Board of Supervisors — 2020-03-10

Yeah. Music playing Yeah.

I'll call to order the March 10th, 2020 meeting of the Santa Barbara County Supervisors. Will the clerk please call the roll?

Mr. Lavinino? Here. Mr. Williams? Here. Ms. Hartman? Here! Mr. Adam? Here Chair Hart?

Mr. Chair, if I could just say that was really a coordinated pledge. That's the best pledge I think I've heard for a very long time so give yourselves a hand.

And as the past chair who tried to pull it off many times, I appreciate you saying Greg did it

better. We have a really highly functioning audience today to start off with. Thank you Supervisor Adam, that was nice of you.

Move approval.

Second. Motion's been made and seconded. All those in favor say aye. Supervisor Lavinino would like to make an announcement to begin our meeting. Supervisor Lavinino.

Thank you very much. Well this last week we lost One of the great community leaders on the Central Coast, Katya Ashagi passed away on March 5th. Katya was a dear friend of mine. He was a three term member of the County Board of Supervisors in San Luis Obispo County. He then spent six years representing the central coast and the state assembly. He was often referred to as the man in the middle, the swing vote.

Very interesting individual, never really let party get in the way of what he knew was common sense. And he could always get to the bottom of a problem just by really cutting out all the BS and just getting down to the core of the matter. It led a very interesting life. He came from Lebanon in 1971 to the Central Coast where he attended Cal Poly He was supposed to be going back to Lebanon, but war broke out. So he stayed here and began working at a Shell gas station in Arroyo Grande.

And when the owner decided he wanted to get out of the business, Cacho ended up buying the gas station, ended up owning a chain of them and really epitomized the American dream. He's survived by his wife Aroxi, his two kids Nairi and Harach, Memorial service Thursday at 930 at Mission San Luis Obispo for those that would be able to attend. And if we could just observe a moment of silence in his honor, I would appreciate it. Thank you Supervisor Lavaniello.

Thank you. Thank You. CEO Miyasato is there a report today?

Chair Hart and Supervisors, I don't have a report myself but we have asked our experts to come this morning to provide an update to you on the coronavirus COVID-19. So at the table today we have our Public Health Officer Dr. Henning Ansorg, Paige Batson our Deputy Director and Registered Nurse, and from Cottage Hospital Dr. David Fisk the Medical Director of Infection Prevention and Control. I also want to acknowledge that Ron Wirf the CEO from Cottage Hospital and several of his Emergency direct department doctors are here today, and we appreciate them being here with that I'm going to hand it over to public health

Thank You dr. Answer miss Bettson hi

hi good morning chair Hart and members of the board My name is Paige Batson, and I am the deputy director for the Community Health Division So I want to thank you today for allowing us to be here to chair our To share a little bit of what's going on with COVID-19 in California and in Santa Barbara County. As you may be hearing in the news, there is a lot of activity going on with COVID-19. It is indeed evolving rapidly ever since we learned of it beginning in Wuhan China. There has just been a lot of activities.

You'll be hearing later on in my presentation that the numbers, in terms of confirmed cases and so forth are changing by the hour. Guidance to local health departments on what we need to do to help mitigate or prevent the disease from spreading and guidance for our public health department is coming pretty steadily from CDC and CDPH. And so a little bit of background in terms of the spread of the disease.

First of all, let me begin. In Santa Barbara County there are zero cases. So we have no cases and we currently have no individuals that are what we call persons under investigation. So that is really good news. And as we began to see cases evolving in or being identified in the US, the US declared a public health emergency. And as we began to see cases in California, Governor Newsom declared a state of emergency for California. And so as you also may know that there are other countries where travel is being, is at a level three travel advisory. We have Iran, Italy, South Korea, Hong Kong and Japan. And so that's an indication of the spread of the virus.

Of importance is recent activity that occurred on March 5th The Department of Managed Healthcare directed full service commercial plans and Medi-Cal plans to assure that their beneficiaries have zero cost sharing. And this is really a good thing because it allows for individuals not to concern themselves with deductibles, cost sharing and so forth. It allows them to seek whatever medical services they need And be able to access screening and testing, and any COVID-19 related medical expenses to be covered at no expense to them. And so for public health this is important because it allows us to identify cases much earlier. And it allows those individuals that do worry about costs to get in early and seek the screening.

