2020 The Long Year - Lessons from the COVID-19 Pandemic and the Texas Response

LESSONS FROM THE COVID-19 PANDEMIC AND THE TEXAS RESPONSE

Cover image: A nurse wearing personal protective equipment (PPE) on duty at the Texas A&M Health Science Center.

(Sam Craft, Texas A&M AgriLife)

“

WE NEED TO GET READY FOR SOMETHING THAT MAY EVEN BE MORE SEVERE IN THE FUTURE.

FEBRUARY 2021

INTRODUCTION Texans are accustomed to facing the challenges presented by natural disasters, including hurricanes, tornadoes, wildfires and floods. Since 1953, Texas has seen 101 federally declared major disasters, more than any other state.1 However severe these disasters are, though, they typically affect only a small share of the state’s 254 counties and 29 million residents. Hurricane Harvey in 2017, the most destructive and widespread natural disaster in recent Texas history, significantly affected 60 counties.2 Despite our long experience, nothing had prepared Texas and Texans for what they’d face with the COVID-19 pandemic in 2020. COVID-19, a new disease with unpredictable effects on individuals, spread with dizzying speed until it engulfed the world, sweeping the U.S. and Texas along in its wake.

■ COVID-19 The disease we’ve come to know as COVID-19 first was reported in Wuhan, China, in late 2019. At the time, it was described as an “unexplained respiratory virus.” In January 2020, the National Institute of Allergy and Infectious Diseases identified the virus that caused the Wuhan outbreak as a new strain of coronavirus, SARS-CoV-2. On February 11, the World Health Organization (WHO) named the disease caused by this new virus Coronavirus Disease 2019, or COVID-19.3 Initially, COVID-19 was believed to be only modestly contagious, somewhat like the previously known SARS virus. That assumption was wrong. The Wuhan virus turned out to be far more infectious, and could spread “asymptomatically” — that is, the virus often was carried and spread by persons who had no idea they were infected.

“That whole idea that you were going to diagnose cases based on symptoms, isolate them, and contact-trace around them was not going to work,” said Robert Redfield, the director of the U.S. Centers for Disease Control and Prevention, in a recent interview. “You’re going to be missing 50 percent of the cases. We didn’t appreciate that until late February.”4 It was the first of what would become a series of grave miscalculations about COVID-19.

The disease spread quickly beyond Wuhan to other parts of China and then to Taiwan, Vietnam and other neighboring countries. From there, it began to spread relentlessly around the globe.

On January 30, 2020, WHO declared a “public health emergency of international concern” in accordance with international regulations.5 COVID-19 cases then appeared in Europe, North America, South America, Asia, Australia and Africa. WHO declared it a pandemic on March 11.6

A NEW DISEASE WITH UNPREDICTABLE EFFECTS ON INDIVIDUALS SPREAD WITH DIZZYING SPEED. ■ PAGE iii

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BY THE END OF 2020, NEARLY 30,000 TEXANS HAD DIED OF COVID-19.

In the first three months after COVID-19 emerged, nearly a million people around the world were infected and 50,000 died. By the end of 2020, nearly 82 million cases of COVID-19 had been reported — and 1.8 million deaths from the disease.7 The first U.S. case of COVID-19 was identified in Washington state on January 21, 2020.8 This patient had visited Wuhan recently. In all likelihood, however, the disease already was circulating in the U.S., particularly near points of entry for foreign travelers. It soon spread along both coasts and began to move inland.

On March 4, the Texas Department of State Health Services (DSHS) and Fort Bend County Health and Human Services reported the first positive test for COVID-19 in Texas outside passengers under federal quarantine at Lackland Air Force Base near San Antonio.9 This person was a resident of Fort Bend County who had recently traveled abroad.

As experts began to understand the disease, it became obvious that the virus affected different people in different ways. Some showed few or no symptoms; to others, it proved fatal. It was more likely to have severe health consequences in older adults than in younger people. It also became clear that an infectious disease outbreak of this severity and geographical spread had not been seen since the 1918 influenza pandemic.

The coronavirus eventually touched every county in Texas — and every Texan, in one way or another.

Since the initial Fort Bend case through December 31, Texas has reported almost 1.6 million confirmed cases of COVID-19. Nearly 30,000 Texans had died from the disease by the end of the year.10 The virus also has had a broad and sharply negative impact on the state’s economy, and has rewritten many of the social norms we took for granted before 2020.

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■ A CRITICAL POINT IN HISTORY The sudden and unexpected surge of COVID-19 caught most Americans by surprise, but experts had long predicted that a pandemic was only a matter of time. In his 2008 book Global Catastrophes and Trends, Canadian scientist Vaclav Smil said: “The likelihood of another influenza pandemic during the next 50 years is virtually 100%, but quantifying probabilities of mild, moderate, or severe events remains largely a matter of speculation because we simply do not know how pathogenic a new virus will be and what age categories it will preferentially attack.”11 Experts warned that the nation needed to be prepared. In 2005, Michael Osterholm, an infectious disease expert at the University of Minnesota, wrote in Foreign Affairs: “This is a critical point in our history. Time is running out to prepare for the next pandemic. We must act now with decisiveness and purpose.”12 In 2017, TIME published a cover article warning that the world and the U.S. were unprepared for a future pandemic: “On a hyperconnected planet rife with hyperinfectious diseases, experts warn we aren’t ready to keep America — and the world — safe from the next pandemic.”13 Before COVID-19, Texas had experienced and responded to major infectious disease events.

In addition to its everyday activity of disease monitoring, DSHS has supported the state’s public health system through infectious disease crises such as novel influenza A H1N1, known informally as the “swine flu,” in 2009 and Ebola in 2014. And in 2015, DSHS had prepared a “public health preparedness, surveillance and response plan,” Respiratory Viruses Having Pandemic Potential.14 This experience and planning helped our response.

As one example of forward-looking thinking, DSHS had medical surge plans in place that provided $1.7 billion in critically-needed extra hospital staffing by December.15 However, despite such steps, DSHS and its partners had never truly been “battle tested“ for the kind of all-of-government response required for an infectious disease of COVID-19’s scope and characteristics.

Beyond the infectious disease expertise at DSHS and the state’s major universities, Texas benefited from two additional resources it could tap.

■ INTRODUCTION /

Portraits by Amanda Dominguez on display at the Arts Council of Brazos Valley as part of the Heroes of COVID exhibit on Thursday, July 2, 2020. (Bryan-College Station Eagle)

First, it already had a statewide Task Force on Infectious Disease Preparedness and Response.

Created by executive order on October 6, 2014, after an Ebola scare in the Dallas area linked to the West African epidemic of that year, the task force includes state agency representatives as well as experts in infectious disease, emergency management and public health. State law requires it to provide expert, evidence-based assessments, protocols and recommendations related to the state response to infectious diseases.16 Secondly, Texas has one of the nation’s most extensive and effective emergency response systems, led by the Texas Division of Emergency Management (TDEM). TDEM and its supporting agencies, which together form the State Emergency Management Council, has long experience with

a variety of natural and man-made disasters. It would prove to be a critical part of the state’s overall response, including the complex supply-chain logistics associated with providing personal protective equipment, tests and other resources.

Yet Texas, like governments around the world, has struggled to keep up with COVID-19 and contain its spread. What began with an obscure warning about a virus in China became a long year of heartache, one filled with hard lessons for all of us. Even as 2020 came to a close and the first vaccines were being distributed in the U.S., case reports were reaching new daily peaks. Unfortunate victims continued to suffer and die.

Texas faces more challenging months of fighting the disease in 2021.

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■ LESSONS FROM THE LONG YEAR

health disasters, to make us better able to confront the next pandemic.

It’s become clear during this long year that while the nation could have been better prepared for a pandemic — particularly after repeated warnings from experts — nothing would have been adequate to prepare us for an event of this magnitude. The response to any event like this will include successes and failures. It’s important that we identify both, to serve as a guide for future planning.

While Eye of the Storm and this report have many similarities in approach, one major difference is timing; the response to Hurricane Harvey had essentially concluded when Eye of the Storm was published, but we are still very much in the response phase to COVID-19. Of necessity, we set a date of December 31 to end our work so that this report could be made available in time for the 2021 legislative session. Also, December 31 — the end of a long year — presents a logical stopping place to take stock of our response to date.

TDEM asked the Texas A&M University System to assemble and examine the lessons learned during 2020, as a reference for the governor, the Legislature and other officials as they plan and prepare for similar events in the future. In a sense, our report is a follow-up to the 2018 report of the Governor’s Commission to Rebuild Texas, chaired by Texas A&M Chancellor John Sharp. That report, Eye of the Storm, served a similar purpose — gathering lessons learned during and after Hurricane Harvey and making recommendations for improvements in its wake.

That report became the basis for significant legislative reforms in the 2019 legislative session. As with Eye of the Storm, the present report discusses potential improvements in the way Texas’ state and local governments plan for and respond to public

A student appropriately masked during his workout at Bryan High School, June 8, 2020. (Bryan-College Station Eagle)

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We know that critical times lie ahead, such as in the recently-started vaccine rollout which is clearly presenting large-scale logistical challenges as occurred with testing and personal protective equipment distribution. While the timing of our report didn’t allow us to evaluate the unique issues surrounding vaccine distribution in any depth, the recommendations in this report do consider the need to improve all aspects of pandemic planning including vaccines.

Our report is divided into seven chapters. It begins with a primer on viruses and pandemics to set the stage. It then provides an overview of the state’s framework for responding to public health

We have spent months following the progress of the disease and the state’s response. We have reviewed state and federal efforts throughout the nation and interviewed dozens of individuals on the front lines of the battle against COVID-19. We believe our recommendations represent workable steps the state can take, beginning in the 2021 legislative session, to make our response to any future pandemic far more effective than was possible in 2020.

Dr. Gerald Parker of Texas A&M University’s Bush School of Government and Public Service, an expert on biosecurity and infectious disease, recently noted: “Although the emergence of the SARS-CoV-2 virus caught the world by surprise, many of us knew a pandemic was inevitable. Infectious disease outbreaks with pandemic potential are occurring with alarming frequency and COVID-19 will not be our last pandemic. We must be better prepared.”

Some of the lessons learned in 2020 can be applied — or, in some cases, are already being applied — in the current pandemic, which is far from over. Others will build the state’s capacity to prepare for future pandemics. All should be incorporated into Texas preparedness planning as soon as is practical.

We know a pandemic can inflict sickness and death on a broad scale. In 2020, we were forcibly reminded that it also can cause unprecedented economic disruption — and that any response is difficult when the enemy is invisible, unpredictable and evershifting.

And we know that more needs to be done to prepare for future pandemics. Failing to do so would mean we’ve wasted any progress we made in the long year of 2020.

■ INTRODUCTION /

emergencies and examines its various aspects, including the public health response, supply chain logistics and key pandemic support functions. It concludes with a discussion of how best to prepare for future pandemics. In each of these chapters, we include findings based on interviews and research and recommendations for improvements to current practice.

Michael Ryan, the executive director of WHO’s Health Emergencies Programme, recently said: “These threats will continue. If there’s one thing we need to take from this pandemic with all the tragedy and loss is that we need to get our act together. We need to get ready for something that may even be more severe in the future.”17

WE KNOW THAT MORE NEEDS TO BE DONE TO PREPARE FOR FUTURE PANDEMICS.

This report is a blueprint for improvement. Texas must recognize that COVID-19 isn’t a unique event; sooner or later, another worldwide pandemic will occur, and possibly much sooner than the century that separated the 1918 influenza pandemic and COVID-19. Today’s world is far more interconnected than it was a century ago. A global pandemic of frightening size and complexity is more than a vague possibility; it’s a reality with which we now must live.

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A social distancing reminder for customers entering H-E-B. (Bryan-College Station Eagle)

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R E C O M M E N D AT I O N S AT A G L A N C E ■ EMERGENCY MANAGEMENT 1

Clarify the statutory responsibilities of the Texas Division of Emergency Management (TDEM) and Texas Department of State Health Services (DSHS) to ensure a more efficient disaster response.

2

Require TDEM to form a working group of stakeholders to propose a disaster response structure that better integrates the roles of public health, medical and emergency management entities at local, regional and state levels.

3

Require DSHS and TDEM to ensure that key local emergency managers are aware of the persons acting as their health authorities.

