The two doctors respond to today. In putting you all together, it was delayed a little bit more than i had hoped for, and i actually just provided these questions to dr. Aragon and dr. Colfax yesterday. I think it was around afternoon when they received it, and so and theres a lot of questions that were submitted. So when i talked to dr. Colfax, i said what id like you to do is if you cannot answer all the questions i think theres a lot of them, about 40 of them today, in the onehour limitation, then you need to come back next week to answer the rest fully. So thats how id like to handle this, is to give them a this hearing about an hour and see how much we can get through. So whod like to start . Dr. Aragon . This is grant colfax. Ill start, and dr. Aragon will continue. Good afternoon. Its a pleasure to present to you an update on the citys covid19 response. In talking with dr. Aragon yesterday, i thought it would be good to provide an overall overview to frame the discussion and also within the context of the presentation answer some of your questions. So a couple of key points to start with. Im really so proud of the supports of mayor breed, the support of the board with regard to the aggressive actions we took as a community to the covid19 response, and it is clear at this time that we have flattened the curve. And not only have we flattened the curve and slowed the spread of the virus in San Francisco, but we have literally quantitatively saved lives. And just to provide some data with regard to that, while any death from covid19 is one death too many, we are currently our mortality rate is four times less than the mortality rate in l. A. Just more than half the rate of california overall, and a striking 35 times lower than new york. And it was not too long ago that i was talking to many of you and the mayor about deep concerns about the situation unfolding in new york. And because of the early hotel citywide actions that we took, the curve has been flattened. So thats the good news. The challenges before us, though, are tremendous, and we are both in a response mode as we enter a modified recovery mode. We are going to be in this for the long haul, and the virus doesnt have a timeline. I think its really important to emphasize that because despite some of the overly optimistic scenarios that are being projected in some places, the virus is here. There is more virus in our community than there was in march, so we have to be very thoughtful and follow the science data and facts as we move forward. We are likely in the second ending of a long, long game here, and i just want to emphasize that because this is not about only what happens next week or even next month, but the best projections are that we will be managing the situation for probably 18 to 24 months if prior flu pandemics and prior knowledge fighting pandemics are applied to this situation. So can i have the slides up, please. So ill go right to the next slide, thank you. So this really emphasizes the actions that were taken with regards to Health Directives and orders. And just how the mayor announced a local emergency even before we had a covid case diagnosed in San Francisco, with this board approving the local Emergency Declaration following the mayors declaration, many of you are familiar with the other Health Orders, directives, and directive orders. But certainly the shelter in place is the most aggressive and wide reaching of those. And just to remind us that thats now been renewed three times, most recently on april 19, with some loosening of some restrictions. Next slide, please. This is where we are today. Weve had 1977 total cases of covid19 reported, with, unfortunately, 35 deaths, and you can see that as we increased our testing, we certainly diagnosed more cases. Next slide. In terms of the cases that have been diagnosed, we see what unfortunately is a longterm pattern with Infectious Disease and longterm disease in San Francisco, which is that covid19 is spreading in communities that already share a whole disproportionate burden of other diseases in San Francisco. You can see in particular that the tenderloin, the mission, the bayview areas have a higher prevalence of diagnosed covid19 than the rest of the city. The blue on the map in the zip code areas, the greater the presence of covid19. And they have a map of hiv and other sexually transmitted diseases, preterm births preterm birth is certainly a condition, not a disease. But you can see that historical patterns of disease inequity in San Francisco are being reflected by the covid19 epidemic, and unfortunately, we are seeing these play out in San Francisco and across the nation. This is the nature of the pandemic, and even before the first case, that we emphasize the need to focus on our vulnerable populations and to strengthen our work in Health Care Setting and in community to be as prepared as possible to address the pandemic in communities across San Francisco but especially in communities where there are already disproportionate or Poorer Health outcomes. Next slide. So this is a slide of our deaths. Weve had a total of 35 deaths in San Francisco. You can see that, by gender, the portion of people who identify as male is consistent, again, with national and international data, which show that people who identify as male have a higher death rate compared to people who identify as female. We have not had a transfemale or transmale deaths in San Francisco at this time. You can see that, again, consistent with the national and international data, deaths are concentrated in people who are 60 and older, and you can see also that by underlying condition, we know that people with underlying conditions are at greatest risk of dying, 34 of 35 deaths in San Francisco have been of people who have underlying conditions, including medical conditions such as auto immune disorders, cancers, cardiovascular disease, diabetes, and so forth. And then, i think looking at race and ethnicity, we see a striking difference in these numbers are small, so statistically, its difficult to draw any firm conclusions here, but i do think it needs to be pointed out that the number of deaths among asians is high, accounting for almost half of deaths. And when we dig a little deeper into those datas, cit appears o be very much correlated with age, that since 90 of the deaths among asian are among asians are among people who are over the age of 60, and 70 of deaths among asians are among people above 80. And also, the deaths in the asian population are more likely to occur among people who are residents of longterm care facilities, which we know are a highrisk setting. So overall in testing, the rates of covid19 diagnosis is lower than the general representation the asian population in San Francisco, but representation of the asian population in San Francisco, but those are correlated with a higher age rate, and also the longterm care facility residents. Next slide, please. So this is looking at our cases, so you will see that the distribution of diagnosed covid19 cases by race and ethnicity. What really stands out in this chart is a couple of things. One is the really high prevalence of diagnosis of covid19 in a population representing almost 41 of all cases diagnosed. Some of that is due to the recent Mission Study which tested a very large proportion of latinx residents in one zip code sorry, one census tract in the mission, but this is consistent with what weve been seeing since march. And this was actually first detected at our Public Hospitals, zuckerberg San FranciscoGeneral Hospital where a very high number of hospitalized latinx patients was noted as consistent. You can see there are a large number of unknown people being diagnosed people whose race and ethnicity are being put as unknown who are dying of covid19. President yee dr. Colfax, i realize youre going to be short on time, and i also realize that, so far, most of the things on the slides that youve shown, we already have received those. I dont know how many more slides you have, but its if we could get through those other