Additionally on March 8th we had, we finally received some updated guidance for schools colleges and for large mass gatherings. This is long awaited in that it provided much more specific information about the importance of what kinds of plans schools And what kinds of planned schools need to have in place, and what they would need to do with regard to social distancing. A lot of that would be in consult with the health officer as it relates to what else is going on in the community. But there's a lot more specificity in those guidance and Dr. Ansar will be speaking to that a little later.

Okay, so as of yesterday morning, mid-morning we had 423 cases in the US. And in California we had 133 confirmed cases. I'm here to tell you that as of this morning, I'm sorry, yeah, as of this morning we have 133 cases. We have 24 that were repatriated. We have 44 that are travel related. 28 person to person and 19 with community transmission, and 18 that are under investigation. I will tell you that these numbers by the time I walk out of this room they will have changed.

And there's only one death in California. So what's happening specifically here in Santa Barbara County? We continue to receive direct notification from the California Department of Public Health of travelers coming from mainland China. It's an automatic electronic process and upon learning that the traveler has arrived in Santa Barbara County, we initiated a 14 day public health supervised monitoring process.

And so, additionally the CDC has broadened its testing criteria for what we call a person under investigation. In the past that PUI public person under investigation was very limited. It was limited primarily to individuals who had traveled, who had been exposed to a confirmed case and so forth. Now it is broadened so that medical providers can use their own clinical judgment to determine whether testing is indicated.

And so it now allows for us to look at seniors greater than 65 years of age and to test them as well as individuals with comorbidities or chronic medical conditions like heart and lung disease. So this is really important for us, as we know the COVID-19 is hitting our elderly a little bit harder. Additionally, we now have 17 testing sites in the US. And we are really proud to say that it now includes LabCorp and Quest. So we're really excited about that. That is a little bit overdue but we have it now.

So as far as local monitoring from the Public Health Department, we have a total of 45 individuals that we've monitored. 20 have cleared their monitoring meaning that 14 days have passed and there were no symptoms and no further action was required. We currently have five being monitored and 18 that either their destination was not Santa Barbara or who self-reported, and we learned that there was actually no travel history at that time. We have three others that we are pending contact, and I learned as of this morning there's only one left that we need to reach out to.

So things are going really well in terms of our monitoring process. Our monitoring processes is pretty solid and we anticipate that we have a little bit more capacity for monitoring should that be necessary. I also want to share that our Public Health Department DOC was activated on March 6th, and we are open from 9 to 12. And it's primarily to provide our medical health community with resources that may be needed whether that be masks, whether that be ventilators and so forth.

And so with that, I will turn it over to Dr. Onsorg.

Thank you Paige. Esteemed Board of Supervisors, Mr. Chairman, I just want to assure you that myself and our very dedicated team from public health we are taking this situation seriously and I want to reassure you that we are well prepared. We are trained for this and we have been in the line of fire a pun intended on several occasions and we have proven that we can step up to the plate if necessary The role of the Public Health Department in restricting or limiting, you know, liberties in order to prevent public health has to be taken with a lot of caution and reason.

And I would I'd like to stress that depending on the level of community transmission, those recommendations or orders would depend on how many diseased individuals we have in our community. So as of right now since we do not have a single case in Santa Barbara County only one case that was travel related And we are. We could change this alert level in a matter of minutes and declare local health emergency, but so far we haven't thought that we need to do So we are working very closely with our partners at the CDC, at CDPH and also with Southern Californian health officers as well as with our really supportive local community physicians. Dr. Fisk is here to my left and he will speak later as a Director of Infection Control for Cottage Health System.

We're also in contact obviously with Northern California, Northern County Hospitals And in very close communication. Once we will have a confirmed case in the county, our level of alertness will ramp up and we are actually already sending out messages that we do recommend social distancing for vulnerable individuals. The vast majority of people who come down with this virus viral illness have fortunately have a mild course of the disease and recover really well without any hospital care or anything. However, about 20%, those are the numbers that we extrapolate from China are likely to need a more intensive hospital care at times or even intensive care and respiratory support in an intensive care unit Cases that have died are almost always elderly folks or people with a weakened immune system due to chronic illnesses, or people who have to take certain medications to reduce their immunity like transplant recipients or people with severe diseases that require immunosuppression.