4

Add the Texas Higher Education Coordinating Board (THECB) to the Texas Emergency Management Council.

5

The Texas congressional delegation and state agencies should work with the federal government to improve pandemic-related federal laws and practices.

■ SUPPLY CHAIN LOGISTICS 6

Require TDEM to submit a plan to the Texas Legislature concerning the adoption of improvements recommended by the Supply Chain Strike Force.

7

TDEM should create a permanent partnership with the private sector that could assist it in response and recovery operations as the Supply Chain Strike Force did during the pandemic.

■ PUBLIC HEALTH RESPONSE 8

Require DSHS and TDEM to develop and regularly update a detailed state pandemic testing deployment plan.

9

Require DSHS to conduct a regular survey of Texas laboratory capacity.

10 The Texas congressional delegation should work with Congress and federal agencies to waive federal requirements that prevent the Texas A&M Veterinary Medical Diagnostic Laboratory from using its full capacity for emergency human diagnostic testing.

11 Require DSHS to develop a Texas public health workforce surge plan in partnership with the state’s public health schools.

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12 The Texas Legislature should fund a consortium of the state’s public health schools to bolster the state’s public health and disaster response surge capacity.

13 Require DSHS to convene a multi-disciplinary taskforce to recommend improvements in the processes and systems used to collect, analyze and report key public health data during a widespread infectious disease event.

14 Require the Texas State Auditor’s Office (SAO) to conduct a COVID-19 data quality audit to identify necessary public health data system improvements.

15 Clarify portions of the Health and Safety Code concerning the DSHS commissioner’s authority to make decisions on data reporting and data sharing during a pandemic.

16 HHSC should suggest statutory modifications addressing the timely reporting of infectious disease in long-term care facilities.

■ KEY SUPPORT FUNCTIONS 17 The Texas Workforce Commission (TWC) should consider allocating additional federal child care funds to a wider range of child care programs.

18 The Texas congressional delegation should advocate for changes to the Child Care and Development Block Grant to give federal agencies more flexibility to issue blanket waivers to program requirements during emergencies.

19 The Texas Legislature should support the ongoing collection and transparent reporting of infection rates in child care settings essential to policymaking and family decisions.

20 The governor should consider expanding child care options earlier in a pandemic to reduce the economic impact on families and the state.

21 The Supply Chain Strike Force’s early and ongoing emphasis on child care responsiveness is a best practice that should be included in future planning for pandemic response.

22 The Legislature should provide guidance on state agency policies regarding sick leave, vacation time, overtime payments or accrual and hazardous-duty pay for eligible state employees working during a pandemic.

23 Require the Department of Information Resources (DIR) to develop a long-term plan for improving the state’s information technology infrastructure for future pandemics and other emergencies.

24 Require all state agencies to develop a telework policy and implementation plan for both normal business operations and emergencies.

25 Require the state’s Broadband Development Council to develop a detailed statewide broadband expansion plan.

26 The Legislature and TWC should continue to prioritize modernization of the Unemployment Insurance system to support higher volumes and quicker processing of claims during an emergency.

27 Require HHSC to convene a work group to make recommendations on the permanent expansion of the list of services eligible for telehealth/telemedicine in Medicaid and the Children’s Health Insurance Program as well as the types of providers who should be allowed to deliver these services.

28 The Legislature should establish a telemedicine work group to review innovative telemedicine programs throughout the state and identify long-term strategies for their sustainability, expansion and growth.

29 The Texas Department of Insurance (TDI) should conduct regular reviews of health-plan websites to ensure their compliance with the state’s requirement that information on telemedicine must be displayed prominently.

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30 Require development of a response strategy, associated implementation plan and biennial pandemic preparedness “report card” to prepare for and evaluate the state’s readiness for major public health disasters.

31 Require the Task Force on Infectious Disease Preparedness and Response to advise state leaders on pandemic planning and develop metrics for evaluating the state’s level of pandemic preparedness.

32 TDEM, in coordination with its partners, should update the State Emergency Management Plan to incorporate changes reflecting lessons learned from the COVID-19 pandemic.

33 The Texas Legislature should provide general revenue to restore key public health and medical preparedness funding to previous levels.

34 Require administrators and staff of nursing facilities and Texas Department of Criminal Justice (TDCJ) prison facilities to be trained in the use of personal protective equipment, sanitation techniques and basic health-related practices.

■ RECOMMENDATIO NS AT A GLANCE /

■ PREPARING FOR THE FUTURE

35 The Texas A&M AgriLife Extension Service should seek exceptional-item funding to provide health literacy education in all Texas counties.

36 Add information about serious infectious diseases to the topics listed in statute to be covered in TDEM’s Disaster Response Guide.

37 Require the leaders of the state agencies and other entities represented on the Texas Emergency Management Council to receive training on the state’s emergency management system.

38 The Legislature should establish a disaster training and certification program for key state, regional and local personnel involved in public health and medical responses to disasters.

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A traveler wearing a mask departs from Easterwood Airport (College Station, Texas) for a work trip. (Bryan-College Station Eagle)

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CONTENTS VIRUSES AND PANDEMICS

1

TIMELINE OF COVID-19 IN TEXAS

9

EMERGENCY MANAGEMENT

21

SUPPLY CHAIN LOGISTICS

35

THE PUBLIC HEALTH RESPONSE

43

KEY SUPPORT FUNCTIONS

55

PREPARING FOR THE FUTURE

69

ENDNOTES 83 CONTRIBUTORS 117

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Typist wearing mask in New York, New York, to protect against Spanish Flu, 1918. (National Archives, photo no.

45499321)

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CHAPTER 1

CHAPTER 1

V I R U S E S A N D PA N D E M I C S Throughout history, viruses have been among humanity’s greatest foes — and most persistent killers. The smallpox virus killed an estimated 300 million people in the 20th century alone before it was declared eradicated by the World Health Organization (WHO) in 1980.1 The 1918 “Spanish” flu claimed 50 to 90 million people worldwide, while about 33 million people have died from AIDS-related illnesses since the 1980s.2 The last 20 years have seen the emergence of dangerous new diseases caused by coronaviruses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) — and now, COVID-19. Emerging diseases such as these increase the threat viruses pose to human health and intensify the challenges public health officials must face.

Modern global civilization is characterized by extensive international trade, increased population density, human development in previously undisturbed habitat, cheap and ubiquitous air travel and, increasingly, the mass migration of populations, prompted by war, civil strife, climate change or the search for greater economic opportunity.

It’s a perfect catalyst for spillover events.

The term “virus” is derived from the Latin word for “poison,” a name that aptly captures the destruction they can unleash on human populations. Viruses are one cause of infectious disease, along with bacteria (such as tuberculosis) and parasites (the cause of malaria, for instance); they differ from these in that they cannot survive on their own. Viruses require a living host to continue their life cycles.

In 2017, the U.S. Centers for Disease Control and Prevention (CDC) estimated that more than 60 percent of all known infectious diseases originated in animals.5 They include many of history’s most devastating epidemics, such as influenza, HIV, Ebola, SARS, MERS and SARS-CoV-2, the virus that causes COVID-19.

Our understanding of viruses has improved enormously since the U.S Army’s Reed Commission identified the yellow fever virus — the first human virus ever discovered — in 1901.3 Today, we can unlock their genetic codes, test for them and develop vaccines and drugs to combat them. But despite these advances, viruses remain perhaps the greatest challenge to human health.

■ WHAT IS A VIRUS?

Many of today’s epidemics are caused by emerging or “novel” viruses previously unknown in humans.

Often, they arise from the transmission of a virus between an animal and a human, a zoonotic or spillover event.4 When a significant genetic shift occurs in such a virus, the result can be a novel virus with high pandemic potential in humans, particularly if the new strain proves capable of sustained transmission.

A virus is essentially a bit of genetic code coated by a protein. RNA and DNA are molecules that carry the “instructions” or code of the genome; viruses can be classified by which of the two they carry. Smallpox and the adenoviruses, common causes of sore throat and diarrhea, are examples of DNA viruses. Influenza, SARS, HIV and the SARS-CoV-2 coronavirus that causes COVID-19 are RNA viruses.

One of the primary differences between an RNA virus and a DNA virus is its rate of mutation. All viruses mutate, but the rate at which they do so is important.

The more quickly a virus mutates, the more easily it can adapt to new environments and species, develop drug resistance and evade immunity.

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RNA viruses mutate more quickly than DNA viruses due to a number of factors, including the fact that most lack a “proofreading” mechanism found in DNA that helps them copy genetic code more exactly.

RNA viruses, therefore, generally are more prone to errors each time they replicate.6 Some researchers have estimated that RNA viruses can mutate up to a million times faster than their hosts, meaning that a person’s immune response simply can’t adapt quickly enough to keep pace with viral mutation.7 Another characteristic affecting mutation rates is the complexity of the virus genome. Smaller genomes mutate more quickly than larger ones, and RNA virus genomes are much smaller than their DNA counterparts.8 Rapid mutation in RNA viruses allows them to quickly find “beneficial” traits — from the virus’s perspective — such as how to jump from animal to human hosts, evade natural immunity and transmit themselves among humans more effectively.9 The influenza genome, for instance, continually “drifts” due to its rapid mutation and the continual evolution of new, closely related strains. This is a primary reason for the annual flu shot; each year’s vaccine is different, based on influenza viruses then in circulation around the world.

The coronavirus family, however, is an exception.

These are RNA viruses that do have a proofreading

SEVEN KNOWN TYPES OF CORONAVIRUSES CAN INFECT HUMANS. mechanism, as well as the largest genomes found among their type.10 For these reasons, they mutate more slowly than most RNA viruses — which is not to say they can’t. In the fall, several new variants began emerging, most notably in the United Kingdom, South Africa, and Brazil. New information about whether these variants spread more rapidly, are more deadly, or more resistant to vaccines is rapidly emerging at the time of this writing.11

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■ HOW VIRUSES SPREAD Some viruses spread in humans only through direct contact, through blood, saliva or other bodily fluids.

Ebola and HIV are the most well-known examples.

These viruses can cause pandemics, as HIV has demonstrated since the first cases were recognized in 1981. But viruses that spread through direct contact often are easier to control than those spread through indirect contact.

And many viruses can spread without the need for direct contact between people — through a cough or sneeze or even a mosquito bite. Many of the most dangerous viral diseases can spread in this way, including influenza, SARS, MERS, Zika and COVID-19.

Respiratory viruses such as influenza and coronaviruses that can be spread by respiratory droplets or small particles carried by air currents are much more likely to spread widely. And today, they can move around the world in a matter of days, borne by air travel and global trade.

Other factors make some viruses more likely to spread. Some can spread before individuals know they’re sick, a characteristic called pre-symptomatic spread, or without the carrier ever realizing they’re sick, in asymptomatic spread. Such viruses can spread faster because infected people will continue going to work, school, church or restaurants.

Today, we know that SARS-CoV-2, the COVID-19 virus, is one of these.

■ NOVEL CORONAVIRUSES Seven known types of coronaviruses can infect humans. Four are mild viruses often responsible for the “common cold,” but three are deadly.

Before COVID-19, the most notorious coronaviruscaused diseases were SARS, which infected about 8,000 people worldwide in 2003 and led to 774 deaths, and MERS, which has caused several outbreaks resulting in 2,494 cases and 858 deaths.

COVID-19 far eclipses these, currently spreading around the world, and responsible for nearly 1.8 million deaths by December, with this number only expected to grow. SARS and MERS aren’t highly contagious but have a case fatality rate ranging from 10 percent for SARS to 35 percent for MERS.12 SARS-CoV-2, the virus that causes COVID-19, is more contagious than either, though less deadly; Johns Hopkins’ Coronavirus Resource Center put the U.S. COVID-19 case fatality rate at 1.8 percent in December 2020.13

■ OUTBREAKS, EPIDEMICS AND PANDEMICS KEY DEFINITIONS Cluster: a set of cases closely associated in time and place.15 Outbreak: An occurrence of disease cases in excess of normal expectations.16 Epidemic: An outbreak with a broad geographical range, usually involving a region and/or several countries.

Pandemic: an epidemic that has spread to several continents.17 As these definitions indicate, infectious disease events typically are classified according to when and where they appear and how many people are affected. Many diseases first appear as a cluster of cases within a community, which then may become a localized outbreak. If not contained, the outbreak can expand further and become an epidemic involving a broader geographic region. If the disease appears on several continents, it can become a pandemic.

