Idaho Matters is back this week with our panel of Idaho doctors to answer more of your COVID-19 questions. It seems like every week, we're learning something new about what the coronavirus does to people who get infected. But for everything we learn, there's an equal if not greater amount of incorrect information circulating.
Joining Idaho Matters today to help separate fact from fiction are:
- Dr. David Pate, part of the governor’s Coronavirus Task Force, and former CEO of St. Luke’s.
- Dr. Andrew Southard, Saint Alphonsus Emergency Medical Director
- Dr. Dr. Bart Hill, St. Luke’s Vice President, Chief Quality Officer & Associate Chief Medical Officer
As Governor Little prepares to announce moving to phase two of reopening May 16, the panel weighs in on your questions about mask use, herd immunity, newly added symptoms to watch for and much more.
Have a question for the panel? Leave us a voicemail with your question and we may use it on next Wednesday’s show. Here’s the number to call: 208-426-3625.
Read the full interview here:
GEMMA GAUDETTE: You're listening to Idaho Matters, I'm Gemma Gaudette. You know, as we continue to cover the coronavirus pandemic, we know so many of you have questions and concerns. And here at Idaho Matters, we want to answer those questions, but we want to do that with facts. And we believe the best way to do that is to bring in Idaho medical experts. So every Wednesday, if you've noticed, we've been bringing in a panel of doctors and other health professionals to get us updated, but to also answer listener questions. If you're a regular listener, think of this as a doctor's version of a Reporter Roundtable. So joining us today are Dr. David Pate, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Taskforce, Dr. Andrew Southard, emergency medical director at St. Alphonsus, and Dr. Bart Hill, St. Luke's vice president and associate chief medical officer. Thanks, everyone for joining us today.
ALL: Thank you. Thanks, Gemma.
GAUDETTE: Dr. Pate, I want to start with you. Governor Little will be holding a news conference tomorrow at 1:00 p.m. We will be carrying that live for folks if you want to listen in. We expect him to announce whether the state will move to Phase 2 of reopening because that is set to to begin on May 16th. Are you confident, Dr. Pate, that we are ready to move forward into Phase 2?
DR. DAVID PATE: You know, I'd have to say that I've been very proud of Idahoans and how seriously they are taking this pandemic. And we've had very good compliance with all the best practices about how to mitigate this pandemic. So, yes, I think we are doing quite well. We monitor quite a few different indicators of how the disease activity is doing in this state. And [inaudible] the case generally look good.
GAUDETTE: Dr. Southard, I would like to know your opinion as well, because you are literally on the frontlines at St. Alphonsus in the the E.R. What are your thoughts on moving to Phase 2?
DR. ANDREW SOUTHARD: Sure Gemma. I do think we're probably ready. What we're seeing is, again, continued decrease volumes by people coming in with coronavirus-like symptoms and continued negative test result. So I think the downward trend has continued. And that points to positive information for us.
GAUDETTE: And Dr. Hill, St. Luke's, the entire health system has updated the list of symptoms associated with COVID-19 to better align with the expanded list of symptoms that were recently identified by the Centers of Disease Control and Prevention. What are some of those new symptoms that people should be looking for?
DR. BART HILL: Well, Gemma, in addition to the original symptoms of fever, cough and shortness of breath, we had added GI symptoms of nausea, vomiting and diarrhea as that was symptoms that we noticed in Blaine County. And when they were not included in the original three set of symptoms, we had exposures and we had cases show up late and with immediate identification. Since then, they've added additional symptoms. I think people may have read of the story of the Idahoan whose only symptoms were a loss of smell and taste. And so those symptoms have been added. Additionally, with this illness, people have had shaking chills, [inaudible] fatigue and weakness. So it's those constellations of symptoms that have been added. And I think we're about at nine now that we are assessing and screening both our staff, patients and visitors for. And I think we're going to see increase in the number of people tested because now there's a sore throat and headache are additional symptoms. So there is such a general group of symptoms. I think we're going to see more people being tested now.
GAUDETTE: Dr. Pate, isn't that what we want, to see more being tested, especially as we start opening up more, I would just think that that's what's going to help us move through this. And I'm a layperson saying that.
PATE: Well, Gemma, you're still almost always correct. And...