Those people are advised to really think twice about going to a movie theater or a concert, or attend a conference even at this time. Because travel is really everywhere and people come from you know everywhere on travel especially to events of that nature. We have worked with our local schools, K-12 as well as institutions of higher education and they have all been very eager and compliant and helpful with issuing very robust endemic preparedness programs. They are all really ramping up their regular cleaning and disinfection. They make sure that no sick individuals attend school, neither students nor staff.

This is really essential. Everybody in the community was very concerned about the cruise ships that do dock at Santa Barbara Harbor and we do not take this lightly. Obviously, the cruise ships are under direct supervision by the CDC as their public health agency And they are also under orders by the Coast Guard, and in our case by the captain of the port in Los Angeles who is actually in charge of quarantining a ship if needed.

We understand that there is an understandable sentiment in the community that, you know, would like cruise ships to be banned. You may have heard that the next scheduled cruise ship has canceled, that it would've arrived here on March 24th. So we are working very closely with the federal government and you will remember that Vice President Pence has been in very intense discussions with their cruise lines over the weekend already.

And the state, because we have so many ports in California is on this and we are waiting for We want to be in line with the cooperation with the state so that we have a concerted effort and do, we do not vary too much with them. But we should have much clearer guidance in the very near future Waterfront area, the city's actually the custodian of the real estate there.

And they would also have authority to weigh in and I will attend a City Council meeting later today and we will discuss that further at that venue. With this I would like to pass on... You want some there? Hand washing? We can't wash our hands enough Obviously. So because this virus is one of many, a whole bunch of viruses that causes upper respiratory infections and it's transmitted via an aerosol which means basically saliva that is expelled by sneezing and coughing and so forth It is very important to protect ourselves. We have to just ramp up our hygiene measures, we have to remind ourselves not to shake hands so much at this time and do the elbow or fist bump instead and my colleagues earlier reminded me very kindly And when I try to shake somebody's hand, and I know how hard it is because it's a formal greeting.

But this time we encourage you to please refrain from that. Also please stay at home when you're sick and don't send your kids to school when they're sick. Let them recover. And I'm not talking about COVID-19 sick, but generally sick because it is impossible to differentiate a common cold from influenza from COVID- 19 adenovirus or other coronaviruses or RSE viruses that are all in our community and causing the same symptoms and the art of medicine is in part to determine with tests and experience and, you know, investigation which is the most likely cause of this illness.

But a lot of questions come up with regard to wearing masks. There are two very clear scenarios where masks are very helpful and it's been proven scientifically that if a sick person wears a surgical mask, that when they have to cough or sneeze or something about 50% of those excretions are actually captured in the mask. And therefore less viruses are spread so it is helpful and all our outpatient clinics and hospitals Have signage on the outside and ask people if they have a cough. And if they do, they will put on surgical mask right then and there before they even get to either into the door or to the counter. That is really important. The other mask that is available is so-called N95 respirator.

And everybody in California knows these because we use them in the fire to get, you know, reduced particle inhalation from the smoke. But those respirators are actually designed for people who work in the healthcare setting with infectious individuals, for instance tuberculosis or any other respiratory And they should remain reserved for those people. We see on TV frequently that people run around with masks, mainly in Asian countries which is a cultural issue. Also the density of the population is so much higher and public transport usage is so much higher than in our area that it's understandable As long as you cannot stay away at arm's length from other people, you are actually at risk of getting infected.

area, it's not recommended. There is no scientific proof that it will prevent you from catching an infection that is actually only transmitted via respiratory secretions. So our community preparation efforts are in full gear. Our emergency response team has solidified their reserves in masks and materials to prevent, to protect health care workers. And working closely with the ambulances, emergency rooms and so forth.

And with this I would like to introduce you to Dr. Fisk who is Medical Director of Cottage Infection Control

Welcome Dr. Fisk, thank you for being here and thank you Dr. Anzurg for that presentation.

Good morning everyone. Can you hear me? Yes. Good morning Mr. Supervisor and thanks for having us today. I would just start my comments by saying Cottage as an institution similar to our colleagues in public health have dealt with situations analogous to COVID-19 in the past. And if you think back to the Ebola episodes when we had Ebola cases entering the United States, Cottage rapidly ramped up its capacity to care for patients with highly communicable diseases like that and we have built extensively on that experience Rapidly since the first cases of COVID-19 were announced in December.