COVID-19 illustrates this progression. The disease broke into Western news with reports of a cluster of pneumonia-like cases in Wuhan, a city in central China, on December 31, 2019. It became an outbreak in Hubei province, spread to other parts of China and then to Taiwan, Vietnam and several neighboring countries. On January 30, 2020, WHO declared a “public health emergency of international concern” in accordance with International Health Regulations.18 COVID-19 cases then appeared in Europe, North America, South America, Asia, Australia and Africa; WHO declared it a pandemic on March 11.19

PANDEMIC POTENTIAL Public health authorities recognize the growing threat represented by emerging infectious diseases with pandemic potential — those with characteristics that favor pandemics (Exhibit 1.1).

In 2018, for instance, the Johns Hopkins Health Security Center conducted a risk assessment that compared various viral classes, bacteria, fungi and other microbes.20 It concluded that RNA viruses spread through respiration pose the highest risk for a global catastrophic event, and the most dangerous of all are novel influenza and coronaviruses.

Exhibit 1.1

Viruses with Significant Pandemic Potential

■ Chapter 1 / Viruses and Pandemics

Coronaviruses can be transmitted through indirect contact, and some can be spread by individuals without symptoms. As noted previously, coronaviruses have a proofreading mechanism and a relatively large genome that prevent them from mutating as quickly or dramatically as other RNA viruses.14 Even so, they were identified as posing a high risk even before COVID-19.

Novel Influenza Viruses These highly contagious interspecies RNA viruses have caused most pandemics.

Novel Coronaviruses These viruses generally are either highly contagious and cause milder infections or less contagious and cause severe infections, but some can be both, as seen with SARS-CoV-2, the virus that causes COVID-19.

Flaviviruses, Paramyxoviruses and Filoviruses Flaviviruses such as the West Nile and Zika viruses generally are spread by mosquitos and flies. Paramyxoviruses such as the mumps and measles viruses are highly contagious, spread through saliva or respiratory droplets, and can be deadly.

Filoviruses such as the Ebola virus are spread by contact with bodily fluids and are often fatal.

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■ THE COVID-19 PANDEMIC The novel SARS-CoV-2 virus first was described as atypical pneumonia when it emerged in Wuhan, China, in December 2019.21 By December 26, 2020, more than 80 million confirmed COVID-19 cases and nearly 1.8 million deaths had been reported globally, with about 19 million cases and more than 330,000 deaths in the U.S.22 Initial research indicated that SARS-CoV-2 emerged in the human population from a spillover event at the Huanan Seafood Wholesale Market in Wuhan in China’s Hubei Province. The initial cluster of patients all were linked to this market.23

■ COVID-19 SYMPTOMS AND COMPLICATIONS

On January 23, 2020, the Chinese government quarantined Wuhan as well as the cities of Huanggang and Ezhou, halting all air, rail and road transport. A wider quarantine of all of Hubei province, home to more than 57 million people, began on February 13. The quarantine caught the attention of the international community because it appeared so extreme. By then, however, the virus had moved beyond China.

Generally, COVID-19 symptoms can range from mild flu-like symptoms such as a fever, cough and nausea to severe complications such as respiratory or heart failure.33 One of COVID-19’s most notable characteristics is its tendency to produce its most severe symptoms in older adults and those with compromised immune systems or other chronic conditions such as obesity or diabetes.34 The young generally experience milder effects.35

The first case of COVID-19 outside China was confirmed in Thailand on January 13, 2020. Japan followed on January 15.24 The U.S. reported its first case on January 21, 2020, a man in Washington State who tested positive after recent travel to Wuhan.25 Within a week, more cases emerged around the U.S. — and the virus began spreading in earnest.

From July 7 to July 22, daily new case counts in Texas hovered near 10,000.26

One theory as to why this should be concerns the ACE2 receptor protein, the mechanism by which SARS-CoV-2 enters the human cell. A September 2020 study found higher expression of ACE2 in early infancy and old age.36 Lower ACE2 expression in older children could explain why they rarely experience severe COVID-19 symptoms.

In August, U.S. cases began to decline steeply in response to tighter restrictions and increased social distancing. Children around the nation began returning to schools, although most places gave parents the option to send their children to inperson classes or to continue with virtual learning.

Some U.S. college campuses resumed in-person teaching in mid-August.

By mid-September, global COVID-19 trends began rising again. The U.S. saw an increase in cases that continued through the end of the year.27 Case counts also rose in Italy, Spain, France, Germany and the United Kingdom. Most European nations responded by tightening public health restrictions, though they loosened them again in late fall.28 Beginning in late October, the number of daily confirmed cases and daily fatalities increased markedly in Texas. The state hit its single-day high of 27,000 new reported cases on December 29, 2020.29

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Globally, as of late December, about 400,000 new cases and 7,300 deaths were being reported each day worldwide.30 The Americas and Europe were the largest sources of new cases. Many U.S. states and European nations maintained or tightened lockdown measures as colder weather and the holiday season pushed people indoors.31 In December, concern over a new variant emerging in the United Kingdom again increased implementation of travel restrictions and other limitations.32

Some scholars also have noted that children with COVID-19 tend to have more respiratory symptoms than adults, meaning they might play a larger role in transmission through coughing or sneezing.37 A CDC study released in July 2020 found that household transmission is highest when the person initially infected is aged from 10 to 19, with a lower risk for younger children.38 A study released in December, however, found that both children and adults are equally likely to become infected with SARS-CoV-2 by a family member.39 Transmission from children to adults occurred in about 20 percent of the cases in which the child was the first case in the household.

At this writing, both the role of children in SARSCoV-2 transmission and reason for its disparate effect on children and adults are far from settled.

While most children experience mild or no symptoms, in May 2020 researchers identified some children previously infected with SARSCoV-2 who were showing signs suggestive of Kawasaki disease or toxic shock syndrome.40 The CDC has dubbed this condition Multisystem Inflammatory Syndrome in Children, or MIS-C. While rare, MIS-C raises questions as to whether children are as safe from COVID-19 as originally thought. Some experts believe the syndrome may be linked to a post-infection cytokine storm, a severe and potentially lifethreatening immune reaction.41 As of December 4, 2020, 1,288 children in the U.S. had experienced MIS-C symptoms, and 23 have died. Cases have been reported in 47 states and Washington, D.C. Most of these cases affected children between the ages of one and 14, with an average age of eight.42

Among adults, COVID-19 can produce an array of other potentially serious complications, including but not limited to: Thrombosis or abnormal blood clotting. The threat of extensive clotting wasn’t discovered until several weeks into the U.S. outbreak.43 This symptom can occur in people experiencing little discomfort who might not seek medical attention. In addition, some evidence suggests that abnormal clotting associated with COVID-19 has led to large-vessel strokes in patients younger than 50.44 “Happy hypoxia.” Some COVID-19 patients have extremely low blood-oxygen levels yet function normally and experience no discomfort.45 The contrast seems to defy basic biology and some speculate that the lack of breathing difficulties might be related to blood clotting in the lungs.46 Doctors who have treated such patients note that while they may be comfortable, they still should be monitored in the hospital because hypoxia can turn rapidly into pneumonia or simply cause death.47 Serious neurological complications. Initial research suggests that COVID-19 can cause neurological conditions that can lead to disability or even death.48 Among these are encephalitis, or swelling

Researchers also suggest that SAR-CoV-2 infection can lead to myalgic encephalomyelitis, better known as chronic fatigue syndrome.51 This condition is characterized by overwhelming fatigue that doesn’t improve with rest. It can make it difficult for people to hold jobs or perform normal daily tasks, and occasionally can cause its victims to become bedbound.52 Some SARS-CoV-2-infected individuals have experienced extreme fatigue long after the infection passes.53

■ Chapter 1 / Viruses and Pandemics

MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN

of the brain; Guillain-Barre Syndrome, which causes the immune system to attack the nerves; and acute cerebrovascular disease.49 Some patients also have shown evidence of ischemic stroke caused by blood clotting in the brain. Similar neurological impacts have been observed in SARS and MERS patients.50

■ FIGHTING THE PANDEMIC Pandemic countermeasures can include a variety of community strategies.

Each of us, of course, has an individual responsibility to protect ourselves and those around us, and public health authorities always encourage frequent handwashing, cough and sneeze etiquette, social distancing and the wearing of face coverings. All of these measures help if everyone does their part.

But community interventions go beyond the individual. COVID-19 is the first event in modern U.S. history to test them at a nationwide scale.

Among these efforts is lockdown, including shelterin-place orders, bans on large gatherings and widespread closures of schools, universities and nonessential businesses. These can help to slow the spread of the virus by limiting the number of contacts each sick individual has, but have serious economic and social consequences.

Widespread testing and tracking help public health and emergency officials follow the virus’ spread and trace infected persons’ contacts. In Texas, local public health departments and the Texas Department of State Health Services generally assume responsibility for communicable disease monitoring and collaborate with the healthcare system and private entities for testing and development of disease prevention activities.

And finally, new medicines can prevent infection or reduce its severity. They’re used to prevent disease; head off infection in those who have been exposed; and treat those who have developed symptoms.

■ PAGE 5

T H E LON G Y EAR

TREATMENT At the end of 2020 there were no definitive treatment options for COVID-19, but several were in development. The most prominent include antibodybased therapies, the antiviral drug remdesivir and the corticosteroid drug dexamethasone.

Safe and effective vaccines are one of modern civilization’s greatest success stories and one of the greatest defenses we have against viral infections.

Vaccines can activate the body’s immune system against a specific virus before the person is exposed.

Another treatment initially considered was chloroquine or the related drug hydroxychloroquine.

The U.S. Food and Drug Administration (FDA) initially gave these drugs Emergency Use Authorization but revoked it on June 15, 2020, calling it “unlikely to be effective in treating COVID-19” and noting that “the known and potential benefits… no longer outweigh the known and potential risks of the authorized use.”54 Five days later, the National Institutes of Health ended a clinical trial of hydroxychloroquine.55

Polio is perhaps the best-known illustration of the impact of vaccines. In the 1950s, the U.S. saw more than 15,000 cases of paralysis due to polio every year. An inactivated polio vaccine was introduced in 1955 and an oral vaccine in 1963. By the end of the 1960s, the nation’s number of polio cases had fallen to fewer than 100. Since 1979, no polio cases have been reported as originating in the U.S.63

The first treatment to be developed and approved by the FDA for emergency use was an antibody-based therapy called convalescent plasma, blood plasma taken from recovered patients and then given to infected patients, essentially as a donation of antibodies. On March 24, 2020, the FDA approved its use in seriously ill patients or those with immediate, life-threatening infections.56 In November, the FDA approved emergency uses of other manufactured antibody treatments called monoclonal antibodies from Regeneron and Eli Lilly which have shown further promise.57 A second promising treatment, remdesivir, received Emergency Use Authorization in May 2020 and formal FDA approval on October 22.58 Studies had shown that the drug has some efficacy against other coronaviruses such as SARS and MERS.59 While a WHO trial concluded that remdesivir had little to no impact on survival rates among those infected with SARS-CoV-2, a study released in November found it shortened recovery times in adults who were hospitalized with COVID-19 and had signs of lower respiratory tract infection.60 Another development in COVID-19 treatment is dexamethasone, a corticosteroid drug with antiinflammatory properties.61 A controlled trial of the drug in the United Kingdom found that it reduced patient mortality compared to a placebo group receiving mechanical ventilation or oxygen alone.62 This provides some basis for optimism that dexamethasone may improve outcomes for severe COVID-19 cases.

■ PAGE 6

VACCINES

On the other hand, such effectiveness can be undermined by the modern emergence of internetfueled “anti-vax” movements. The measles vaccine, for instance, helped cut global deaths from this highly infectious disease by 73 percent in the past 20 years, but measles vaccination rates are now declining.64 The creation of a vaccine represents a huge task; developing and licensing a new one can require more than 10 years and billions of dollars.

Nevertheless, considerable progress has been made.

The first COVID-19 vaccine received Emergency Use Authorization in the U.S. on December 11, 2020.65 This vaccine, developed by Pfizer, was found to be 95 percent effective in clinical trials involving 43,000 people.66 While a significant accomplishment, this report is being published before we know whether the vaccine prevents the transmission of the virus or how long the immunity it produces will last.