slides quickly because, again, i dont think were seeing anything new. I think the okay. Yes, president , i can go more quickly. I just one of the questions i believe we were asked was why were there so many people of unknown ethnicity were on the test results . I ist i was trying to answer that here, that we werent getting that data from our testing partners. I can go faster here. I just do want to emphasize the factor of testing. Supervisor peskin mr. President . President yee yes . Whos speaking. Supervisor peskin supervisor peskin. With regards to dr. Colfaxs testimony, which was statistically quite significant, is there any reason why the chief medical officer has not ordered those organizations to produce that testing Demographic Data . So dr. Aragon can answer that specifically. I think we would encourage testing even if the person wouldnt report that, so ill let dr. Aragon report on that in just a few minutes. Supervisor peskin okay. Thank you. Ill go faster, supervisors. Let me get to some other slides that i think is helpful for folks. President yee mmhmm. Next slide, please. So this is the curve of hospitalizations across the time from april 8 all the way through to may 10. This is what i talk about when were talking about flattening the curve. You see that weve ranged from 94 to 70 over the past few months. Its really quite remarkable how flat that has been, but we will be watching that carefully Going Forward. Just again, people may have seen the sites in terms of the purple bars that show suspected covid19 patient counts. Just to emphasize, when you see some of those higher numbers, say, on the 14, 26, and 6, those are really receptive of our testing at laguna honda, because when we do widespread testing at that site, its in our hospital system, so those numbers can spike if were doing an investigation or were starting to increase our testing there because of the routine testing of staff and residents. Next slide. So i believe this is a new slide, so i wanted to focus on this, and it does get to one of the questions several of the questions, i believe, that the board submitted. This is a slide on the y axis, shows the mobility index, so basically a measure of how many people are moving around in San Francisco as determined by cell phone data. And on the x axis, of the date, shows how much people are moving around on those dates. And then super imposed on this slide is the the reproductive number or the estimated reproductive number of covid19. These are estimates. I think its really important to emphasize these are based on models that we have been working with. Dr. Maya peterson at u. C. Berkeley and her team, so there is some level of error, but i think whats striking about this is the more we move around, the more virus is transmitted. So a reproductive rate of 3. 5, which you see in early march, before the shelter in place or any action is taken basically means for every person whos infected with covid19, they they transmit to 3. 5 more people, which is a very, very high rate of transmission. Youre going to see, then, that the reproductive rates decrease to about 2. 6 as we took more action, and then, to the best of our of dr. Petersons modelling estimations with the shelter in place, the reproductive rate was reduced to below one, and this is an incredibly important concept because if the reproductive rate goes just above one, the virus will continue to spread throughout our community. If its just below one, even. 94, the virus will slow, and you can and so this is very important. Its also encouraging and remarkable that we have pushed the virus to below one, to. 94, to the best of our knowledge, an estimate. So you can see here as the movement decreased, you can see on that blue line how Much Movement needed to decrease to get to just below one, of. 94. So just conceptually, these are data that were going to be watching very carefully as we gradually and cautiously determine how to best decrease the shelter in place restrictions, but you can see here everything applied. So these are data these are basically data from other pandemics, specifically the pandemics that researchers at the university of minnesota have post skbulated as possibl scenarios of covid19. Because of the asymptomatic spread and higher reproductive rate, covid19 is spread more easily than the flu. Based on patterns of flu pandemics, outbreaks will last likely last 18 to 24 months; and depending on cofactors, we may see different waves of different heights. So scenario one, with peaks and valleys, this would be a situation where we would have periodic large outbreaks of covid19, followed by a decrease, with increased controls. But as those controls get reduced again, that we would see additional increases. Scenario two is if there is a correlation with seasonality. We dont know yet for covid19 if there will be, but this is the for covid19 whether the transmission of covid19 will be accelerated by seasonal changes. Thats shown on the slide, but i think also needing to consider is the fact that eechbl even if we get to a covid19 base rate, if seasonal patterns of flu are sustained as they have been in a past. So a peak due not only to covid19 but super imposed on the condition of the flew. So scenario three is a slow burn, where we would have smaller but manageable outbreaks Going Forward. So this is really important for us to think about as a city response, as a community response, as a county response, thinking about how we manage potential outbreaks Going Forward and by keeping track of the data to see whether any of these three scenarios will come to fruition. Ill also say the differences in whats happening internationally and nationally, other states opening are quickly, in my view, recklessly, and also whats happening internationally, now in south korea, you may have read that they had a cluster of cases reported. Were talking to a reporter about those situations so we can be better prepared in our ongoing response. Next slide. So these are our scenarios, and i dont believe theyve been formally presented at the board, is that correct, president yee . I just wanted to make sure that these were shared with all the board in a consistent way. These are the indicators we will be watching particularly carefully with regard to those curves and the possible resurgence of covid19 beyond flattening the curve, so in terms of our surveillance supervisor walton just real quick, president supervisor yee, how long do we have with dr. Aragon, dr. Colfax . I think you were muted, president yee. President yee we have 45 minutes in total left. I have one more slide left after this. I can go through this really fast, just to emphasize that were looking at the hospitalization curve. Were needing to keep Hospital Capacity at a high level with some redundancy that we havent had historically in a hospital because we need to be able to care for people efficiently and effectively across our Hospital Systems. Our Testing Capacity needs to go to 1600 to 2,000 a day. Our contact tracing, to be increased, and you can see our goal is to reach 90 of cases and 90 of all patients will be i. D. Ed, so were scaling that up. The p. P. E. Struggle, youve seen that nationally and locally. Were making sure that we have a 30day supply so we can protect our Health Care Workers and first responders. Next slide. And this is the slide for the iteration of the state of california reopening. I will just say, if our data continue to hold, we will be moving on may 18 to curbside pick up and manufacturing, and well move to phase 2, 2a, very early in the stage, with the assumption that were able to maintain the positive patterns that we have had to date. So that concludes my portion of the presentation. Thank you so much, and ill turn it over to dr. Aragon. President yee before anybody starts, if this is kind of a similar presentation, i can tell, even myself, you know, we were hoping that we could get into specific answers to questions. Even though you cant get to all of them, wed like to see some progress, if possible. Dr. Aragon, youre next. Okay. Thank