And I would say at this point, I feel that cottage is ready to manage patients on the inpatient side with COVID- 19 and let me walk you through some of our preparations as an organization And I also would say that I'm here today with our ER lead, Dr. Brett Wilson and our CEO Ron Wirth who are also available for questions on behalf of Cottage. The focus at Cottage has really come from morning meetings we're holding every day They're multidisciplinary and they last between an hour and two hours, and involve people that you would expect to be there but maybe people you would not expect at first glance to be there. So it involves hospital leadership, medical staff leadership, it involves public relations, it involves ER staff, it involves facilities management people, it involves people involved Our supply chain and ensuring we have access to supplies, not only supplies such as N95 masks that are directly used in the care of COVID patients but also supplies for our routine processes such as surgical implants that might be compromised by the supply chain disruptions from Asia.

Furthermore, we have our transfer center involved in these meetings so that we can appropriately screen patients who are going to be transferred from other hospitals to cottage. So that we know if they have any symptoms it could be similar to COVID or if they have any risk factors for exposure to COVID. Our meetings also involve our infection control personnel with their expertise And many others. And so it's a meeting, I would say probably of about 30 individuals from throughout the organization plus or minus on a daily basis. So there's very, very detailed effort to this that's permeating the organization.

And I would just say that our efforts are really looking with the goals of being able to care for our community but also a goal on the hospital side of being able to protect our staff from COVID-19, from inadvertent exposures to COVID- 19. Because if now there is an exposure of a medical person the standard recommendation has been that they are then off work for 14 days and as you can see that happened for example in Northern California with exposures in hospitals there One patient came in and 150 staff members had to be furloughed from Northern California Hospital.

So we are putting extensive effort into identifying potential COVID patients not at the door, but before they get to the door out in the parking lot over the phone before they come on to cottage premises. So if any of you've been to cottage lately, you'll see signage outside our public entrances You'll see security personnel also in various locations like the ER to help if people who have suspect symptoms need to be immediately masked before they enter the building. Because from a healthcare standpoint, if a potential source patient is masked before they enter the facility then the exposure level to the healthcare providers and other patients for example in the ER waiting room goes down dramatically, so that helps protect all of us. So that's a theme of our efforts and in addition to that really we are working on education, educating our staff throughout the organization all the way from physicians in our critical care unit People involved in patient transport because their risk of exposure and they're critical to the function of our, of our hospital as well.

And we're also working on communication and that our lines of communication with Dr. Ansorg and our colleagues at public health have been wide open and he and I are on the phone regularly throughout the day and night lately. Also, the ER has taken a very amazing role at helping to educate its staff so they know how to care for a suspect patient on the way in the door. But also reaching out to take the lead and helping shape the communication from cottage to educating our community and educating our colleagues throughout the hospital based on their extensive experience at managing patients with highly infectious conditions.

In terms of communication as well, we're communicating very closely with Sansum where I'm employed and with the leadership of that organization and UCSB as well. And the county clinics so that's a key thing that we do have a unified approach throughout our community for how patients with COVID are managed whether they're in the outpatient setting whether they're in an ambulatory health clinic or whether they're on the inpatient side We need to have a standard approach and we're all striving for that. And I know more meetings are scheduled to actually just hope, achieve that and really into the level of perfection that we would like.

We also have a key role in this outbreak, I think to anticipate what is going on. And we need to be very adaptive quickly as I know Paige just mentioned things literally change by the hour and so how we are handling Potential and suspect patients and our outreach and partnering with our community organizations changes very regularly. Examples being at Cottage, we went ahead and decided to consider individuals coming into cottage with symptoms of COVID and symptoms of severe COVID as suspect patients for this, even though they may not have had a travel history. We decided to do that before the CDC sort of officially announced that that was one of their criteria because we realized that this was likely circulating in the United States already at that point and again our goal being Achieve early diagnosis, early detection and getting patients who may have this virus into negative pressure rooms and isolation so they can't spread it and make others sick.

So the guidance from the CDC has been fabulous but it does take time and sometimes we even want to be more adaptive than at times than the guidance from the federal government because that takes a little time in the face of a rapidly changing epidemic And and scenario like we're dealing with so adaptation is key In terms of supplies at cottage, let me just touch on a few of these. This is an issue I know that's been in the news a lot in terms of how many You know What's the supply of personal protective equipment? The gowns the gloves the goggles and 95 masks that dr. Ansorg mentioned a moment ago Cottage has had a good supply of N95 masks, but we are very protective of those masks at this point because we realize there are national and international shortages of these and supply chain disruptions that are looming.