GAUDETTE: My kids would not argue with you on that statement! [laughter]
PATE: [laughter] But, yes, you know, when we have widespread community spread, it's very difficult to do anything other than mitigation. You can't really be terribly effective at containment. But the nice thing about where we are in the state of Idaho with getting these cases down so much like Dr. Southard was saying, it's much more manageable. And this is where it can be very effective to quickly test. And especially now that we can get turnaround of our tests in a lot more prompt manner than when this first started. Get those tests, find out if we are dealing with COVID. And and if so, do the tracing and actually contain the spread. It's also getting easier for us because of the fact that in the last few months we've been dealing with a high level of other respiratory viruses. As we move into the summer now, a lot of those other things are gonna kind of fade away. And so respiratory symptoms are going to be much more concerning if you have those in June or July than they were if you had them in January or February. And so we do want to promptly test anybody that has the symptoms that Dr. Hill mentioned. We want to get those people tested right away, find out if that's what they have, trace, figure out who they've potentially exposed, get all of those people contained, and then we have a good shot at keeping this under control.
GAUDETTE: And then where are we in terms of that contact tracing, right? So let's say someone does test positive and then, you know, to contain it, you want to find out who they were in contact with in the last couple of weeks.
PATE: Correct.
GAUDETTE: And with you being on the task force, where is the state when it comes to having the ability to do that?
PATE: Well, we've made significant progress and the state has been very creative. They have recruited the help from nursing students, medical students, the medical corps, others, because there's parts of this tracing process that we can teach someone to do. That is some of the time-consuming legwork. And that has freed up our epidemiologists to deal with the more technical aspects of the contact tracing. The other thing that's pretty exciting is there are new technology options to help with this tracing process. And Idaho is looking at some of these. And my guess is that we will utilize some technology to help make the follow up of these people that have been exposed so that we can use, for example, Gemma, if you were exposed today and we need to watch you for the next two weeks instead of a person having to contact you every day. We may be able to use this technology to help extend our efforts.
GAUDETTE: And Dr. Southard, I'm just curious, since we are in Phase 1, what have you been seeing at St. Alphonsus since we've gone into this first phase?
SOUTHARD: We've actually had a little bit increase in volume at our at our main facility, the Saint Alphonsus Regional Medical Center. We had decreased about 30 or 40%. And I think we're still down about 10 to 15% overall. And just our patient volume is for the average day. Part of that is we are starting to see more non-coronavirus related injuries and illnesses. So I think people are feeling a little more comfortable coming to the emergency department for their conditions. It's also probably partly because some of the urgent cares and family practice offices and other places where we actually get referrals into the emergency department are opening. So we're getting some people that are presenting to their offices that maybe put off some some things for a little longer than they should have and now are requiring inpatient hospitalization as they come to the emergency department. So just from a pure volume standpoint, we're seeing more patients that are, I guess, more typical for the emergency department. We're seeing a little bit less of a straight up respiratory coronavirus type of symptoms. And then it's becoming summer, so we are maintaining a heavy trauma presence and people are getting outside a little bit more recently and riding their ATVs and mountain bikes. So that keeps us pretty busy.
GAUDETTE: And Dr. Hill, same question for you. What have you been seeing at St. Luke's since we've been in Phase 1?
HILL: It's similar to what Dr. Southard has mentioned, that we are starting to see more non-typical COVID or more non typical E.D. [emergency department] patients. The volume still is down. I think 10% is is consistent with what we've been seeing as well. There is something unique. Nationally, it's been noticed and we've seen it across our sites is a pretty marked decrease in people presenting with strokes, and with heart attacks. And those are the conditions that you would not expect would suddenly stop occurring in the two month period that we've been dealing with the pandemic, that our volumes are down in those two conditions. And that's been a pattern that we've seen across the nation as well.
GAUDETTE: And that I would think that that's a bit concerning Dr. Hill, because from what I've been reading is, you're right, people aren't not having strokes and heart attacks. They're just not getting the care. They're not getting themselves or a loved one to the emergency room.
HILL: Yeah, and that's going to be one of the challenges for healthcare systems and hospitals is to reestablish that confidence that coming to the health care entity for services is safe. And we'll be able to provide meet the needs. I agree that it's a challenge that we have to overcome.