you. I do not have any slides. First of all, can you hear me . President yee yes. Fantastic. So first of all, let me start by answering supervisor peskins question about the Racial Equity data. So the way that data comes to us is two ways. We have the offices and hospitals to send us data, or we get it directly from laboratory reporting. Oftentimes, hospitals do not provide the Racial Equity data, and laboratories almost never report that. When they do report, we contact if we do a case investigation, sometimes well contact the physician to collect that information, and we do that for high priority conditions like hiv, where we have a tremendous Surveillance System that goes out and collects all that information. And so now with covid, covid is now very different because with covid, its not just providers in laboratories, but now, we have all these popup providers that are spending thnot spendi collecting that information. This is an area that we do need to improve, because sometimes people do register online, and thats an area that we brought up to them, and we hope to improve. One of the things that the state did, youll notice the gap right now is about 18 . When it first started, it was over 30 , so it is improving, and through our case investigation, well get better at closing that gap. What i wanted to do now is just to go through the questions and give you some concise answers because i know i know theres theres a lot of questions, and i wont get through all of them. What ill try to do is group them into some themes that i recognize. So first question here. We understand that San Francisco has engaged in general agreements across the bay area counties, and the question here was what commitments, formal or informal, have you made on behalf of San Francisco with respect to Health Officer guidance for San Francisco and with the other counties . So in the bay area, we have whats called the Bay Area Association association of Bay Area Health officials or abaho. Its basically the Health Officers and the Health Directors of the region that have come together. This started years ago back in the hiv aids epidemic because they realize in order to fight hiv aids, we needed to act as a region, and this was critical for Infectious Diseases because Infectious Diseases across boundaries, were interconnected, were connected, were commuting back and forth. The other thing here is were hearing we have inconsistent policies across counties. Residents get very upset, and theyre wondering why are you doing things differently than someplace else . So the officers communicate and collaborate to shield the public from Public Health threats. Theres no formal agreements. From our perspective, its just good Public Health practice. Just to let you know, were organized across the whole state. Health officers are agents of the California Department of Public Health. Were part of the local Health Officers, part of the state Health Department. So we provide advice to the state Health Department on things like Communicable Diseases. The second question here is how often do you meet with your counterparts from the other five counties, including the city of berkeley, and what do you report to after those meetings . So abaho officially meets biep monthlbiep bimonthly. So since the pandemic, weve been able to meet once a week by phone, and were trying to align around orders, so we try to coordinate our decisions for the reasons that we mentioned above. I report to dr. Focolfax. I keep him and our d. P. H. Team apprised of all of our productions. During the initial phases of the covid19 pandemic, as part of the e. O. C. Regular briefings, i was providing briefings to the board of supervisors and staff three times a week, and the workload just increased dramatically that i have not been able to participate in those briefings, so thats an area that maybe we can improve as we move into the future. So the pandemic has really caused us on having a Strategic Alignment across the region, and most recently, this is where i really spend the vast majority of my time. Number 3 is that the role of the Health Officer to initiate draftings of the San Francisco of the Health Orders who has input and reviewed the Health Orders from city policy body before the Health Officer signs the document, creating formal policy for the city and county of San Francisco. Does this include any members of the board of supervisors . So just to let you know, so Health OfficerLegal Authority and orders, weve been doing this forever. People dont normally notice were doing it because its just part of what we do. We do it around Communicable Diseases, varicela, measles, Communicable Diseases. Theyre really based on Public Health science and principles of Communicable Disease transmissions. For difficult scenarios, we difficult with the California Department of Public Health and or the c. D. C. , and this is definitely true for Communicable Diseases because they obviously cross boundaries. One of the challenges that we have is in doing orders, we we use a Public Health ethical framework to balance the rights of individual freedoms and then the rights of community protection, so were trying to do the least restrictive option that we believe will be effective. Just to give you an idea of the types, in general, the orders that you have been seeing primarily have been around restricting movement and freedom of choices. And the types of things that youve seen, this pandemic has has caused us to pool basically almost everything out of the play book, so isolation, quarantine, sheltering in place, social distancing, including prohibiting schools, mass gathering, whats called protective sequestration, where we started visitors from coming. We wanted to really protect the residents, and thats one of the reasons why, compared to other places, that weve done better. And then laboratory and disease reporting are major areas. I consult primarily with Public Health experts, taking direction and guidance and input from the experts that we have at the department of Public Health, including dr. Colfax. Were fortunate, in San Francisco, that we have really an amazing team of Communicable Disease specialists in all different areas, and so im fortunate because i get to pick their brain and sort of figure out what might be a best option. The question there was a question in terms of who was involved. Primarily, we work with the City Attorney. In general, elected officials arent involved in drafting the Health Officer orders. However, keeping communication is really, really critical, and i get emails, and i get great ideas, and theres sometimes things that i cant see, and people point out, did you see this, and it gives me some great input and feedback onto whats happening. Dr. Colfax already covered around the increase in asian mortality. I just knew i want to mention to summarize the major takehome for message in San Francisco is that the asian population is getting infected at a much lower rate compared to, for example, the latinx population. However, when they are infected, theyre dying at a higher rate, and as dr. Colfax pointed out, thats primarily due to much older age and being in a longterm care facility where the risk is highest. And were going to continue to monitor that carefully. Theres a team at ucsf thats monitoring this, not just in San Francisco, but in california, where we have a large asian population to see if theres something happening that we need to take into account. President yee just one remark. I shouldnt be stopping you. No, thats fine. President yee i saw the data in terms of the asians versus the rest of the people that were dying, and the age categories for the asians and the other people that were dying were almost identical. So what you just said doesnt make any sense to me. Yeah. Well, its a combination of well, just in general, ill just this is just, if you just look at the demographics in San Francisco, the asian population has more Older Persons than, lets say the latinx population that has a lot younger and immigrant population. So the age