And so we have instituted processes for keeping close tabs on those masks so that we have them available to our staff to protect themselves so they don't then get sick and then have to be off of work and not be able to do their duties as healthcare providers. Other supplies, we had identified some potential shortages at a time of our regular exam gloves size medium from supply chain disruptions. And so that's the level of granular detail that we are looking Stay stay prepared for this.

That supply has since improved since we initially identified that shortage, but I know there's daily monitoring and updates to our working group on our supply status every day are we have a good you might have heard of these PAP so called pappers which are the powered air purifying respirators I'd like to Well supplied with those, and we actually just obtained many more of those as well. So we have a good resource of those due to the new construction at cottage if this situation gets really bad. Cottage is fortunate that we have 47 negative pressure rooms throughout our organization meaning rooms that are ready to go at this moment to handle and treat patients with COVID-19.

And that is much more in terms of a percentage of beds than most institutions have available to them. So we're very, very pleased with that. We also do have surge capacity for potential opening of other dedicated unit if for COVID-19 patients if things get really desperate. So I do feel we are well positioned to handle Occasional cases that we could be dealing with or even a much larger number of cases if that were the case to happen. Now, we have had patients who have met so-called PUI criteria per people under investigation or persons under investigation who have come through our system and have been ruled out as having COVID-19.

And we work very closely with our public health colleagues on each and every one of those, but I think it's actually been useful in a sense from an organization standpoint to have had the luxury of having patients who tested negative but also to sort of test our processes and refine our processes based on those experiences. Our staff has gained experience at treating someone as if they potentially had COVID-19, and I think are confident in their ability to manage more patients should we get more people under investigation or people who have actual disease. But I would emphasize again, as Dr. Ansorg mentioned that we have not had any confirmed cases of COVID-19 at cottage and with that I'll stop there.

Thank you very much, Dr. Fiske. That is very reassuring to the public and to us to know the very close collaboration between County Public Health and Cottage Hospital on all of the resources in daily contact and planning that you're doing. I appreciate specifically Mr. Werft and Dr. Wilson and Dr Piotrowski who are all here too from Cottage Hospital to answer any questions. And I know board members do have questions so with that let's start with Supervisor Hartmann.

Thank you. So if I understand the cold, the flu upper respiratory infection is indistinguishable from the COVID virus so if you have that you should stay home and when it gets serious is there any distinguishing way to know that it is or you actually have to be tested?

Yeah, thank you very much for that question Supervisor. I would offer that the common cold is an upper respiratory infection. COVID-19 can be an upper respiratory infection but actually it can be a lower respiratory infection also so it is more able to be distinguished when it becomes a lower respiratory infection ie infects the lungs itself and not your back of your throat Um, namely because people are sicker. They may require oxygen supplemental oxygen to breathe and they're going to have abnormalities on imaging chest X rays, cat scans and the like. So when someone has COVID-19 that is in the phase where it may just be an upper respiratory infection truly is indistinguishable from the common cold.

But once it becomes a lower respiratory tract infection, there are some distinguishing clues that we can pick up Even in the absence of the ability of having a test. The problem is that once it moves into the lungs, then you have pneumonia and as you know there are dozens and dozens and dozens of causes of pneumonia. And it's, you can't look at an x-ray and tell that this is a cause from COVID versus this is a cause from influenza that moved into the lungs or more common bacterial pneumonia.

Testing is key to helping us distinguish the actual cause, but the clinical symptoms that someone presents with are very common that we're seeing on a daily basis throughout healthcare around the world. So therein lies some of the inherent challenges of this virus.

So I have a few more questions so you're at home and you suspect maybe you have it. What should you do?

And also, Dr. Ansari, I want him to feel free to chime in his role too but as an infectious disease physician, I'll answer that question. If you're at home and you have the common cold, you should stay at home and treat your symptoms. And if that common cold actually happens to be caused by COVID-19, you should stay at home and treat your symptoms. When you should seek medical attention for it is if you have shortness of breath, pain with breathing or unrelenting fevers over a period of days Those are really some of the warning signs that more serious disease potentially moving into the lower respiratory tract have arisen. But I think your point is well taken, that there's a very essential role for those who are sick now to stay home and that's something we struggle with as health care providers too.