GAUDETTE: Our panel, Dr. David Pate, former CEO of St. Luke's Health System and a current member of Idaho's Coronavirus Task Force, Dr. Andrew Southard, emergency medical director at St. Alphonsus. And Dr. Bart Hill, St. Luke's vice president and associate chief medical officer. You guys have some long titles. Let me tell you how hard it is. They can be some tongue twister sometimes. We have a really difficult question, and that comes in from Vivian. And she would like to know if there are any cases in Eagle. And here is why. She says, I am 80 years old and I want to see my daughter in law who is diagnosed with ALS. She is in her final stages. We live a mile apart. Is it safe for me to go see her?
SOUTHARD: Gemma, this is Drew Southard, and I'll give kind of the E.R. opinion, and then if Dr. Pate or Dr. Hill disagrees, they could weigh in. But I think that it is not a zero risk situation. But in my opinion, be a low-risk situation for her, even though she's 80. That's making a few assumptions. One is that her daughter, or I guess her daughter-in-law is pretty ill. She probably has caregivers coming in. They are probably being diligent about following their precautions. And so that's a pretty low risk. And then I assume that the family members that live with her are also taking precautions. So the exposure risk for them is pretty low. So I think overall, the chance of her getting it just by visiting hers is going to be relatively low and probably worth doing so, if she's in the final stages of ALS. Some precautions she could use or just be to wear a mask for herself and potentially have the other families mask up when she's there and use really good hand hygiene both when she arrives and after she leaves. So that would be my impression if I had a loved one in that situation and what I would do.
HILL: Gemma, this is Dr. Hill and I had the opportunity to take a look at St. Luke's experience with testing of patients from that zip code, the Eagle zip code. And there were two positive cases at St. Luke's that identified in late March. But since that time, all the coronavirus tests that we have done, some people from that zipcode have all been negative. That being said, I'm sure the disease is there, they can get tested outside of St. Luke's. And what Drew mentioned was along the lines that I was thinking: if she's being good about who she's been exposed to, it really is going to come down to who has her daughter-in-law been exposed to. Even with that assuring she doesn't have acute symptoms. The masking keeping, the social distancing while they're good hand hygiene. Her risk of exposure would be considered a very low risk. And in that situation, I certainly understand the human side of things. And I could support her visiting her daughter.
GAUDETTE: We have a question from Cohen. It says: If someone has coronavirus but is asymptomatic, will they ever show symptoms or will it just take longer for the symptoms to show? And then also, can you get it again once you've recovered?
PATE: So this is Dr. Pate, I'll take this one. So if somebody is asymptomatic, meaning that they don't currently have symptoms, or sometimes we hear people say they're asymptomatic, but they actually have symptoms, but they're attributing it to something else, like their allergies or something. But if somebody is truly asymptomatic, then there's a couple of things that can happen. One is they'll remain asymptomatic. The other is that they're really just pre-symptomatic and means that they may not have symptoms today, but they may start getting sick in the next day or two. So that that is kind of the approach to somebody that's asymptomatic. Whether they can get the virus again once they recovered is the million dollar question. We don't know the answer to that. We presume that they will have some protection for some period of time, but we don't know that yet. And unfortunately, we don't believe this is going to turn out to be one of those viruses like some others, where if you do get infected once, you're protected for life. So that person needs to continue to take precautions and assume that they could get reinfected again at some point until we know better.
GAUDETTE: And then Steve has a question: He says there is a fair amount of information in other countries on the R0 statistics. This is what measures the average number of people infected by one person afflicted with the disease. Are there any estimates of R0 for Idaho? And if so, what is the trend?
PATE: Yeah, I can I can take this one. So, yes, there are estimates for the R0. To be technical about it, R0 is at the very beginning of an illness when you are not taking any mitigation measures and everybody is susceptible. So, you know, the R0 can vary from country to country or even region within a country, but we think the R0 for this virus is somewhere between two and three. There are projections in some places that is higher, but I think two to three is a reasonable assumption. And what that means is that somebody who has this infection would spread it to two to three other people if there were no mitigation factors and everybody was susceptible. Now, after we've taken mitigation steps and after people have been getting infected, as we are now, a lot of people refer to it as the R0, but it's not, it's more the effective reproduction rate or the transmission rate. But you can think of it as essentially the same thing. Six weeks ago in Idaho, estimates were that we were at about 0.93. And the significance of that is anything less than one is ineffective transmission of the virus. So it means that it's not going to continue to propagate. Anything over one, like where we started, two to three, means that it will spread and move to many others. So you want it below one. Six weeks ago, estimates where we were at about 0.93 For the last month, we've been at 0.9. The lower the better. 0.9 is good. I'd like to see it go down even further because that gives you some cushion. But it does tell us exactly what we're seeing in the numbers, and that is that we don't have growing spread by and large here in Idaho.