distribution in both of those are just very different to start with, so youre going to have a bigger group youre going to have a bigger group thats at risk. What were seeing is what were seeing is the number of cases the number of cases, but theres a higher number of asians who are older. And of the oldest, they compared to other groups, they tended to be in longterm care facilities. So you have older age in the longterm care facilities. One of our epidemiologists told me today that theres a number that were also part of cruise ships, so they got exposed on cruise ships. So that taken together i think partially explains what were seeing. I think its still early. Weve only been in this pandemic for a few short months. I think as more data becomes available, we will learn more, and we do have ucsf researchers that are interested in understanding this better. President yee supervisor peskin, did you just raise your hand . Supervisor peskin i did. I appreciate dr. Aragon putting forth all the data to the board of supervisors and president yee, but i think it would be helpful to jump in on things. I just wanted to go back to an earlier contention that dr. Aragon brought up, which is how abaho and the individual Health Officers consult folks, and what we heard is it is entirely within a or almost entirely within a chain of command that is cal d. P. H. And the c. D. C. And not in consultation with the executive branch of San Francisco or the legislative branch of San Francisco and for the other counties. Did i get that right . Well, no i mean, we dont we dont operate independently, so as the the by law, every county has a physical Health Officer. The Physician Health a physician Health Officer. The physician Health Officer works at the city, with the exception of the city and county of San Francisco. The Health Officers are appointed by the board of supervisors, so they work very closely together, and they communicate frequently. In my case, because im part of the Health Department, all officers are part of Health Department. They usually run the Public Health component of the Health Departments. Our case, were actually a Health Agency because we have much we have our services are way beyond Public Health. Includes Public Health, substance abuse, and clinical services, so were a big agency, and Public Health is just one component of that. I run that component, which is called Population Health division, and im part of the Health Department, which the Health Agency, and i report to dr. Grant colfax, and im part of the executive branch. So most of my interaction is in direction. It comes from dr. Colfax, and most of my interactions working with the team here in terms of influencing Public Health policy. But i would never say that its never me alone. Its really im one of many people that come together to problem solve around the complex the complex problems. I would say the area that i tend to be more involved in is in Communicable Diseases because thats just one of the areas where Public Health has a big footprint in is Communicable Diseases. Supervisor peskin so through the president , dr. Aragon, i guess what im trying to determine is how you and your similarly situated counterparts in the city of berkeley come up with some of the these things. Look, were obviously all living through a very frustrating period, and it falls on the elected folks, the 11 members of the board and the mayor, to experience not only our personal experiences with the virus but that of our constituents. So what im trying to figure out is and obviously, all of this is evolving very quickly, but there are things that happen that we dont understand and are very hard to explain that, in my mind, go beyond the purview of straight ahead Health Decisions. So, for instance, when the Health Officers came up with the directive that construction could go forward in projects that had 10 Affordable Housing but not projects that had 0 or 50 or 100 Affordable Housing, that did not appear to this supervisor as a Health Decision per se. There was an element of nonhealth policy and politics in that. And what im trying to understand is did abaho collectively or did you individually how did you come up with that . Because the metric, how many people are in an elevator together, building that building or whether or not they can socially distance as they put up sheet rock . No, youre absolutely right. So basically, we came up with principles, and we tried to stick with the principles as much as possible. And things around Affordable Housing is we were ill just share with you the way that we are thinking about that. The shelter in place, we knew that it was going to have a big economic impact. People are going to lose jobs, people may actually become homeless, and were thinking boy, we just need to just knowing the epidemiology, dr. Colfax just presented to you, this is really a long haul, and were thinking boy, weve got to make sure that some of that pipeline of housing continues because were probably going to need it. And thats how we were thats how we were thinking about it. But i agree with you, we felt sort of we were in a we were outside of our comfort zone in making some of those decisions, and i think it some of those areas some of those areas were challenging, but i would say the major focus would be is what big intervention can we do not to become new york, not to become italy, and i would say that was 95 of our focus was on really avoiding new york city catastrophe. One of the things we learned is shutting down, opening up is much more difficult because it requires much more expertise than we have. Were shifting were shifting our focus on really focusing on the Health Issues and looking to outside guidance on how we move forward because we realize is that its going to take a bigger group of people to do this. Supervisor peskin okay. I have many more things, but i will leave you i will make space for other folks. So i was covering i was briefly covering about how often we meet, and i think i already mentioned i think i already mentioned most of those. So ill keep going, and just feel free to interrupt me if you want to just i think i covered i covered the Different Things of laboratory reporting, i covered asians. There was a question question number 6 was the Health Officer has been in conversations with at least one supervisor around issuing a health order requiring system wide health data sharing across all hospitals and Health Clinics providing testing and treatment of covid19. Why have you not issued a health order to mandate this type of anonymous data or disclosure . Is it because youre waiting for other counties to agree to do it . At the same time, is there medical rationale why were not mandating Public Hospitals and clinics to share this retroactively, and where is the data . So first, ill cover for a Health Care Emergency like this, i have access to all that data. I just dont have the band width to go and look at all that data. So we we have access to the Clinical Data around reportable Communicable Diseases, and thats true for all of them. And where we where we implement that in a in the most rigorous and comprehensive comprehensive way is through hiv. So we with hiv, we go into hospitals, we review medical records, we have access to everything we need, and thats just a General Authority that the Health Officer has, so we dont need to write Health Orders for that. We dont consult with other counties around that. What has been different with this one is that what is new is that all of a sudden we really need to get our hands on better metrics, so really because we knew of the issues of hospital surge, i. C. U. , shortages of leaders, we needed to figure out how we were going to get good Hospital Data across the region and across the state. And the way to do that has really been through the state Health Department. So rather than each county trying to go to each hospital and just figuring out how to do it, we really turned that responsibility over to the state. Basically, what the state is doing is the state is telling all the