You know, we don't like to stay home but we need to stay home when we're sick too. And in a time like this where we're trying to protect our most vulnerable particularly the elderly those in nursing facilities extended care facilities and those with weakened immune systems it's all the more important that those of us who are sick but feel well enough to go out of the house think twice and actually stay at home

And another question, and this has come into my office. We know it's not here in Santa Barbara County because if it had been, it would be spreading outwards so if somebody was sick and recovered or was sick and died from something we know that wasn't this virus because otherwise we would have had spread right?

Well, actually my personal opinion is that it is in Santa Barbara County. But we just haven't had someone sick enough with it to achieve a need to be tested and diagnosed. My suspicion personally is it's been here for over a month. And in a way I find that reassuring that we're not seeing a huge surge In people presenting to Doctor Wilson in the emergency department with critical respiratory disease or respiratory failure who need to come into intensive care.

And the reasons I feel it's likely circulating, even though we haven't had testing are simply because we live in a global society And this virus has spread globally in the matter of weeks. And Santa Barbara has a lot of international travel and we go places, and we have a lot of people who have weakened immune systems and are at risk for this. So that's just a theory I have no proof of that but It is something that I think many of my colleagues in the world of infectious diseases share that opinion, that it's likely here. It's just in such a state that it is not causing severe enough disease that it has yet warranted testing.

And just two more questions if I may. Again, someone's home they're sick they suspect they may have it we don't want them just to go to the emergency room or urgent care what would you do? What would you recommend that they do?

Yes, thank you. And one of our big efforts has been if people think they're going to need to come in to be evaluated in the emergency department for this that they call ahead a big effort from our marketing and communications team and from our ER and throughout cottage has been to try to get the word out And also from Sansom, that we would prefer that you not just show up at the door. Because that way we can be prepared to receive you if you think you need to come in for care but receive you in a way that we can then protect other patients in case you have this and also protect our staff. So we ask people if they do plan to seek medical care at a medical office or at the emergency department to contact the place they're going ahead of time And those numbers are posted on our signage and on the communications that have gone out from Cottage and on the Cottage website as well.

Then I'll get my last question and make it actually two. The contagion period, if you have it or you've had a cold or flu or something, is it two weeks from the start or two weeks from the end? And then my final question is can you talk about the arc of what we would expect to see over the next several weeks or months

Thank you. Um, uh, my the average incubation period of this virus from what we've learned from the Chinese experience is about four to six days. So that's the time frame from exposure to onset of symptoms 4-6 days. I emphasize that that's an average. Um I don't think we know yet the outer limit of the period where someone can transmit this virus It's felt that the majority of people no longer transmitted after two weeks. But as we know from other viruses in this family, In similar experience and occasional cases that we're hearing from other countries, there may be shedding of this virus from an infected individual for significantly longer than 14 days. How long? We really don't know. And I think the more time we have to learn about how people who have weakened immune systems manage this virus, that will really be the group that is most at risk for shedding this the longest As to your second question in terms of what to expect from this, and I welcome all my colleagues' input as well because this is just one opinion.

But my personal opinion is that we will see cases of this in Santa Barbara County We will see the vast majority of cases and people who do not need hospitalization. We may end up needing to have some who do require hospital care for this, and that this process will go on probably for at least another two months. But beyond that I really wouldn't want a hazard to guess.

I think the unknown is, is there potential for there to be a huge upsurge in those who are critically ill from this requiring hospitalization and supplemental oxygen things. I think that's, I would say unlikely for that to happen here but not 0% possibility of it.

Thank you Dr.

Frisk. Supervisor Williams? So I just want a little bit more precision on the symptoms. Just as a father of young kids, there's almost no day that they don't exhibit some runny nose. So it's like, are we going to? So I just want a little more precision. Are we talking about keeping everyone home with a runny nose or keeping people that exhibit a cough and temperature or a cough We've learned that temperature is not a prerequisite to have COVID-19. It was around 45% of the patients in a recent New England Journal of

Medicine report out of China were found to have fever when they were diagnosed with COVID-19. So whereas we first thought that fever was a critical and essential symptom to be considered COVID-19, we know that's no longer the case. So really anyone who has a significant cough and runny nose, sore throat, those are patients who do have the potential of having COVID.