U.S. hospitals began receiving their first doses of the Pfizer vaccine in mid-December. The CDC provided guidelines for its distribution, though the specifics are left to the individual states. By the end of December, the U.S. had ordered 200 million doses of the Pfizer vaccine, which requires two doses per person, to be delivered by July 31, 2021.67

VACCINES ARE ONE OF MODERN CIVILIZATION'S GREATEST SUCCESS STORIES.

■ Chapter 1 / Viruses and Pandemics

A health care worker receives a COVID-19 vaccine at the Texas A&M College of Dentistry, January 29, 2021.

(Texas A&M Health Science Center)

Another vaccine, developed by Moderna and employing the same technology as Pfizer’s, received Emergency Use Authorization on December 18.68 In mid-December, the U.S. announced it would purchase a total of 200 million doses of the Moderna vaccine, which also requires two doses, to be delivered through the end of June 2021.69 A massive logistics and public relations mission to vaccinate the country was underway.

With several other promising vaccine candidates being distributed in other countries and likely heading towards FDA authorization in the U.S., the world closed 2020 embarking upon a vaccination campaign of extraordinary aggressiveness and scope. Only time will tell how quickly the vaccines can help stem the spread of the pandemic and reduce the devastating burden COVID-19 has caused.

ONLY TIME WILL TELL HOW QUICKLY VACCINES CAN HELP STEM THE SPREAD OF COVID-19.

■ BECOMING ENDEMIC? Diseases that once caused pandemics or epidemics can become endemic — meaning the disease persists within a population but at a relatively lower frequency than an epidemic or pandemic.70 An endemic disease has not disappeared. HIV, for instance, has slowly become an endemic disease, due to the development of effective antiviral drugs and the widespread adoption of safe-sex practices.

Its deadliness has been reduced to the extent that it generally can be managed without major disruptions to society. Of course, HIV and other endemic diseases still can have significant long-term health, economic and societal effects.

Whether COVID-19 disappears or becomes endemic will depend on several factors, including its transmissibility, the share of the population that remains susceptible and the length of immunity held by individuals. Some speculate it will become endemic rather than disappear.71 At this writing, not enough data exist for a prediction.

■ PAGE 7

T H E LON G Y EAR

A server mixes drinks after bars reopen during the COVID-19 pandemic.

(Bryan-College Station Eagle)

■ PAGE 8

CHAPTE

CHAPTER 2

TIMELINE OF C O V I D -1 9 I N T E XA S The world has spent a year fighting COVID-19, yet this long, complex and often tragic story is far from over.

The following timeline provides key highlights of the story as it has unfolded through December 31, 2020, focusing on Texas but including important events that tie our state to the larger picture. COVID-19 is a worldwide event, and events elsewhere inevitably shaped Texas’ experience.

■ MAJOR STATE EVENTS February 7 The first American citizens repatriated from Wuhan, China are quarantined at Joint Base San Antonio-Lackland.

March 11 Indications of community spread.

March 2–24 Major Texas cities issue shelter-athome orders.

March 25 State unemployment claims at 30,000 per day.

March 13 Governor declares statewide emergency.

April 17–June 24 Governor begins reopening Texas, announcing reopening phases 1, 2, and 3.

March 19 DSHS declares public health disaster.

June 25– Bars closed inside, masks ordered, Mid-September other steps taken.

March 19–30 Governor issues major orders for business and school closures, visitation restrictions on nursing homes, social distancing, travel, and more.

March 22 Governor appoints Supply Chain Strike Force.

September 17– Governor eases restrictions on Mid-December various long-term care facilities, capacities allowed for certain businesses, elective surgeries, and more.

December 14–15 Vaccine distribution starts at four medical sites in Texas.

December 31 The U.S. COVID-19 case count exceeds 19.8 million; total deaths reach almost 344,500. Texas has reported almost 1.6 million confirmed COVID-19 cases and is approaching 30,000 deaths.

■ PAGE 9

T H E LON G Y EAR

MAJOR STATE EVENTS AND KEY MEASURES THROUGH DECEMBER 31, 2020 The graph shows COVID-19’s progression in Texas during the year using the critical metrics of hospitalizations, testing positivity rate and reported cases, along with key dates.

Hospitalizations

New Confirmed Cases (7-day Mov. Avg.)

22,000

Molecular Test Positivity Rate

25%

(by specimen collection date)

20,000 Dec. 14-15 Vaccine distribution starts at four medical sites in Texas

March 13 Governor declares statewide emergency

16,000

March 19 DSHS declares public health disaster

14,000 12,000

15%

July 4 Independence Day

10,000

10%

8,000 6,000 4,000 2,000 0

February

March

April Closing Texas

Sept. 7 Labor Day

May 25 Memorial Day

Feb. 7 First repatriations, Lackland AFB

Early Days

May

June

Reopening Texas Begins

July

August

Reopening Paused Restrictions Applied

September

Nov. 26 Thanksgiving Day Nov. 11 Veterans Day

October

November

December

Reopening Texas Begins Again

Notes: • Disclaimer: The Texas Department of State Health Services (DSHS) COVID-19 dashboard, the source of the data graphed here, says that "all data are provisional and subject to change." Data definitions and data used here are downloaded from the DSHS website 1/12/21.

• Hospitalizations: DSHS defines this measure as "the total number of patients in Texas hospitals who have tested positive for COVID-19."

• Molecular Test Positivity Rate: The DSHS formula "divides the number of new cases reported in the past seven days by the new molecular test results received in the past seven days."

• New Confirmed Cases: DSHS indicates that new confirmed cases are those "reported for the first time on the DSHS dashboard that day." The 7-day moving average, also presented on the DSHS dashboard, is calculated here using Microsoft Excel.

Sources: Texas Department of State Health Services (DSHS),"Texas COVID-19 DATA — Accessible Dashboard Data" (Last updated: 1/12/2021) (dataset); DSHS,"Texas COVIC-19 - Data Definitions"; and DSHS, "DSHS COVID-19 Dashboard."

■ PAGE 10

20%

5%

0

Positivity Rate

New Cases and Hospitalizations

18,000

DECEMBER 2019

FEBRUARY

31 The World Health Organization (WHO) receives the first report of a “viral pneumonia” in Wuhan, China.1

JANUARY 2020

Lackland one of four COVID-19 quarantine sites for U.S. citizens returning home.7 2 The Philippines reports the first COVID-19

death outside China.8

11 WHO announces a novel coronavirus is

causing the outbreak.

1 HHS names Joint Base San Antonio-

2

21 The U.S. Centers for Disease Control and

Prevention (CDC) confirms the first case in the U.S. in Washington State, a recent traveler to Wuhan.3 22 The U.S. Health and Human Services

(HHS) Secretary declares a Public Health Emergency.4 30 WHO declares the novel coronavirus a

Public Health Emergency of International Concern.5 CDC confirms the first person-to-person spread in the U.S., affecting a woman from Chicago.6

3 The Texas Department of State Health

Services (DSHS) activates the State Medical Operations Center.9 4 Reported cases in China pass 20,000, with

nearly 500 dead.10 The U.S. Food & Drug Administration (FDA) authorizes emergency use of a CDC diagnostic test for the virus at qualified public health laboratories.11

■ Chapter 2 / Timeline of COVID-19 in Texas

■ EARLY DAYS: DECEMBER 31, 2019 — MARCH 18, 2020

7 The first American citizens repatriated

from Wuhan, China are quarantined at Joint Base San Antonio-Lackland.

11 WHO names the disease “COVID-19,”

short for “coronavirus disease 2019.”12 12 WHO says face masks are not

recommended for asymptomatic members of the general public; the virus was not yet known to be spreading widely from asymptomatic people.13 14 France reports the first coronavirus death

in Europe.14 23 Italy becomes an epicenter of the virus; the

Lombardy region is locked down.15 24 Texas confirms its first six positive

cases, all at the Lackland quarantine site.16 25 San Francisco declares a state of

emergency, the first U.S. city to do so.17 29 The U.S. reports its first confirmed death Evacuees from the Diamond Princess cruise ship, contaminated with coronavirus, prepare to leave the hotel on Lackland Air Force Base where they were quarantined for weeks. (Tyler and Rachel Torres, www.thetorrestravels.com)

from COVID-19 in Seattle. California officials later confirm earlier COVID-19 deaths on February 6 and 17.18 Washington State becomes the first U.S. state to declare a state of emergency due to the coronavirus.19 The FDA authorizes the emergency use of diagnostic tests other than the CDC test by private laboratories.20

■ PAGE 11

T H E LON G Y EAR

■ CLOSING TEXAS: MARCH 19–30, 2020

MARCH 2 San Antonio Mayor Nirenberg declares

the first public health emergency in a Texas city, after a person released from the Lackland quarantine site tests positive.21 3-9 States of emergency are declared in

California, New York and Florida.22 4 The first COVID-19 case in Texas outside

the Lackland quarantine site is reported in Fort Bend County.23 6 The city of Austin cancels the annual South

by Southwest festivals.24 11 The first potential case of community

spread in Texas is announced in Montgomery County.25 The Houston Livestock Show & Rodeo is cancelled. The City of Houston issues an emergency health declaration.26 WHO declares COVID-19 a pandemic.27 12 The U.S. stock market sees its worst day

since 1987.

28

13 President Trump declares a State of

National Emergency.29 Gov. Abbott declares a Texas State of Disaster and activates the Texas Division of Emergency Management (TDEM).30 The first Texas mobile testing center opens in San Antonio for medical professionals and first responders.31 15 New York City closes its school system, the

nation’s largest.32 16 The DOW records its worst drop in

history.33 President Trump announces federal guidelines for social distancing for 15 days.34 17 The first Texas COVID-19 death is

confirmed in Matagorda County.35 COVID-19 cases have been reported in all 50 states.36

■ PAGE 12

19 Texas Health Commissioner Hellerstedt

declares a public health disaster in Texas.37 Gov. Abbott issues the first statewide social distancing order limiting gatherings; requiring closures of many establishments; prohibiting most visits to nursing homes and long-term care facilities; and temporarily closing schools.38 California becomes the first state to issue a stay-at-home order.39 20-24 Gov. Abbott takes numerous actions to

respond to COVID-19 in Texas, postponing elections; expanding the nursing workforce; expanding hospital capacity; suspending elective surgeries; increasing the supply of personal protective equipment (PPE); and strengthening daily testing and hospital capacity reporting.40 22 Gov. Abbott announces the creation

of the Supply Chain Strike Force to focus on hospital preparedness, asset procurement and child care for essential workers.41 23-24 Austin, Dallas, El Paso, Fort Worth,

Houston and San Antonio issue shelterat-home orders.42 24 The Joint Base San Antonio-Lackland

quarantine site closes.43 25 Gov. Abbott announces the White House

has approved a major federal disaster declaration for Texas.44 Texas unemployment claims reach 30,000 per day.45 26 The U.S. takes the global lead in confirmed

number of COVID-19 cases.46 Gov. Abbott requires airport screening and self-quarantine for travelers from New York, New Jersey, Connecticut and New Orleans.47

Aid, Relief, and Economic Security (CARES) Act, a $2 trillion coronavirus rescue/economic stimulus package.48 29 President Trump extends federal social

distancing guidelines through April 30.49 30 Gov. Abbott mandates a 14-day quarantine

for travelers coming to Texas by road from anywhere in Louisiana, California, Washington, Atlanta, Chicago, Detroit and Miami.50 FDA authorizes the emergency use of malaria drugs hydroxychloroquine and chloroquine to treat COVID-19.51 31 Gov. Abbott issues an executive order

requiring all Texans to minimize social gatherings and in-person contacts and closes schools through May 4.52

14 Travis County requires residents to wear

masks in public.60 The International Monetary Fund warns the global economy is heading toward the worst economic downturn since the Great Depression.61 16 The White House releases broad

guidelines for how people could return to work, places of worship, restaurants and other venues. The plan cites benchmarks in reduced COVID-19 cases or deaths for states and metropolitan areas to achieve before taking the next step toward reopening.62

■ REOPENING TEXAS: APRIL 17–JUNE 24, 2020

■ Chapter 2 / Timeline of COVID-19 in Texas

27 President Trump signs the Coronavirus

17 Gov. Abbott creates the Strike Force to

APRIL 2 The number of Texans filing for

unemployment has soared by 1,600 percent in two weeks.53 5 Gov. Abbott waives certain regulations to

expand the healthcare workforce, such as allowing licensure candidates to enter the workforce under an emergency license.54 8 Gov. Abbott announces a partnership

between the Texas Military Department and Prestige Ameritech, a north Texas PPE manufacturer, to expand mask production.55 9 Gov. Abbott and the Texas Health and

Human Services Commission (HHSC) announce an emergency rule to increase the supply of care providers in nursing facilities.56 Gov. Abbott waives regulations for telehealth to expand healthcare options.57 10 Gov. Abbott announces the creation of

the Frontline Child Care website to help essential workers find child care.58

Open Texas, and begins easing some hospital capacity constraints and social distancing guidelines. Schools will remain closed (remote learning only) for the rest of the 2019-20 academic year.63 20 Gov. Abbott and the Texas National Guard

announce expanded COVID-19 mobile testing sites.64 Bexar County requires residents to wear masks in public.65 22 Gov. Abbott temporarily waives national

certification requirements for advancedpractice registered nurses to increase nursing capacity.66 Harris County requires residents to wear masks in public.67 27 Gov. Abbott announces Phase 1 of

the plan to open Texas.68 The plan permits many commercial and retail establishments to reopen under 25 percent occupancy restrictions. Counties with five or fewer positive COVID-19 cases are allowed to increase occupancy limits up to 50 percent.69

11 Gov. Abbott eases regulations on

physicians in training to expand health care capacity.59

■ PAGE 13

T H E LON G Y EAR

MAY 1 FDA grants emergency-use authorization

to Gilead Sciences for the antiviral drug remdesivir as a treatment for COVID-19.70 5 Gov. Abbott issues an executive order

expanding the reopening to additional Texas businesses at 25 percent capacity and exempting essential services from capacity limits. The order affects cosmetology salons, hair salons, barber shops, nail salons, tanning salons, swimming pools, offices and gyms.