hospitals across the state, this is the information that you have to report to us every single day. That gets input into a database and sent to us locally, and then we map our hospitalization. So were getting the data we need, but we do it by working through the state so that the whole state has consistent, good data. Of course, theres always things that we can improve, but thats where it is at the moment. The hospitalization data is the most stable data we have in terms of monitoring the pandemic. The limitation of the Hospital Data is it tells us what happened two weeks ago. And so while its reassuring to see it creeping down, awesome, we also get a little nervous, realizing that its really something that tell is us whats that tells us something that happened two weeks ago. Number 7 is the reproductive number president yee that was answered. Okay. So i can leave that alone. Supervisor peskin but is that data going to be shared publicly . That data, that was the first time we ever saw that slide. Will that be shared publicly Going Forward . Yeah. So one of the so one of the challenges with measuring what we call the effective reproductive number on average, how many how many how many persons get infected by a case, that number changes over time as you implement interventions. Its not possible to measure that directly, so a lot of that is measured indirectly, and what happens is that you take what you can measure, which is incubation periods, hospitalizations, and then, you look at what other people have determined from research, like the basic reproductive number, which is its basic potential to spread in a population, and the modelers fit it into data, and they back calculate what the effective reproductive rate number is. So we do have we do have we have a model thats being calibrated for San Francisco, and dr. Colfax showed you that. You can go online right now, and you can find effective reproductive numbers for pretty much any part of the country. So you can go and compare San Francisco county to seattle, so there are modelers that have calculated it for the california and counties across the country, and it gives you an idea, but we actually feel we actually feel we want to have stuff thats more anchored to our local data. And were going to make the numbers available the program that were using is open source. Were actually making it available to everybody in the world because we think its a really good product, and we want other people to use it. Its been good in helping us extend our intuition in what can happen in different scenario projections. Number 8, given the importance of this number president yee you just answered that. Okay. So thats great. Number 9 here, i know that dr. Ph phil dr. Philip came and presented on testing, and i think its an incredibly important topic. The way that were doing testing is different than weve ever done with different Communicable Diseases. One of the things that weve done is the popup sites that weve created. Another innovation is people creating rapid types of tests. The other thing that we are required by law this is a Public Health order, is that we required all negative tests to be reported to us, and thats really critical because we want to know not just whos becoming a case, but we want to know the intensity of testing. That really helps you understand if a group or a geography is not getting enough testing, and it also gives us the proportion of tests that are positive, and that gives you an idea of what the probability as the tests become more common and more representative of the general population, it gives us the idea of whats the possibility of an average person in that population being infected with an agent, so its actually an important parameter, that it helps us understand how the epidemic is moving through our community. Currently, we have the capacity to do 2100 tests through our Public Health lab, our Clinical Health laboratory at zsfg, and then through city test s. F. The testing number right now in San Francisco is 5800. We had a goal as an indicator to be to be above 2 per 1,000. Were as a city, were clearly above that number, so weve reached that milestone, and now, were working on making it more more accessible to higher risk groups, so thats the area that were moving into. And theres other questions on testing, so ill cover some of them as i continue to move through. Number 10 was why was the Health Officer not issued a Public Health order requesting the information on testing resources and supplies on hand across the provider the Provider Network . So in general, we dont issue orders around information that we can just get by just by just partnering with folks. We did do it around testing because we felt that it was so critical, for example, for them to report negative to us. We felt that it was critical to our system, and we felt that we needed it. So d. P. H. Did hire a team to focus on improving Testing Capacity. And just so you know, San Francisco is doing more testing than any county in the bay area, and were just getting started. Were committing were committing to even doing more testing to make universal access a reality. The big challenge that you face with a pandemic thats different thats different from, lets say a wildfire or an earthquake, when you have a local disaster, you can you can seek mutual aid for what you need. When you have a pandemic, everybody in the world is asking for the same materials, and so thats why there was a big shortage of testing swabs, reagents, personal protective equipment, and this was really everyone knows this. This was a hue mmongous testint the federal level. It made it difficult for us, and something that impacts the whole world, these shortages. Things are getting better, and as resources improve, youre going to see us move towards universal testing. The next question was about collecting has a Health Officer considered taking steps to consolidate resources across the hospital Provider Network and to develop a prioritization and to develop those resources . So what happens is in general, we dont we dont control those resources. It would require a whole logistical infrastructure to do that. So in theory, it could happen, but it wouldnt be efficient. Its better to allow the Health Systems to use their resources and then to and then to help support them as they run out. So what would happen is is that as Hospital Systems needed more resources, they would make requests through the e. O. C. , and then we would make a request regionally, and it would go up to the state. And then, over time, as resources became available, those resources filtered down to the local level. We we dont try to take away the resources because it wouldnt make sense since its really better for them better for them to manage it. It says here, doctors across the country grapple this is number 12. Doctors across the country grapple with making decisions over who will get access to limits supply, such limited supply, such as ventilators and life making resources. Has the officer considered developing resources across the network in order to avoid having to make those types of decisions . So this is a really good a really good question, and yes, we this is like, this is our passion. Our passion is figuring out how can we whats whats the most effective, least restrictive, least intrusive strategy thats going to have the biggest impact . And so we were fortunate because we implemented shelter in place. We actually there was a series of interventions that dr. Colfax showed you on the slides. So we actually got involved really early, and what we know from data, first of all, we flattened the curve. We utilized less than 10 of our hospital surge capacity. Thats how successful we were. We had cpmc ready to help with 200 beds. None of that was required, so we were so successful in not having to not having to face of tough decisions how to ration ventilators. And so we really stuck from day one, we had three strategies, which was to mitigate community spread, protect Health Care Workers, protect vulnerable populations, and