And the more severe The symptoms, the greater the likelihood of that I think. But certainly the symptoms that we are on highest alert for are indeed pain with breathing and shortness of breath for those who also have a cough and general sense of weakness and fatigue and body aches as well. There's a relatively small number of individuals who have diarrhea as one of their symptoms of COVID-19 but that is not something we're asking you know necessarily to be at list for identification is primarily respiratory symptoms.

So I'm sorry, I'm going to be really precise and try to repeat it to you based on your answer to John's question. But I just really think this is important to get out to the public because You know if we don't know likelihood that most people in the public don't now so you should stay home if there is a cough Or a temperature, or a severe runny nose, or body aches.

Pain breathing, shortness of breath and a long fever over multiple or a long fever over

multiple days. I think if you have any questions about your health we encourage people to contact their doctor because we cannot give standard answers for all symptoms and it's very important to know someone's risk profile too. The risk profile of someone who is 80 years old and has pre-existing lung disease from doing poorly from COVID-19 It's very different from the risk profile of a healthy 18 year old.

But in terms of symptoms and guidance to stay home, yeah as with any common cold we would encourage people to stay home because of the high potential for transferring that and the high communicability of that. Same with influenza which is circulating in our community and actually killing tens of thousands of Americans right now We don't want people moving around and they have that, and the hallmark of that is fever and body aches as well.

So we don't limit our guidance on staying home to symptoms necessarily from COVID. We wanna include all of the communicable respiratory illnesses in that. So there is some variation in symptom from group-to-group and person-to person but the common themes are yes, cough, sore throat, body aches plus or minus fever. and running noses as well. Now, children though have been relatively spared this infection Children, I was just on a call with the state health department this morning and again everyone was emphasizing how we children although they don't seem to be getting sick with this. We truly do not know if they can transmit it.

And we know from other viruses that children can have no symptoms yet transmit the virus just like many adults can so we suspect that children may be vectors of this within able to transfer it without actually And then

one of my previous questions was how many testing kits we have ready. But but one other question that my thought was Or at least my impression was that's no longer all that relevant of a question because of how rapid testing is with various testing spots. Is that the case, Dr. Ansar?

Well not quite because this test was just approved by the FDA and is quite labor intensive You know we have these rapid tests for influenza, for instance or strep throat and things like that. They're like a pregnancy test pretty much to take five minutes and you have the result plus or minus and in the near future but probably not this season this will be available as well. But for right now it is you know culture from the fairings and it has to be transported to the lab and its labor intensive so they turn around time for the commercial labs is probably three, four days at the moment. But they just rolled it out yesterday so we have to cut them a little bit of slack, just a little bit and public health labs are much faster right now because they were able to require a lot of test kits and the turnaround time is like often that's the same day or 24 hours which is great and we'd like Reserve the fast testing capability for really vulnerable populations like the nursing home, where we need to get a handle on an outbreak that we are anticipating or that we are being afraid of.

So that we have fast results for those really critical situations. Or for instance, for healthcare workers or an outbreak at cottage. That would be a nightmare if all the nurses gets sick. who's taking care of the patients. And so we want to reserve the really fast turnaround testing for those instances at the moment, but it will change obviously they will.

The improvement in the test availability has been really rapid. I mean, last week we didn't have a single test and now the first tests are being ordered by College Hospital to LabCorp. So it's very reassuring and I think they're going to ramp up

very rapidly. And one of my previous questions was how many beds capable putting someone in once we have a case? And what I heard is we have 47 Negative pressure beds, but that we have the capability of expanding that in case there were more needed. What's the level of ability of expansion?

So we have 62 airborne infectious isolation rooms throughout our five hospitals. And I understand that we also had a question about how many ventilators we have, and we have 32 vents available. Plus we also in our Santa Barbara at the health department, we also have caches of some ventilators available if needed.

With the construction and design of cottage, we do have the potential to rapidly convert other rooms to negative pressure to add to our current tally. But if we do that it then disrupts the air flow in the other rooms in that unit so it would correspondingly potentially decrease our ability to care for general patients on the same ward. So we might have to commit entire wards. To COVID-19 if that were the case, but there is some capacity to expand based on our engineering of those rooms.