you (your county) not to become red. The goal is not to become red.”
Additional measurements still in development include county-level data on contact tracing, tests per capita, and percent positivity, according to the governor’s office.
Detailed descriptions for each indicator can be found at https://coronavirus.ohio.gov/static/OPHASM/Summary-Alert-Indicators.pdf
Each alert level includes specific risk-level guidelines, including the requirement that all citizens comply with all health orders. These guidelines can be found at https://coronavirus.ohio.gov/static/OPHASM/COVID-19-Risk-Level-Guidelines-GP.pdf