then later on, we expanded testing and then optimizing hospital surge. So weve been able to achieve on most of those. I would say the areas that were turning our attention to right now, weve achieved one, two the big areas right now is protecting vulnerable populations and expanding our testing, and i think thats one of the themes that i recognize that came through, and i think testing is really is really critical. Initially, when testing was limited, we had to prioritize, and we focused on people kwwho had symptoms and people that were hospitalized, so we had the highest percentage of positive tested. Weve moved to testing asymptomatic folks, and i would say thats really the area that theres a lot of movement a lot of movement that ill mention in a second. Then, we moved to testing all workers, anyone who works outside their home. So right now, were telling if you work outside the home in San Francisco, you have free Testing Available to you. So people can either go to their health care provider, or they can go to citytestsf, and they can get tested. Within our own free testing sites, in addition to the two s. F. Testing sites, we have testing at Southeast Health center in the bayview, maxine health center, and then at ucsf. And then, theres a site thats going into the bayview thats being supported by the state Health Department. We have a link that has all of our protocols. Every day, we spend time talking about we implement c. D. C. Protocols, state protocols, but then, they get customized to the situation that were facing here. I do want to announce a game changer that was Just Announced today by Governor Newsom that pharmacies are now going to be allowed to do testing. So the fact that pharmacies are going to allow to do testing is going to be a game changer because we want to get to the place where, during your lunchtime, you have no symptoms, youre a food handler and we want food handlers to get tested because they work in close quarters with other workers. We want them to go on their lunch, walk in a pharmacy they go into on a regular basis, and get tested. I think thats going to become a part of our future, is that testing is going to become more available. So i think the thing thats coming out of testing is the testing of asymptomatics. We know that the information that were seeing here in the city, for example, from the Mission Study, of everybody that tested positive, 53 of them did not have symptoms. Thats how the epidemiology of this virus is teaching us completely new lessons, so thats what we had was completely phenomenal, completely upside down. Supervisor walton thank you, dr. Aragon. While we know that were not testing every Single Person where we know that theres a high concentration of folks with covid19, not just essential orders, but every Single Person in those areas of communities where we know that there are high concentrations of folks who contracted the virus. Because you just said right, right, right, right, right, right, right. Supervisor walton because you just said you tested people without symptoms at 53 . Youre absolutely correct, and that relates to some of the other questions that have been brought up, and that is testing of high risk settings and also communities. Within the area of let me start off with congregate settings. Were prioritizing were prioritizing congregate settings because we know thats where the highest risk of transmission is, the highest risk of mortality, and so currently, were starting with our longterm care facilities that was mentioned earlier, that almost half the deaths in california come from persons in longterm care facilities, and so were going to start were already started. Were testing at laguna honda, residents, close to 800, and staff, which is 1500. Then, were going to move to the next biggest one. We anticipate were going to be able to test the jewish home in the next two weeks, and were going to work through the other longterm care facilities. Im sorry. Go ahead. Supervisor walton just out of curiosity, what are the longterm numbers of testing at laguna honda and testing at other longterm care facilities . What would you say is the number of people . So laguna honda is 800 residents and 1500 staff, so its a lot of people. Its over 2,000 people, and its very resource intensive for us to do the testing because it requires a team of people who have personal protective equipment, and so and and so we have currently, we have two mobile teams that are belong to d. P. H. , and were also bringing on board some private providers, private testers to help us with this. Yes, its a big one of the specific challenges with this specific virus is we have to retest. Our goal is to retest, every two to four weeks, everybody. So its a huge commitment, but thats how were going to be able to prevent infection and save lives in the near future. Supervisor walton so the answer to my question of why were not doing testing of asymptomatic testing in every area that we see communication of the virus is because we dont have Testing Capacity . So right now, the capacity the capacity is increasing, so right now, when i mentioned that ive prioritized right now, is so anybody who works outside the home can go to any site, even if you do not have symptoms right now, you do not have to have symptoms to get tested. Supervisor walton so but you have to be an eventual worker. Yeah. Anybody that works outside the home that works outside the home. Supervisor walton correct. What does that do to our unhoused population or people who live in those areas of high concentrations of people who have contracted virus that dont go to work . Yeah, and i agree with you. That provides a different strategy, and were working we are working on doing a better job of meeting the needs of both the Homeless Population and also the areas like the mission district, like bayview, where theres crowded housing and also where people are at risk, and so those are areas that were working onto do a better job. I absolutely agree with you, including in the Homeless Population. Supervisor walton so my last question, if were about 5800 capacity, im asking specific numbers. You havent hit 5800 yet, and i know were not doing that every day, so im a little confused as to why we havent tested everybody in your priority category, and thats focused in care, living in cares, and folks in laguna honda and other congregate settings. Those measures have been in place for a while. If my math is correct, we should have started testing of asymptomatic already. Yeah. Its been harder. Thats our capacity today, but its really taken a while to get up to this capacity. I can just tell you, as of a week ago, we were debating on the types of swabs that we had access to. All of that is improving, and really, thats what i can communicate right now. I agree with you. Believe me, i wish it can go faster. It just takes a long time. Supervisor president yee wait, wait, wait, wait, wait. I see two other people on the roster. Go ahead. President yee im sorry. Whos talking . Dr. Colfax was just president yee okay. Go ahead. So our goal is to have universal access for testing for covid19, and i share your vision. Okay. President yee okay. Dr. Colfax, go ahead. Our goal is to have universal access to testing for all. Our capacity is the machine that can run the test, and youre exactly right. We do not have the operational aspects, all of the solid supply chains, the staffing, the p. P. E. , the mechanisms all have to be worked out to reach that vision. So our goal is to get there not only through d. P. H. But our private partners, as well. So its not like we can turn on a switch and get to that number overnight. Thats why were starting with laguna honda first, so we can improve our ability to do things faster and then move onto the other s. N. F. S. Supervisor walton my apologies for jumping the roster, president yee. President yee no problem. Supervisor mandelman . Supervisor mandelman thank you, president yee. I guess i share my colleagues desire to understanding what capacity means. Im gleaning that this means a workforce