GAUDETTE: And then Laurie has a question. She says: My understanding is that the danger of COVID-19 is that it can develop into pneumonia, which is what can lead to death? So, she says, first, is that correct? So maybe Dr. Hill, can you answer that?
HILL: Sure. Pneumonia is one of the hallmarks of this disease. But it's viral type of pneumonia, has a very particular pattern. I think what has been the main contributor to people dying from the disease has actually been what we think is an immune reaction. And it leads to a different set of conditions in the chest. And that's called Acute Respiratory Distress Syndrome or ARDS. And this is where it fills with fluid, it's very difficult to get oxygen, and because there really isn't an effective treatment, there's the mortality when people reach that point. So the pneumonia itself, I don't think, is what is the biggest risk to patients to have that long standing hospitalization, ICU stay, or death. It's pretty common to see that as a component of most people who are sick enough to be hospitalized with or without ICU care. And that generally is considered a viral pneumonia that with supportive care, people are able to overcome.
GAUDETTE: And then M.J. had a question: Is there a source for children's gloves? Because tiny hands in adult gloves don't work well. Or will handwashing protocols and hand sanitizer be best for kids?
SOUTHARD: You know, I have not found kids gloves yet either, and my kids walk around with giant gloves on their hands. But I think just the typical handwashing is probably the right way for kids. I am not sure if Dr. Hill at St. Luke's the children's center, if they have small gloves or not.
HILL: Oh, I asked. We don't. And as a parent, I remember the challenges of teaching them to brush your teeth and to do it effectively. And I think this is a wonderful opportunity to teach our children at an early age the importance and how to do effective hand hygiene and not touch their face. It's a lifetime skill that they need to develop. And starting early is the best option. I think.
GAUDETTE: I'll tell you, my kids are still working on the toothbrush thing, but they're very good at washing their hands. So I will take the handwashing right now over getting them to brush their teeth twice a day... So, Shawn, a listener, wants to know: I have heard that the mortality rate for diabetics is higher than the baseline for COVID-19. What are the causes of this increased risk? And are there any additional precautions that should be taken beyond the typical recommendations for everyone right now?
SOUTHARD: Well, this is Drew Southard, I think, you know, diabetes itself is just a tricky disease and it causes some immunosuppression in people. And so it is true that they're going to have a higher mortality from COVID-19. It's also true that they're going to have higher mortalities from flu and a lot of other processes. It's just harder for them to get over illnesses and such. So the different general precautions that we're doing, I think, for everyone with COVID is the number one thing to be doing. The second for any diabetics is just to continue their general health, meaning make sure you have good glucose control, make sure that you're staying healthy, otherwise exercise, et cetera. So nothing else really to do other than prevention and maintaining the best you can at your baseline diabetic level.
GAUDETTE: So another listener, wrote in saying, you know, gyms are set to reopen in Phase 2 and then they give us a list of what their gym is doing when it reopens. So they want to know if it's safe to go back. So one of the things that this gym is doing is they're doing an air purifier and ionization that's going to be running during class. They say the technology parallels the air-cleaning technology used by NASA. They're going to have non-contact temperature screening with FDA rated temporal scanner for every guest and employee and if and if someone has a fever of 100.4 or above, they will not be able to go in. They are using EPA-rated antiviral disinfectant. They are spraying the entire facility with hospital grade sanitizer and then they will be disinfecting between every class. So when a gym like this reopens, because other gyms are saying, just check yourself if you feel good, come in. So would this be okay for someone to go back to their workout facility?