Counties with five or fewer COVID-19 cases are allowed to increase capacity limits up to 50 percent.71 Gov. Abbott announces the formation of Surge Response Teams to combat any COVID-19 flareups.72 9 From March 14 to May 9, nearly 2 million

Texans have filed for unemployment insurance benefits, triple the number of all claims filed in 2019.73 11 Gov. Abbott directs TDEM to test all

staff and residents in Texas nursing homes.74 12 Gov. Abbott and HHSC announce $1

billion in pandemic food benefits for Texas families.75 DSHS begins receiving remdesivir from HHS and distributing it to Texas hospitals.76 13 Gov. Abbott and TDEM announce that

seven community-based testing sites will continue through June 30.77 Gov. Abbott and the Texas National Guard initiate a “disinfection mission” for nursing facilities.78

15 The Trump Administration announces

Operation Warp Speed, a national program to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics and diagnostics. The goal is to have a safe and effective vaccine ready to administer to Americans by January 2021.79 Gov. Abbott and TDEM partner with local fire departments to increase testing in nursing homes.80 18 Gov. Abbott announces Phase 2 of

the plan to reopen Texas, allowing a number of previously closed services and activities to reopen at 25 percent capacity in the following weeks.81 20 Gov. Abbott directs state agencies to

reduce budgets by 5 percent due to a projected state budget shortfall.82 21 Gov. Abbott terminates air travel

restrictions as part of the state reopening plan.83 Gov. Abbott and CVS Health announce 44 new drive-through COVID-19 testing sites in Texas.84 26 Gov. Abbott announces the following

services and activities can reopen under Phase 2, most at 25 percent capacity: driver education programs (immediately); water parks (May 29); practices for recreational sports programs for adults (May 31); and games and similar competitions (June 15).85 27 The U.S. death toll from COVID-19

reaches 100,000.86 Gov. Abbott provides an update on the state’s response to a spike of cases in Amarillo. Surge teams serving nursing homes, meat packing plants and other facilities receive PPE, testing supplies, onsite staffing and assessment assistance.87 Gov. Abbott and HHSC announce a $3.6 million initiative to connect nursing facility residents and their families via tablets, webcams and headphones.88

■ PAGE 14

3 Gov. Abbott announces phase 3 of

the reopening. With few exceptions, businesses now are allowed to operate at up to 50 percent capacity.89 5 WHO now says people should wear a

face mask, changing its guidance due to better understanding of asymptomatic transmission and community spread of the virus.90 8 Gov. Abbott and TDEM announce

expanded testing in underserved communities disproportionately affected

by COVID-19.91 State and local partners have completed more than 188,000 tests for Texas nursinghome residents and staff.92 10 U.S. COVID-19 cases hit 20 million as

new infections continue to rise in 20 states.93 12 Texas allowable restaurant capacity

increases to 75 percent.94 15 FDA rescinds its authorization of the

emergency use of hydroxychloroquine and chloroquine.95 23 Gov. Abbott issues a proclamation

expanding local authority over outdoor gatherings in excess of 100 people.96

■ REOPENING PAUSED: JUNE 25–SEPTEMBER 16, 2020 25 Gov. Abbott announces a temporary

pause in additional reopening phases to respond to the rise in Texas cases and hospitalizations.100 Gov. Abbott issues an executive order to increase hospital capacity in the state, suspending elective surgeries in Bexar, Dallas, Harris and Travis counties.101 Texas cases have more than doubled since May 25, to 75,000.102 The U.S. sees its highest daily case increase to date. More than half of states report a record number of new daily cases.103 26 Gov. Abbott issues an executive order

■ Chapter 2 / Timeline of COVID-19 in Texas

JUNE

limiting capacity to 50 percent of total listed occupancy for most business establishments; bars close for in-person service. Outdoor gatherings are limited to 100 people unless approved by a local official.104 30 Gov. Abbott and HHSC announce a $9

million initiative for a nursing facility COVID-19 control project.105 Cameron, Hidalgo, Nueces and Webb counties are added to the elective surgery suspension.106

Gov. Abbott directs HHSC to enact emergency rules to increase safety at childcare centers.97 24 The U.S. reports its highest single-day total

of new cases.98 Twenty-six U.S. states are seeing a sharp rise in cases.99

■ PAGE 15

T H E LON G Y EAR

JULY 2 Gov. Abbott issues an executive order

mandating masks when in public for everyone above 10 years old, with certain exceptions. The order authorizes fines for noncompliance.107 Gov. Abbott limits gatherings to ten or fewer.108 4 Texas reports the state’s largest daily rise

in new confirmed cases to date.

109

DSHS has distributed 1,425 cases of remdesivir to Texas hospitals.110 6 The Texas Attorney General rules that

HHSC should release COVID-19 nursing home case data after redacting personally identifying information.111

18 FDA issues the first emergency-use

authorization for pool testing for COVID-19, which allows more people to be tested using fewer resources.118 23 Texas sees 278 deaths from COVID-19 in

a single day, the highest toll to date.119 27 The first Phase III U.S. trials of two

COVID-19 vaccines, developed by Pfizer and Moderna, begin.120 Gov. Abbott extends the early voting period for the November 3 election and waives grade promotion requirements for 2020-21 STAAR testing.121 HHSC releases COVID-19 nursing home case data.122

7-31 Gov. Abbott engages in a variety of efforts

to address COVID-19 hot spots, including additional testing; additional federal resources to support surge response; expanded hospital capacity and alternate care sites; and the creation of Joint Task Force Texas, a partnership between the Texas National Guard and active-duty and reserve personnel to support hospitals.112 9 Six states including Texas set single-day

case records. Nearly one in 10 new Texas cases are in the Texas-Mexico border region.113 More than 100 Texas counties are added to the elective surgery suspension.114 10 Gov. Abbott announces a partnership with

Omnicare/CVS Health to provide on-site, same-day testing and results for residents and staff in assisted living facilities and nursing homes, with the goal of processing 100,000 tests in the first month.115 17 The Texas Education Agency (TEA)

announces public school reopening guidelines for the 2020-21 school year.

School boards are given up to four weeks of back-to-school transition, during which they can offer only remote learning; afterward, they can extend the transition period for up to another four weeks with a vote of the school board and receipt of a TEA waiver.116 Gov. Abbott announces CARES Act funding for TEA to purchase devices and equipment to facilitate remote learning for students who lack connectivity.117

■ PAGE 16

Nurses look over the X-rays of coronavirus patients in the COVID-19 unit at the DHR Health Center in Edinburg.

(Miguel Gutierrez Jr., The Texas Tribune)

6 HHSC announces limited visitation for

nursing homes and other long-term care facilities.123 Gov. Abbott, the Houston Astros and TDEM announce a free COVID-19 testing site in Houston capable of processing 2,000 tests per day.124 7 Gov. Abbott announces additional federally

funded testing sites in Harris County.125 13 Baylor College of Medicine announces

a licensing agreement with India-based Biological E. Limited for a coronavirus vaccine under development.126 15 Since mid-March, 3.2 million+ Texans have

filed for unemployment relief.127 17 Texas exceeds 10,000 COVID-19

deaths.128 20 HHSC announces it will regularly post the

names and locations of Texas child-care providers reporting COVID-19 cases.129

■ REOPENING RESUMES: SEPTEMBER 17 — DECEMBER 31 SEPTEMBER 17 Gov. Abbott issues executive orders

for expanded reopening in the state, allowing increased capacity for Texas businesses and visitation at eligible nursing facilities, hospice centers and assisted-living facilities under HHSC guidance.135 25 Gov. Abbott announces $171 million in

CARES Act funding for rental assistance and eviction diversion.136 29 A federal judge orders the Texas prison

■ Chapter 2 / Timeline of COVID-19 in Texas

AUGUST

system to provide greater protective measures such as hand sanitizer, unrestricted access to soap and water and face masks for staff and inmates.137

The Texas Education Commissioner announces that TEA and DSHS will begin regularly posting information on COVID-19 cases among students and staff in public schools.130 Gov. Abbott announces an initiative between TEA and local education agencies, funded by CARES Act money matched by Texas school districts, to procure more than 1 million devices and WiFi hotspots to ensure students can participate in distance learning.131 23 FDA authorizes the emergency use of

convalescent plasma treatment for hospitalized COVID-19 patients.132 24 New COVID-19 cases begin falling in half of

U.S. states, including Texas.133

Visitors are once again allowed in all Texas longterm care facilities starting on September 24, 2020. (Allie Goulding, The Texas Tribune)

26 The Texas Alcoholic Beverage Commission

allows bars to count sales from prepackaged food and food trucks as revenue, allowing more to be classified as restaurants and reopen under the 50 percent capacity rule.134

■ PAGE 17

T H E LON G Y EAR

OCTOBER

NOVEMBER

2 Gov. Abbott announces $3.5 million in

federal funding to purchase plexiglass barriers and tents for nursing facilities to facilitate safe visitation.138 7 Gov. Abbott issues an executive

order to open bars in qualifying counties at 50 percent capacity and to increase capacity in other business establishments to 75 percent.139 Gov. Abbott encourages health care professionals to enroll in the DSHS Immunization Program to be eligible to provide COVID-19 vaccines once available.140 9 Gov. Abbott and HHSC announce an

additional $20 million in federal funding for disaster crisis counseling services for Texans affected by COVID-19.141 12-25 TDEM and DSHS increase state resources

to support COVID-19 response in El Paso, Amarillo and Lubbock and to significantly increase hospital capacity in El Paso.142 14 TEA and TDEM announce the creation of

a COVID-19 Rapid Testing Pilot Program for Texas school systems.143 22 Remdesivir becomes the first fully FDA-

approved treatment for COVID-19.144 30 El Paso County issues a stay-at-home

order and shuts down nonessential businesses for two weeks in response to growing COVID-19 hospitalizations. (An appeals court subsequently strikes down significant parts of these measures.)145

6 Gov. Abbott announces a surge of Defense

Department medical resources to El Paso.146 9 FDA grants emergency-use authorization

to Eli Lilly for a COVID-19 antibody treatment.147 The federal government begins sending weekly shipments for DSHS to allocate across Texas.148 Texas exceeds 1 million COVID-19 cases, the first state to do so.149 10 U.S. COVID-19 hospitalizations reach a

record high of nearly 62,000; new daily cases reach a record high of 139,000.150 CDC updates its mask findings, now saying that cloth masks control the spread of coronavirus by protecting wearers as well as those around the wearer.151 15 Clinical results show both the Pfizer and

Moderna COVID-19 vaccines are highly effective.152 16 The vaccine under development by

Biological E. Limited and the Baylor College of Medicine begins clinical trials in India.