problem, but you never said that. I am assuming that to have teams of d. P. H. Folks or folks under contract set up to go out to each nursing home in San Francisco every two weeks is a project that requires people, and im wondering if d. P. H. Has those people. And im wondering if layering on top of that. Maybe you can tell me if this is true. I imagine youd like to do a similar exercise for every vulnerable population in a congregate living situation, and that theres also a capacity problem which im also imagining is sort of a, like, bodies or people problem, but i dont have a great sense of that. It would be great to have a sense of when you say capacity, its not it doesnt sound like were hitting up against the lab number capacity problem, it sounds like the materials problems are, you know, may or may not be getting resolved. But it does occur to me that lodge sticks and number of people that you need to manage and this is also probably true of contact tracing, you know, that theres a lot of people that need to get put into these roles, and maybe im not completely understanding. Yeah. So let me just briefly summarize that, and let me do it in two phases. One, my colleagues remind me that its not just about testing because when you test, youre going to find staff and residents in longterm care facilities, some of whom are positive, and then, you have to figure out what to do with them. So theres this whole infectious control, training on how not to get infected, and then they have to go out to all of these facilities. So they have to mitigate whats happening in their site but also figure out a path forward how theyre going to continue to operate, so its a big challenge for them. Youre absolutely right, and thats really why, for us right now, this is a transition period as were trying to think about how do we begin to lift shelter in place because of the health Harms Associated with shelter in place and the disrupting of the economy, but then, how do we build how do we do what were currently doing . Some people because were activated right now, were using Disaster Service workers. Some of them are going to have to go back to do their regular operations. How do we backfill those positions . How do we expand in those areas that were going to have to expand, and each one of those is very different. So whats required for a longterm care facility is very different than whats required for shelters, very different than whats required for s. R. O. S, different than whats required for contact investigation and training, so theres work issues across all of those that have to be scaled up, and were going through were going through intensive planning right now, figuring out how were going to do that. And i dont know if dr. Colfax wants to add anything, but yes, what youre describing is absolutely is absolutely where were at right now. Supervisor mandelman and who is in charge of all that . Thats thats the way that right now, thats being done through the e. O. C. , and the e. O. C. , the d. O. C. , all that infrastructure exists, that we depend on all that infrastructure for everything that were doing. Supervisor mandelman so thats being governed by a committee . So our testing head on this is dr. Amy lockwood, as well as dr. Philip, who is leading the testing concept. President yee supervisor haney . Supervisor haney thank you, president yee. I have just a couple of things that have been hard for me to understand. One of them is a thing that a lot of people are focusing on, which is why we seem to have a different strategy that were stating compared to other counties like los angeles, who have been very open that theyre able to and willing to test anyone who wants to be tested . I have a district where we have many s. R. O. S where there were positive cases, and people who live in those buildings want to be tested, but they dont currently fit into the categories where theyre tested, so theyre not being tested. It seems like youre explaining a lot of what our plans are and what were doing, but we seem to be doing different and having a more limited approach than even places like San Joaquin County who has taken a similar stance as los angeles. Can you just quickly explain why arent we saying exactly what los angeles is saying right now on testing . Yeah. So im sorry, was someone going to Say Something . I so the way the way that were saying this, as dr. Colfax is saying, were moving in the direction of universal testing. And given the limitations that we nshlinitially had, we have prioritizing, and we started off in a prioritized way with the asymptomatics, focusing on outbreak detection, and so right now, for example, if we have in a shelter, if one person has developed symptoms thats positive, were treating that as an outbreak. And so and we and we absolutely need to move beyond that, and thats exactly the direction that were moving into, is going to be the universal access. And i completely agree with you. I dont know and i think what we need to do is because we because we received these questions last night, i think and i know dr. Phil dr. Phillips came last week. Its a complex problem, but i think we would be able to go more into these questions in detail by having the people in this work explaining whats been done. Supervisor haney any thing that im trying to understand is your approach at the department of Public Health to spechl people that are homelesare specifically people that are homeless, in shelters, and h. S. A. S. Weve heard presentations on that, etc. It seems to me that because of how vulnerable these individuals continue to be and i can tell you, from my experience, from what i can see, very little has changed with regards to the number of people who are on the streets in very vulnerable situations. There its basically the same as it was, if not worse than two months ago. So as we begin to go to these next set of phases around opening back up, and nothing has changed to put these people in any sort of greater level of protection, and nothing looks like its going to happen any time soon, considering the rate at which people are going into hotels, how can we be confident that there wont be spread, rapid spread among these populations as we start to open up for everyone else who has some protection while we have done very little to protect those that are most vulnerable . I just dont see how were going to drop the metrics when we havent helped people who havent had any change in their vulnerability . Yeah. We appreciate your comments, and we realize that that is one area that we need to build up our Early Warning systems, and thats one of the focus that we have, as youre exactly describing. I think one of the things that would be useful, at a future time, in addition to coming back and talking about testing, to have folks that do the community hub, that do the work on the ground and work with these community populations. You can learn about how theyre adapting testing to the population that have Mental Health and Substance Use challenges. So its a work in progress, and i think it would be useful for us to come back and report to you on how that is going. Its not an area that im spending im spending more of my time on a higher level, but i think it would be great for them to come back and speak to you. Supervisor haney yes. Weve heard from h. S. A. A number of times, but this is an issue of Public Health and how were meeting certain metrics and how were controlling the spread. Last question i want to ask, because i know that other people want to ask questions, its related to the vulnerable population and Homeless Population. So the plan, as i understand it, is for people who are positive to go into an isolation and quarantine, and once they are negative again, they are spent back to a shelter where they are in a congregate living environment. Ive asked h. S. A. Before, but again, i feel this is a Public Health question. What does it say to the people that are post covid . It seems to me that these people are still in danger because their immune systems are way compromised, having just