HILL: Gemma, this is Dr. Hill. Hearing what they are doing, it's encouraging that they're taking those additional extra steps, the ionization, the cleaning, the checking of fevers. It's still, however, not certain that it's going to be enough. It will help. And we know that the ionization or ultraviolet light can markedly reduce the number of viral elements that are expelled in the air. But we also don't have evidence that it's 100% effective and that would be the solution. You can imagine that people working out are going to be breathing hard, almost the equivalent of coughing or singing. And if they are pre-symptomatic or early symptoms and they're not really aware that they have them and not yet with a fever, they're going to be spreading those viral of products on to equipment in the area. And generally, the risk of catching this is you touch something that has the virus, then you accidentally touch your face, your mouth, who knows your eyes. That's how you generally going to be passing this if it's not directly breathing or talking with someone coughing on them. So, yes, it helps. I'm not sure that I would be comfortable yet going back into that environment.
GAUDETTE: Dr. Pate, can you help out Deann? She wrote in saying, I am considered a high risk due to moderate-severe rheumatoid arthritis and immunosuppressant medications. She says she's on a biologic steroids and a DMARD. She wears a mask every time she leaves home. She says if she contracts COVID-19, she will be required to stop her R.A. medications until the illness resolves. She goes on to say that she had a podiatry appointment. No one checked her temperature. None of the staff had masks on. And she asked the doctor. He said he was promoting, quote, herd immunity and he doubted masks would work. She says she was told there are no actual requirements on the governor's order requiring health providers to follow masking or social distancing rules. And she wants to know why not.
PATE: Wow. Well, first of all, I hope very much that Deanne misheard him or misunderstood because all of this is wrong. So first of all, Deanne falls into the high risk group. And so the concept of this practice, wanting to promote herd immunity is frankly irresponsible. So let's talk about herd immunity for a second. Herd immunity is that amount of immunity in a population that is sufficient to make transmission of the virus ineffective. And why that's important is because there are people like Deanne who are very high risk that we need to protect. And there are people that are immunocompromised who may not be able to take a vaccine or for which the vaccine wouldn't work well. And so the idea is if a sufficient number of us get infected or vaccinated, then the virus won't transmit very effectively. And people like Deanne will be protected by the rest of us. Across the United States, we don't know what level of infection we have, but we have some reasonable estimates. And it's estimated that no more than five% of Americans have been infected. In Idaho, it may very well be less than 2%. And most virologists believe it's going to take 70 to 80% of the population to be immune to achieve herd immunity. So this practice, trying to promote herd immunity, first of all, it's not going to happen. We're not going to get anywhere near the numbers necessary by promoting infection in that practice to get herd immunity. Second of all, it just represents a complete misunderstanding of herd immunity. Herd immunity is to protect high risk people. You don't try to get herd immunity, including high risk individuals. So that's just irresponsible. The issue about masks is just uninformed. There are models that suggest the combination of wearing masks and social distancing can reduce the transmission of this virus by more than 80 percent. There are many conditions for which masks are not appropriate. However, in this case, like our previous discussion about asymptomatic individuals, there are people who are shedding the virus who don't have symptoms or don't recognize the symptoms, who are transmitting it. And that is the reason that masks are effective in this particular condition, because when those virus particles come out of your mouth or nose, they come out enveloped in fluid and these droplets are large enough that they can be stopped by your mask in many cases. And so what it really does is wearing a mask actually protects us from you. If you're infected, and I just wear a mask, I'm not going to have very much protection. But if you're infected and you wear the mask, it is going to help me be protected significantly. Finally, you just have to look at the governor's order. And there are very few times in the governor's order that he says you shall do something. But the social distancing is one of the things he says. You shall do this whenever possible. So again, I hope that Deanne misunderstood or there is a miscommunication. But if that really is the opinion of this healthcare giver, Deanne's should give consideration to alternative choices.
GAUDETTE: And can we go back to the masks for a moment? And feel free, any of you to answer this. I have seen this quite a bit now on social media, so take it for what it's worth, however, a lot of people get their information that way. It is this idea of if you wear a mask, that means you are breathing in carbon monoxide, which is, you know, not good for you. Or, 2, that the virus will come out of your mouth and then go back in your body and potentially reinfect you. Can we talk about the facts of these two ideas going around and actually, you know, really taking off in a lot of people believing that it's true.