Results are expected in February 2021.153 22 FDA grants emergency-use authorization

to Regeneron Pharmaceuticals for another COVID-19 antibody treatment.154 23 Gov. Abbott and DSHS announce a

state COVID-19 vaccine distribution plan. The plan prioritizes the vaccination of healthcare and frontline workers and vulnerable populations.155

Residents wait in line at a COVID-19 testing site at the University of Texas at El Paso.

(Joel Angel Juarez, The Texas Tribune)

■ PAGE 18

11 FDA issues the first emergency-use

authorization for the Pfizer COVID-19 vaccine.156 14 The first Pfizer vaccine doses are

administered in Texas.157 18 FDA issues emergency-use authorization

for the Moderna COVID-19 vaccine.158 22 Gov. Abbott receives the COVID-19 vaccine

in public, saying, “I will never ask any Texan to do something that I’m not willing to do myself.” Polls consistently show a large number of Texans remain hesitant to receive the vaccine.159

28 Texas has been allocated about 1.2 million

doses through the first three weeks of vaccine distribution.160 The Pharmacy Partnership for Long-Term Care Program, a federal program to vaccinate residents and staff of long-term care facilities, begins in Texas.161 29 Texas marks its single highest day of new

reported COVID-19 cases, at 27,000.162 31 The U.S. COVID-19 case count exceeds

19.8 million; total deaths reach almost 344,500. Texas has reported almost 1.6 million confirmed COVID-19 cases and is approaching 30,000 deaths.163

■ Chapter 2 / Timeline of COVID-19 in Texas

DECEMBER

A COVID-19 vaccine being given at the Texas A&M College of Dentistry, January 29, 2021.

(Texas A&M Health Science Center)

■ PAGE 19

T H E LON G Y EAR

Gov. Greg Abbott provides an update on the status of PPE distribution from a state warehouse, April 6, 2020.

(Texas Division of Emergency Management)

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CHAPTER 3 CHAPTER 3

EMERGENCY MANAGEMENT In terms of the sheer number of lives it has touched, COVID-19 is the largest public health disaster in Texas history, and state officials were quick to officially designate it as such.

Texas law explicitly charges the governor with meeting “dangers to the state and people presented by disasters.”1 The governor holds sole authority to declare a state disaster; Governor Abbott declared one due to COVID-19 on March 13, 2020.2 State law defines a public health disaster as occurring when the governor has declared a state of disaster and the commissioner of the Department of State Health Services (DSHS) determines the existence of an “immediate threat from a communicable disease.” A public health disaster declaration may continue for not more than 30 days, and the DSHS commissioner may extend the declaration one time for an additional 30 days.5 The governor may terminate a declaration of a public health disaster at any time.6 DSHS Commissioner Hellerstedt declared a public health disaster for the entire state on March 19, 2020.7

Texas’ emergency management structure functions in much the same way for a public health disaster as it would for a major hurricane or wildfire. The governor’s disaster declaration activates this structure according to the Texas Disaster Act of 1975, which establishes the governor as the “commander in chief of state agencies, boards, and commissions having emergency responsibilities” during a declared disaster and the recovery period that follows.8 Among other powers, the act authorizes the governor to issue executive orders, proclamations and regulations that carry the full force and effect of state law.9

WHAT’S A DISASTER? Texas law defines disaster as “the occurrence or imminent threat of widespread or severe damage, injury, or loss of life or property resulting from any natural or man-made cause, including fire, flood, earthquake, wind, storm, wave action, oil spill or other water contamination, volcanic activity, epidemic, air contamination, blight, drought, infestation, explosion, riot, hostile military or paramilitary action, extreme heat, cybersecurity event, other public calamity requiring emergency action, or energy emergency.”3

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T H E LON G Y EAR

The state’s emergency management system fits within and aligns with the National Preparedness System and its National Response Framework, which provides a blueprint for the nation’s response to all types of disasters.10 This framework and Texas’ emergency management structure both are based on the premise that every disaster is local, the community being the first line of defense in any emergency. Local entities can request assistance from the state and federal governments when their resources become exhausted.

■ LOCAL EMERGENCY MANAGEMENT In Texas, the presiding officer of an incorporated city or a county, usually a county judge or mayor, serves as the emergency management director in his or her jurisdiction.11 Emergency management directors serve as the governor’s designated agents to carry out the requirements of the state’s emergency management act during emergencies. They can declare local states of disaster and order evacuations within their jurisdictions.12 Under state law, each county also must have an emergency management program or participate in a local or interjurisdictional program that serves the entire county or a larger area.13 These programs must prepare an emergency management plan that provides for disaster mitigation, preparedness, response and recovery.14

■ LOCAL PUBLIC HEALTH Public health in Texas is administered through a complex and largely decentralized public health system. DSHS is the state’s public health agency, but the vast majority of Texas’ direct public health services are delivered by local entities in the state’s urban areas, with DSHS providing financial support in the form of federal grant funding, guidance and assistance as needed.

These local entities include city and county health departments and health units as well as public health districts, which serve two or more city or county jurisdictions.15 Local health departments and public health districts offer a broad range of public health services (Exhibit 3.1); local health units often have an environmental focus such as mosquito control.

Public health entities vary considerably in size and scope, offering a range of services based on their funding, expertise and community needs. While they often receive funding and guidance from DSHS and must comply with grant requirements, they are largely free from direct state control.

Local health entities serve only a small portion of the state’s geographical area but most of its population (Exhibit 3.2). Eight DSHS public health regions act as primary providers for the remainder of the state, providing services in 194 of the state’s 254 counties, most of them rural.16 Exhibit 3.1

Services of Local Health Departments Services typically offered by local health departments include: • immunization • communicable disease prevention and treatment (such as HIV/sexually transmitted diseases) • tuberculosis treatment and prevention • zoonotic (animal-related) disease surveillance and treatment (such as rabies) • chronic disease prevention (such as diabetes) • maternal and child healthcare • public health emergency preparedness • disease surveillance and tracking The Texas Emergency Medical Task Force mobilizes a field hospital in the parking lot of University Medical Center in El Paso to relieve pressure on the overburdened healthcare system, November 2, 2020. (Southwest Texas Regional Advisory Council)

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• food safety and sanitation • environmental health services (water, sewage, air quality) • health and public health education and promotion Source: Texas Department of State Health Services

State and Local Public Health Coverage17

Source: Texas Department of State Health Services, Feb 2019

■ Chapter 3 / Emergency Management

Exhibit 3.2

■ HEALTH AUTHORITIES State law also requires local jurisdictions to have a health authority, a physician who serves as an officer of the state in administering certain state and local laws related to public health.18 During a communicable disease outbreak, they can impose control measures (Exhibit 3.3) such as quarantine and disinfection to curtail its spread.

A health authority can be appointed in a variety of ways. The governing body of a city, county or public health district can appoint a physician to serve as its director and the health authority; if the director isn’t a physician, he or she can appoint the health authority. In the absence of a health department,

the governing body can appoint the health authority directly. If no local appointment is made, a DSHS regional medical director, by law a physician, serves as the jurisdiction’s health authority. DSHS personnel serve as health authorities for about a third of Texas’ counties.19 Before the pandemic, many health authorities had few opportunities to exercise their roles. According to TDEM, a few mayors and county judges were unaware of the identity of their health authorities, who, in addition to DSHS are the only officials authorized to impose local control measures.20

Exhibit 3.3

Control Measures State law defines control measures to include: • immunization

• quarantine

• detention • restriction

• chemoprophylaxis (the use of drugs to prevent disease)

• disinfection

• preventive therapy

• decontamination

• prevention

• isolation

• education

Source: Texas Health and Safety Code §81.082(f)

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T H E LON G Y EAR

■ STATE EMERGENCY MANAGEMENT The Texas Division of Emergency Management (TDEM), a component of the Texas A&M University System, coordinates and manages the state’s emergency management program for the state under a governor-appointed chief.21 TDEM provides this coordination with the help of the Texas Emergency Management Council, appointed by the governor to advise and assist him or her as well as TDEM in emergency management activities. The council comprises state agencies as well as various voluntary organizations.22 State agencies included in the council have specific legal responsibilities, expertise or resources needed for emergency response (Exhibit 3.4).23

EMERGENCY MANAGEMENT PLAN The State of Texas Emergency Management Plan, an extensive document managed by TDEM, details the responsibilities of all council members. The plan includes a basic document as well as more detailed plans called annexes that address specific “emergency support functions” (ESFs). These functions are common to most emergencies, such as communications, transportation and public health and medical services (Exhibit 3.5).

The plan identifies the lead agency for each ESF along with specific organizations supporting the response. DSHS is the lead agency for the “public health and medical services” annex.

While not an official member of the council, the Texas Higher Education Coordinating Board has helped it coordinate the roles of the higher education community in the pandemic, and will continue to do so in the future.

Exhibit 3.4

Texas Emergency Management Council Membership • American Red Cross

• Texas Department of Public Safety

• Public Utility Commission of Texas

• Texas Department of State Health Services

• Railroad Commission of Texas

• Texas Department of Transportation

• State Comptroller of Public Accounts

• Texas Division of Emergency Management

• Texas A&M AgriLife Extension Service

• Texas Education Agency

• Texas A&M University System

• Texas Facilities Commission

• Texas A&M Engineering Extension Service

• Texas General Land Office

• Texas A&M Forest Service

• Texas Health and Human Services Commission

• Texas Animal Health Commission

• Texas Military Department

• Texas Commission on Environmental Quality

• Texas Office of the Attorney General

• Texas Commission on Fire Protection

• Texas Parks and Wildlife Department

• Texas Department of Agriculture

• Texas State Auditor’s Office

• Texas Department of Criminal Justice

• Texas State University System

• Texas Department of Family and Protective Services

• Texas Tech University System

• Texas Department of Housing and Community Affairs

• Texas Workforce Commission

• Texas Department of Information Resources • Texas Department of Insurance • Texas Department of Licensing and Regulation • Texas Department of Motor Vehicles Source: Texas Division of Emergency Management

■ PAGE 24

• Texas Voluntary Organizations Active in Disasters • The Salvation Army • University of Houston System • University of North Texas System • University of Texas System

Emergency Support Functions in the Texas Emergency Management Plan 1. Transportation

10. Oil and Hazardous Materials Response

2. Communications

11. Agriculture and Natural Resources

3. Public Works and Engineering

12. Energy

4. Firefighting

13. Public Safety and Security

5. Emergency Management 6. Mass Care

14. Cross-Sector Business and Infrastructure - in planning stage

7. Logistics and Resource Management

15. Public Information

8. Public Health and Medical Services 9. Search and Rescue Source: Texas Division of Emergency Management

■ Chapter 3 / Emergency Management

Exhibit 3.5

TDEM ASSISTANT CHIEFS AND DISTRICT COORDINATORS TDEM has organized the state into six regions and 24 disaster districts, the latter coinciding with the boundaries of the state’s 24 planning regions (Exhibit 3.6).24 Each region is assigned a TDEM assistant chief; these in turn provide oversight for district coordinators within their regions. The assistant chiefs and district coordinators serve as TDEM’s field response personnel.

Disaster district emergency operations centers, known as DDEOCs, serve as the initial point of contact for state assistance in their areas. Each is led by a disaster district chair who is the district’s senior Texas Department of Public Safety (DPS) Highway Patrol officer. DDEOCs include local representatives of the organizations on the emergency management council.25

Exhibit 3.6

Texas Disaster Districts Source: Texas Division of Emergency Management

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T H E LON G Y EAR

■ REGIONAL ADVISORY COUNCILS

REQUESTS FOR ASSISTANCE Cities and counties needing help in a disaster can request state assistance through their Disaster District Committee. Each committee chair liaises between local governments and the State Operations Center during large-scale emergencies.26 During such a disaster, the state relies on the State of Texas Assistance Request (STAR) process to fulfill local requests for resources of all types, including those related to public health and medical resources such as ventilators, personal protective equipment (PPE), durable medical equipment and vaccines.

When emergency health or medical needs exceed local capacity, organizations through their emergency operations centers can request assistance through their city and county emergency operations centers; these requests travel up the chain for fulfillment at whatever level can provide the resource. The same concept applies to DSHS regional medical operations centers and TDEM’s regional operations centers. Information and resources flow back and forth between these centers at each level (Exhibit 3.7). The coordination between these centers, crucial to an effective response, occurs in different ways across the state.