survived a deadly virus, or from everything that ive read, i dont feel 100 confident that they cannot catch covid again, that we are putting them into a knowingly vulnerable environment, a congregate shelter environment, in some cases on a floor, having just survived this deadly virus. Can you please justify that from a Public Health perspective . Yeah, and again, we can have somebody come and tell you more details on how theyre setting up those sites. Youre absolutely right. Theres a lot we dont know. We know that persons who have for example, Health Care Workers that have recovered do go back to work, z and so as long as theyve recovered, they can go back to doing what theyve done in the past. But of course, youre right. We dont know in terms there are some people that may excrete the virus for a longer period of time, and people may get reinfected, and thats why we continue to practice distancing with face coverings because that is an unknown. So to the extent that people can recover, that they should be able to go back and deserve to go back to do what theyve done before, but we do have to be extra cautious and recognize that we dont know, and that people still need to practice social distancing, facial masking, washing hands, etc. Supervisor haney and if i could just add, the concerns that youve raised are obviously importan and if i could just add, the concerns that youve raised are legitimate, and are key in getting policies moving forward, so weve working in the Health Department and making sure that things are aligned with experts in Infectious Disease and people who have been in homeless medicine as much as possible. President yee so are you done, supervisor haney . Im sure you have many others. Supervisor haney no, i can ask another question, but i just want to say. I appreciate that, but i do want to be clear that i have not seen any Public Health guidance that says it makes sense to take somebody that has just survived this deadly virus and all its unknowns, and take them and put them back in a congregate living environment. President yee no. It doesnt seem that were going to get to all the questions, obviously, and were going to make sure that they come back. I know that youre about 20 minutes more than what i asked you to do, dr. Aragon, but i want to stay at least ten more minutes because theres three more people in the roster. So whoever comes first i will try to answer them, and then dr. Colfax will back me up if i cannot answer them. President yee so im going to go by this order. Supervisor ronen, then safai, and walton, i know that youre before safai, but i want to give them a chance first. Supervisor ronen. Supervisor ronen thank you, president yee, and director dr. Colfax, and dr. Aragon. I want to say thank you very much for your work. I know youve both been just working nonstop and have done a tremendous job at flattening the curve and not overwhelming the hospitals during this time, and im so appreciative to both of you. But i just want to follow up on some of the supervisor haneys question because as you know, the place that weve been having a really hard time understanding the strategy around the department of Public Health has been with the Homeless Population. So we are now about seven weeks into the shelter in place order. I know, you know, that, like so many other san franciscans that are blessed to be housed, we are getting antsy. I know this weekend, the parks were filled and people had no masks and were trying to inform them that were not out of this yet, and that in order to keep the curve flat, it isnt a done deal; that we have to continue to shelter in place in order to do that. But whats so hard for me when i talk to my housed constituents is that outside they door, they see massive, massive tent encampments where people are out in the streets without masks, theyre clearly interacting, sharing equipment, have no access to showers, no access to water, have no access to food or very little access to food. Theyre going to work, some of them, because despite the stereotypes, many unhoused members of our city are working. And ive just been frankly shocked that there has not been one health order issued yet directly related to this population. And it seems like youve operated with two separate standards a standard of protection, an expectation for the housed population, and a standard of care and expectations for the unhoused population, and its been really upsetting to me the entire time. And ill finally get to my question. Why havent you issued a health order requiring shelter or some sort of setup where people are safe and distancing and have access to showers, water, and hygiene for the massive unhoused population of this city during this crisis . And im sorry, supervisors. I just per president yee, i let him know that i unfortunately had a hard stop at 6 00, and supervisor ronen, dr. Aragon will answer your question. I do want to emphasize, though, that from the beginning, the population experiencing homelessness was an acute priority of ours. In working with h. S. A. And h. S. H. , we have housed in hotels hundreds of people that are particularly vulnerable. In doing that, weve saved many saves, and the isolation and quarantine hotels, we currently have 200, and we have a capacity of 500. I hear your concerns, very much appreciate them, but i do want to emphasize that this is a population that the Health Department and other departments have been focused on during this pandemic. So unfortunately, i do have to leave at this point, but ill turn it over to dr. Aragon. President yee dr. Aragon . Yes, thank you for that question. I know when i started looking into this, we did consult with the City Attorney of what of just the whole topic of commandeering property. And one of the things that i learned theres actually two things that i learned, and that is in order in order to commandeer property, we would have to show that persons are not cooperating in our in our attempt to secure hotel rooms. And the other thing i learned is that because of due process, it could take longer. Supervisor ronen can you repeat your first statement . I missed that. So the communication that i have from the City Attorney was that we would have to show that we were unable exhausted all resources all resources to get hotel rooms, and as long as long as the city can secure hotel rooms, that that should go forward. So that was that was my understanding. So it didnt seem to me to make sense to do an order if the city has the capacity to negotiate and get hotel rooms as the board of supervisors has also passed an ordinance, as well. Supervisor ronen well, dr. Arag aragon, i completely disagree with your statement. But second, you have a unique power to order individuals that walk out on the street and may someday need help in the hospitals have decided not to issue that order in the past seven weeks. I want to know why because it doesnt make sense to me, and it doesnt make sense to my constituents, both housed and unhoused. If you walk the streets of the city, it doesnt make sense to any of those thousands of people that are obviously dangerously camping in the street right next to each other with no access to hygiene. So i dont want you to hide behind the City Attorney, i want to know why you havent issued a health order requiring intervention on the basis of Public Health facility. You just shutdown the entire economy of San Francisco, and you were willing to do that, and i stood by you, and i stand by you in that decision. You have not been willing to do that for the Homeless Population, and i dont understand it. We as supervisors have done everything in our power to try to force the situation, but were not the public Health Officer. Thats you, and i want to understand why you havent issued that order. Ill explain it to you the best way i could, and thats really all im prepared to say at the moment. Supervisor ronen well, thats really disappointing, dr. Aragon. I have nothing more. President yee okay. Thank you, supervisor ronen. Ill say it mildly. I dont disagree with supervisor ronen