PATE: Yeah, well, it's David Pate again, so both of those are false. Wearing the mask is perfectly safe. The there's not going to be risks. First of all, wouldn't have risk of carbon monoxide poisoning from that regardless. But there's not going to be any problem to your being able to maintain adequate oxygenation and so forth. So that that first one is false. The second one that you're somehow going to be breathing in the virus and reinfecting your yourself is is also not correct. The fact that you are shedding the virus indicates the virus is already there. Since we're not aware of carriers in this kind of disease where we do see that in some other conditions and we currently believe that everybody that has the virus is actually infected. You have just millions of these viruses, particles in your system already. So breathing it out and then breathing it back in is not going to reinfect you. And so neither one of those are true.
GAUDETTE: And Dr. Southard, maybe you can answer this. A listener wants to know whether all of these hand sanitizers and antibiotics we're using in the fight against COVID-19 is creating a new kind of danger, mainly antibiotic resistance.
SOUTHARD: Sure, so there is a theoretical issue with using one type of cleaner continuously and that you will develop some resistant bugs eventually, or there's going to be bacteria that are going to develop the ability to live in the conditions that you're creating. However, in this situation, it's a little bit different because we're not promoting just one type of cleaner. There's multiple types, I think that's one thing. And the second is the frequency of use in the general public of this is probably far too low to really do anything demonstrable. So at this point, I wouldn't worry about that particular issue. If you're really concerned about getting some resistant bacteria. You could alternate between, say, like an alcohol, disinfect it on your hands one time and then washing with soap and water because they'll actually be two different forms and you won't be exposing any of the bacteria or other things to the same chemical repeatedly.
GAUDETTE: And I would think that handwashing is still the best bet. I mean, I have got, you know, those sanitizing wipes in my car if I go to the grocery store. So I wipe my hands down, wipe the steering wheel down. But if I'm home, I'm washing my hands.
SOUTHARD: Yeah. And I tend to do the same thing even on shift. And we have several different types of product available to us. And I feel personally that washing the hands, you're going to get more volume of water across the hands, if you get alcohol in contact with the right services is going to kill it. But a squirt of the alcohol, there's a little bit harder to get in all the cracks and crevices, whereas you're pushing your hands under, you know, whatever the PSI water coming out of the faucet is probably 40 and you get half a gallon of water in your hand. You've done a pretty good job of flushing it out.
GAUDETTE: And last question, listener Richard wants to know, why isn't the US mortality rate publicized so people would realize how serious the disease is? Who would like to take that?
HILL: Gemma, this is Dr. Hill. I'd like to take that. It gets to, when you think of the disease as a rate instead of the individuals that are truly impacted, you miss the forest for the trees because there are real people that are dying. And if you say, well, it's only 1%, it seems like that's an acceptable mortality when it's the 70 people in the state of Idaho and some of them are people that, you know, it's very real. Additionally, we're going to see that mortality rates vary. In the beginning, we were only testing those that were truly symptomatic and needing to be hospitalized because we didn't have enough testing equipment. And so we artificially selected a smaller group to test the sicker ones. So when we see a mortality rate that might be 5% or 10%, as we start testing younger people, people with less symptoms, less severe symptoms, we're gonna suddenly see that the mortality rate, as they notice in China and other countries, begins high and gradually settles at a much lower rate. And it's from my perspective, it's misleading and it's really easy to dismiss a rate when the reality is it's real people. And that's why I'm much more supportive of publishing our actual numbers of mortality.
GAUDETTE: I want to thank all three of you for taking time out of your day and talking to us. As we mentioned in the very beginning of the show, every Wednesday, it is so critically important to get facts right now. And so I so appreciate you as medical experts the information and the knowledge that you have and sharing it with all of us.
ALL: Thank you, Gemma.
GAUDETTE: Absolutely. We have been talking with Dr. David Pate. He is the former CEO of St. Luke's Health System, a current member of the Idaho Coronavirus Task Force, Dr. Andrew Southard. Emergency medical director at St. Alphonsus, and Dr. Bart Hill, St. Luke's vice president and associate chief medical officer. If you have COVID-19 questions for our doctors, you can always send us an e-mail at idahomatters@boisestate.edu, because, of course, we will bring our medical experts back next week. Again, thank you so much, all three of you, welcome. This is Idaho Matters.
As COVID-19 cases spread through the U.S. and Idaho, we’re committed to keeping you updated and informed. You can get updated info on cases, closures and how to stay healthy at any time on our Coronavirus news blog.
Have a question or comment for the show? Tweet @KBSX915 using #IdahoMatters
Member support is what makes local COVID-19 reporting possible. Support this coverage here.