In addition to state and local health entities, Texas has 22 regional advisory councils (RACs) that have played a key part in the state’s response to the coronavirus.

RACs came into being in response to a 1992 legislative directive that divided the state into 22 trauma service areas with a regional advisory council for each. Each RAC develops, implements and monitors a regional emergency medical services (EMS) trauma system plan to facilitate trauma and emergency health care within designated regions.27 The membership of today’s councils varies but can include hospitals, physicians, EMS providers, community groups and others.28

TRAUMA The term trauma can apply to either physical or mental and emotional trauma or injury, but Texas’ statewide trauma system, as discussed here, primarily addresses physical injuries and the medical services devoted to treating them.

Exhibit 3.7

Flow of Requests for Assistance through the State’s Emergency Management Structure* Requests for assistance for items such as PPE and nursing home disinfection teams travel through this system for fulfillment.

TDEM State Operations Center

DSHS State Medical Operations Center

TDEM Disaster District Emergency Operations Centers

DSHS Regions Medical Operations Centers

Local Emergency Operations Centers

Local Medical Operations Centers

STATE

LOCAL

DISASTER STRIKES

* Basic design courtesy of the Texas Department of State Health Services.

■ PAGE 26

Exhibit 3.8

Regional Advisory Council Provider

City

Panhandle RAC

Amarillo

North Central Texas Trauma RAC

Arlington

Piney Woods RAC

Tyler

Southeast Texas RAC

Houston

Capital Area Trauma RAC

Austin

Southwest Texas RAC*

San Antonio

Border RAC

El Paso

Coastal Bend RAC

Corpus Christi

*DSHS contracts with the Southwest Texas RAC to serve as the “state coordinating office” for the Emergency Medical Task Force.

■ Chapter 3 / Emergency Management

DSHS’ Hospital Preparedness Program Providers

Source: Texas Department of State Health Services

In addition, DSHS contracts with eight RACs to serve as the Hospital Preparedness Program (HPP) providers through the federally funded HPP, which oversees regional “health care coalitions” in planning for and responding to large-scale emergencies and disasters (Exhibit 3.8).29 These eight RACs’ responsibilities include operating disaster coalitions to plan medical responses for all kinds of hazards; developing plans to respond to mass fatalities in disasters; and transporting and tracking patients to and from care destinations when normal emergency transport systems are overburdened.30 The HPP providers have been active in the COVID-19 response. TDEM and DSHS have used these RACs as major distribution centers to move PPE and medical supplies and equipment along the supply chain to their final destinations, an innovation brought about by the sheer volume and urgent demand for these resources.

TEXAS EMERGENCY MEDICAL TASK FORCE The Texas Emergency Medical Task Force (TX EMTF) was created in 2009 in the wake of 2008’s disastrous hurricane season. TX EMTF comprises eight regional teams and a State Coordination Office, currently housed at the Southwest Texas RAC in San Antonio.

Through its regional teams, TX EMTF offers specialized teams and units providing a wide variety of services such as ambulance buses, mobile medical units and registerednurse strike teams in cooperation with local EMS providers, fire departments, hospitals and other entities.31

In addition, DSHS activated three specialized RAC components, the State Coordination Office for Emergency Medical Task Force (EMTF), EMTF Team 8 and the EMTF Infectious Disease Response Unit, to assist in the first repatriations of U.S. citizens exposed to COVID-19 at Lackland Air Force Base.

The Southwest Texas RAC in San Antonio (STRAC) serves as the State Coordination Office for EMTF and has played a key role throughout the pandemic, including assistance with the development of the state testing program.

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T H E LON G Y EAR

■ KEY STATE-LEVEL PARTNERS The pandemic has drawn many member agencies of the Texas Emergency Management Council into the response, including: Department of State Health Services. Public health and medical support are important in almost any significant disaster, but public health is the entire focus in a pandemic. The state’s emergency management plan names DSHS as the primary agency for the plan’s public health and medical annex, Emergency Support Function 8 (ESF-8). In addition to ESF-8, DSHS is fully engaged in all aspects of the response because of its central role as the state’s public health agency.

Texas Military Department. Civilian and military personnel of the Texas Military Department (TMD) — the Texas Army National Guard, Texas Air National Guard and Texas State Guard — respond to various national, state and local needs, including the governor’s requests for disaster assistance. As of November 2020, the department had activated more than 5,200 personnel for the pandemic, providing support to 235 Texas counties and 17 state and volunteer agencies.32

Texas A&M University System agencies. In 2019, the Texas Legislature transferred TDEM’s operations to the Texas A&M University System, in part to provide more efficient coordination with the extensive emergency management resources available from system agencies.

TDEM has mobilized these resources in support of the coronavirus response.

Texas A&M Engineering Extension Service (TEEX): TEEX has supported TDEM on a daily basis since April 2020, providing personnel and other resources at locations across the state and at the State Operations Center in Austin, playing an important role in logistics coordination and assisting the Texas Military Department with mobile testing and the decontamination of nursing homes and care facilities.33 Texas A&M Engineering Experiment Station (TEES): TEES has assisted TDEM and the governor’s Supply Chain Strike Force in acquiring and ensuring the quality of PPE for distribution around the state. TEES also has produced and delivered 3-D printed PPE for multiple hospitals and conducted research on various coronavirus issues.34 Texas A&M AgriLife Extension Service: AgriLife has used its statewide network of extension agents to distribute PPE and medical supplies and assist in contact tracing. It also has provided training and educational resources concerning federal coronavirus aid to city, county and school district officials. At the request of the Texas Frontline Child Care Task Force, AgriLife also prepared online courses to help parents and childcare providers find one another.35

Gov. Abbott, TDEM Chief Kidd and state officials tour the TDEM warehouse in San Antonio, a primary location for storing and distributing PPE, August 4, 2020. (Texas Division of Emergency Management)

Texas A&M Forest Service (TFS): Since COVID-19 operations began, TFS emergency response personnel have assisted in tracking, receiving and distributing supplies and equipment. TFS has supported local emergency operations centers and state disaster districts, distributed PPE, trained warehouse forklift operators, and helped with contact tracing and nursing-home testing.36 Texas Health and Human Services Commission (HHSC): HHSC has made many efforts during the pandemic to assist affected clients with Medicaid, the Children’s Health Insurance Program and other programs.37 These have included temporary benefits for program recipients and eased requirements to boost the availability of healthcare providers. HHSC also has carried out crucial efforts to control the virus’ spread in nursing homes and assisted-living facilities, entities that it regulates.

■ PAGE 28

TDEM and DSHS had worked together in previous disasters, but never before with the intensity demanded by COVID-19. At times, the line between their responsibilities became unclear and problematic, particularly in the early days.

These problems arose from the extraordinary circumstances of the pandemic and a system that hadn’t been fully “battle-tested” before.

The demands of the pandemic have required DSHS and TDEM to share some roles typically within one or the other’s province. DSHS’ normal activities include acquiring and distributing PPE and medical supplies when necessary, and testing people for infectious diseases. The urgent statewide need for both necessitated the use of TDEM’s logistical and disaster management expertise and the participation of other partners such as the Texas Military Department, the Supply Chain Strike Force, the Texas A&M Engineering Extension Service, the Texas A&M Forest Service, and others.

Our analysis indicates that TDEM directives predominate over any contrary state agency or local directives, including DSHS directives when TDEM acts under the governor’s delegated authority in a disaster. These relationships generally could be described as the governor serving as chief executive officer; the TDEM chief as the chief operating officer; and the DSHS commissioner as the chief medical officer, providing advice and recommendations in disaster-related activities and fulfilling its other statutory duties. Both agencies’ roles are critical, and state law could define their roles and responsibilities more clearly in disaster-related operations.

Exhibit 3.9 provides more specifics on statutory roles in Texas disaster management.

In addition to state statutes, the state’s emergency management plan and its public health and medical annex, revised as the pandemic was just beginning, don’t yet accommodate a public health disaster with the unique characteristics of COVID-19. The pandemic continues to bring new challenges — and to require adjustments in plans and the partnership between TDEM and DSHS as well as with other partners.

Exhibit 3.9

Disaster Management Roles • Governor: TDEM’s and DSHS’ disaster-related roles start with the governor. State law authorizes the governor to declare a state of disaster by executive order or proclamation, which have the force of law.38 The governor acts as the commander in chief of state agencies with emergency responsibilities, and can delegate or assign this command authority.39 • TDEM: By executive order GA-05, the governor has delegated authority for coordinating disaster management and carrying out powers granted to the governor under the Texas Disaster Act of 1975 in the administration and supervision of the Act to the chief of TDEM. The chief is authorized to issue resulting necessary directives upon approval of the governor and in consultation with the Texas Emergency Management Council.40 With the TDEM chief’s coordination as council chair, council agencies carry out the functions assigned them through the state’s mandated emergency management plan.41

■ Chapter 3 / Emergency Management

■ INTERAGENCY COORDINATION

• DSHS: The emergency management plan designates DSHS as the primary entity to assist the governor in planning the state’s public health and medical response.42 DSHS provides medicalrelated advice to the governor, TDEM and other state agencies, and performs other medical services according to the provisions of the plan.

DSHS also administers the state’s communicable disease law.43 These establish its authority to protect public health and defines certain authority of the agency to control communicable diseases, including during a “public health disaster” as described at the outset of this chapter.44 DSHS and appointed health authorities have specific statutory authority to deal with infectious diseases, including during a public health disaster. These include the application of control measures such as quarantine, restriction, immunization and the isolation of individuals, property or areas.45 A health authority is a state officer when performing duties prescribed by state law.46

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T H E LON G Y EAR

■ THE FEDERAL PARTNERSHIP Many federal programs and entities have assisted state and local governments. Inevitably, the strain of the pandemic revealed significant problem areas as well as successes in Texas’ partnership with the federal government. Common issues generally fall into the categories of regulatory inflexibility, inadequate communication and ineffective guidance.

Examples of such issues follow.

Communication: The U.S. State Department repatriated and quarantined three groups of U.S. travelers at Lackland Air Force Base in February and March 2020; some of them were the earliest confirmed COVID-19 cases in Texas.47 Texas officials said the State Department gave them little or no advance warning before the arrival of the first passengers. As some of them began to exhibit symptoms or test positive for the virus, the state then learned that Defense Department rules wouldn’t permit them to remain on the base, causing state and local governments to scramble to take care of them — and engendering concerns in the community about the possible spread of the virus.48 Regulatory inflexibility: The Texas Veterinary Medical Diagnostic Laboratory (TVMDL), a nationally and internationally accredited veterinary diagnostic laboratory, has been unable to fully assist with coronavirus testing due to federal regulatory requirements.49 The federal government gave TVMDL permission to perform human testing, but attached personnel requirements the lab couldn’t meet on its own. TVMDL today is limited to about 10 percent of its potential capacity for coronavirus testing.50 Funding Guidance: TDEM coordinates or manages federal disaster funding streams for local jurisdictions. One of these, the Federal Emergency Management Agency’s (FEMA’s) Public Assistance Category B Grant Program, can be used for “emergency protective measures,” such as supplies and commodities, medical care and transport, evacuation, sheltering and temporary public health facilities.51 A more recent source, the Coronavirus Relief Fund (CRF), part of 2020’s Coronavirus Aid, Relief, and Economic Security Act, can be applied to a wide variety of purposes including public health and medical expenses.52 Recipients found guidance for this funding inadequate, however. The U.S. Treasury issued multiple versions of its CRF guidance, creating problems for recipients who had planned future

■ PAGE 30

expenditures under rules that suddenly changed midstream. FEMA, in one case, said that certain eligible items for funding might be made ineligible if another funding source was available, which led to confusion and concern because purchasers could use either FEMA public assistance or CRF funds to buy some common items such as PPE. Such issues create uncertainty — and the understandable fear that funds may have to be paid back if future audits disallow certain expenditures.

Perhaps because of such issues, as of December 30, 2020, only 844 of 1,225 eligible local jurisdictions had provided TDEM with the paperwork for CRF funding, a necessary first step to receive the funds.53 Best Practices: Other federal efforts resulted in speedy solutions and greater efficiency in times of serious need.

Operation Warp Speed is a White Houseinitiated project to speed the development of countermeasures to combat the coronavirus. One of its goals is to have substantial quantities of a safe and effective vaccine available by January 2021, a goal that may be met given positive reports from three separate vaccine trials as of late November 2020.54 Due to its connection to the White House, Operation Warp Speed has accomplished complex tasks of coordination without many of the time requirements of the federal bureaucracy.

Texas A&M University’s Center for Innovation in Advanced Development and Manufacturing (CIADM), one of three such centers across the nation, is participating in Operation Warp Speed.

The center and its subcontractor, FUJIFILM Diosynth Biotechnologies, are expanding manufacturing capacity for several potential COVID-19 vaccine programs. The expansion is planned for completion on a significantly shorter timeline than is typical for the vaccine industry.

The Higher Education Emergency Relief Fund, part of the federal CARES Act, appropriated about $12.6 billion nationally for direct grants to all institutions of higher education (IHEs), a distribution method that speeds much-needed funding to recipients. Texas is receiving $1.02 billion from this program.55 These grants, distributed in a manner that gives greater weight to institutions with low-income students, have helped counter the financial disruptions IHEs have faced during the pandemic. The American Council on Education has said that direct grants have “the advantage of allowing for rapid disbursement of funding that is urgently needed.”56

1 Clarify the statutory responsibilities of the Texas Division of Emergency Management (TDEM) and Texas Department of State Health Services (DSHS) to ensure a more efficient disaster response.

Two separate state laws govern disaster response in Texas for disasters such as COVID-19: a general emergency management statute for all disasters in Chapter 418 of the Texas Government Code and a section concerning infectious disease and defining “public health disasters” in Chapter 81 of the Texas Health and Safety Code. These laws, however, don’t clearly articulate a dividing line between DSHS and TDEM responsibilities in dealing with disasters involving communicable disease. Clarification of their separate spheres would help ensure more efficient action during pandemic response.

The Legislature should amend Chapter 81 of the Texas Health and Safety Code to clarify that during a declared state of disaster, control measures such as quarantines or disinfection implemented by DSHS or a health authority are subject to directives and executive orders of the governor issued pursuant to Chapter 418. The Legislature also should amend Chapter 81 to clarify that DSHS’ authority in such an event must be consistent with the governor’s executive orders and directives issued under Chapter 418 as well as the state emergency management plan activated pursuant to Chapter 418.

■ Chapter 3 / Emergency Management

RECOMMENDATIONS

This recommendation is not intended to diminish either agency’s role or importance. It would simply provide clear guidance consistent with the process that developed during the current pandemic. Nothing in this recommendation is intended to alter DSHS’ normal, day-to-day public health responsibilities.

2 Require TDEM to form a working group of stakeholders to propose a disaster response structure that better integrates the roles of public health, medical, and emergency management entities at local, regional and state levels.

Emergency management, public health and medical entities such as TDEM, DSHS, local public health and medical entities and the regional advisory councils (RACs) should work together seamlessly during a public health and medical disaster. Yet the degree to which they do so varies among different parts of the state and at the local, regional and state levels.

The working group would examine Texas’ current organizational emergency management system and propose a more fully integrated structure for public health and medical support functions. The group should include emergency managers, public health officials and medical personnel from TDEM, DSHS, member agencies of the Texas Emergency Management Council, local and regional public health officials, RACs, doctors, nurses and other appropriate individuals.

TDEM should deliver a report on the outcome of these deliberations to the governor and Legislature no later than November 1, 2022, in time for consideration during the 2023 legislative session. The report also should suggest any legislation necessary to implement its conclusions.

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T H E LON G Y EAR

3 Require DSHS and TDEM to ensure that key local emergency managers are aware of the persons acting as their health authorities.

A health authority, by law a physician, has specific public health responsibilities in his or her local jurisdiction, such as quarantines, isolation and other “control measures” to control communicable disease.57 A health authority can be appointed in several ways, including by local health department directors or by DSHS in the absence of a local appointment.58 The health authority serves a term of two years and may be reappointed.59 State law requires this person to file a copy of his or her appointment with DSHS.60 Health authorities play a crucial role in controlling infectious diseases in their jurisdictions, especially during a pandemic. However, some county judges and mayors, directors of emergency management in their areas, weren’t aware of the identity of their health authority, perhaps due in part to the multiple ways in which these officials can be selected.

State law should direct DSHS and TDEM to work together to ensure that emergency management directors and coordinators throughout the state are aware of the health authority serving in their jurisdictions. As part of this effort, DSHS should maintain a current list of health authorities on its website.

State law requires county judges and various other state and local officials with emergency management responsibilities to receive at least three hours of related training.61 This training should cover the responsibilities of health authorities. The Legislature also should consider whether state law should require health authorities to undergo training in emergency management.

4 Add the Texas Higher Education Coordinating Board (THECB) to the Texas Emergency Management Council.

One key issue in the pandemic has been the state’s desire to see higher education continue in safe and practical ways. In addition, higher education institutions play a key role in responding to such emergencies through their research and response capabilities.

While it isn’t an official member of the Texas Emergency Management Council, THECB has participated in its activities and helped it coordinate issues related to higher education. The Texas Education Agency (TEA), a voice for Texas’ public school systems, is already a member of the council; adding THECB would cover the remainder of the educational spectrum.

State law allows the governor to implement this recommendation by executive order.62

■ PAGE 32

Several areas of concern in the pandemic highlighted a need for better federal coordination.

The regulatory inflexibility of the federal Clinical Laboratory Improvement Amendments (CLIA) program, for instance, prevented the Texas A&M Veterinary Medical Diagnostic Laboratory from using much of its ample capacity to process coronavirus tests (see Recommendation 10). The federal government’s repatriation of American citizens to Lackland Air Force Base in San Antonio was marred by infrequent and inadequate communication with Texas state and local officials. Also, state and local entities would have benefited from timelier and more effective guidance and communication on the use of Coronavirus Relief Fund and Federal Emergency Management Agency (FEMA) Category B Public Assistance funds.

On the other hand, the pandemic response highlighted two instances of successful collaboration with the federal government.

Operation Warp Speed, the White House effort to speed the development of vaccines and countermeasures, accelerated the expansion of vaccine manufacturing capacity at Texas’ Center for Innovation in Advanced Development and Manufacturing and its subcontractor, FUJIFILM Diosynth Biotechnologies. This effort improved on typical industry schedules by an estimated six to nine months.

■ Chapter 3 / Emergency Management

5 The Texas congressional delegation and state agencies should work with the federal government to improve pandemic-related federal laws and practices.

Secondly, the federal government’s direct disbursement of grants from the Higher Education Emergency Relief Fund, part of the CARES Act, to all institutions of higher education, sped up the receipt of badly needed funding.

n

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T H E LON G Y EAR

Medical personnel put on personal protective equipment at a COVID-19 testing site at the University of Texas at El Paso on Nov. 3, 2020. (Joel Angel Juarez, The Texas Tribune)

■ PAGE 34

CHAPTER 4 CHAPTER 4

S U P P LY C H A I N LOGISTICS In a pandemic, personal protective equipment (PPE) and other basic medical supplies are essential to protect both health care workers and the general population (Exhibit 4.1). As with many other states, Texas couldn’t meet the sudden and enormous surge in demand for these items in the pandemic’s early days.

Exhibit 4.1

Examples of Personal Protective Equipment and Medical Supplies PPE and medical supplies sought and acquired by the state during the COVID-19 response include: Personal Protective Equipment • Gloves • Gowns • N95 face masks • Surgical masks • Face shields • Coveralls • Medical gowns Medical equipment and supplies • Nasal swabs and other viral transport media • Ventilators and ventilator filters • Endotracheal tubes Source: Supply Chain Strike Force

Texas couldn’t look to the federal government to solve this problem. The U.S. Department of Health and Human Services’ Strategic National Stockpile is intended in part to support the states’ emergency health services in a bioterrorist attack or other emergency. But it isn’t intended to meet all their needs in a major pandemic; it’s a stopgap at best.1 But Texas also couldn’t depend on other national or international supply chains, which were “fully allocated,” tapped out in February and March.2 Governments around the world were competing for PPE, and often keeping what they could for themselves.

One estimate suggests that as much as 80 percent of all PPE imported into the U.S. comes from Asia.3 According to the Congressional Research Service, in 2019 the U.S. relied on China for about 72 percent of its surgical masks and certain other types of face masks; 55 percent of its protective goggles and spectacles; and 77 percent of its plastic gloves.4 The service stated that “reduced exports from China have led to shortages of critical medical supplies in the United States.” 5

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■ COMBINED AGENCY EFFORT

■ SUPPLY CHAIN STRIKE FORCE

The Texas Department of State Health Services (DSHS) normally procures and distributes PPE and medical supplies when local authorities become overwhelmed in an emergency.6 It typically fulfills such requests from its own inventory, which may come from the Strategic National Stockpile or contracted suppliers such as McKesson.

On March 22, Governor Abbott announced the establishment of the Supply Chain Strike Force, an innovative partnership of public and private entities with highly specialized skills including supply chain and inventory management (Exhibit 4.2). Abbott directed this strike force “to ensure health care facilities have the supplies and resources they need to respond to COVID-19.”7

COVID-19, however, presented a problem rarely experienced in previous disasters such as hurricanes.

The agency and state government as a whole were limited in their ability to purchase and distribute sufficient amounts of PPE and medical supplies from an overcommitted global supply chain. DSHS had several contingency contracts in place, including warehouse, logistics and distribution contracts, but these too were affected by the worldwide shortage. The agency had neither the resources nor the logistical infrastructure to buy and distribute sufficient amounts of these supplies throughout the state.

Texas’ urgent need yielded two significant if temporary changes in state government procedures.

First, as COVID-19 expanded beyond DSHS’ resources, the Texas Division of Emergency Management (TDEM), which coordinates the state’s response to disaster, stepped up to provide statewide support through its extensive experience in purchasing, warehousing and distributing emergency supplies. TDEM and DSHS combined their efforts to purchase large quantities of PPE and other supplies, supplemented by distributions from the Strategic National Stockpile. Both agencies stored these materials in TDEM’s warehouse for statewide distribution.

This team effort represented a wise use of state resources that produced a much stronger response — and highlighted the interdependence of the two agencies’ roles in a public health disaster.

The second change was the creation of a publicprivate group authorized to acquire supplies quickly and efficiently.

The strike force worked primarily through TDEM, in coordination with DSHS, to quickly acquire PPE and other medical resources in high demand. DSHS offered public health and medical advice on the types and grades of materials needed. The strike force reached out to secure assistance from Dell Technologies and a variety of other public and private organizations. Its work ended in mid-June.

Since then, TDEM and DSHS continue to coordinate and review purchases of medical supplies and equipment.

Within four weeks of its creation, the strike force established a beginning-to-end supply chain process with the assistance of third-party experts. This structure sourced and distributed millions of PPE and medical supplies in 12 weeks (Exhibit 4.3). The supplies generally met order requests during the group’s life span.

Exhibit 4.2

Leadership of the Supply Chain Strike Force Supply chain director for the Supply Chain Strike Force • Keith Miears, senior vice president of Worldwide Procurement, Dell Technologies Supporting leadership • John Zerwas, M.D., assisting with hospital relations and preparedness • Clint Harp, vice president of Transmission Strategic Services for the Lower Colorado River Authority, assisting with asset research and procurement • Elaine Mendoza, chair of the Texas A&M Board of Regents, assisting with statewide child care infrastructure for critical workers Source: Office of the Texas Governor

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PPE and Medical Supplies Delivered through the Strike Force Supply Chain

PPE/Medical Supplies

Total Received through June 12 and Distributed through July 31 (millions)

Masks

183.6

Gloves

137.1

Gowns

16.8

Face Shields

5.1

Coveralls

2.3

Swabs

6.6

Viral Transport Media

2.7

Source: Supply Chain Strike Force

The success of the strike force’s operation resulted from several factors.

Its creation by Governor Abbott, Texas’ highest elected state official, added considerable weight to the group’s ability to act quickly. The governor’s authority and keen interest helped the group recruit companies with the expertise needed to build Texas’ supply chain and distribution channels, providing skills not readily available in state agencies (Exhibit 4.4).

Also, as public partners in the strike force, TDEM and DSHS linked private-sector experts with the state’s emergency management structure and public health system, helping them navigate the complex business systems of state government.

Finally, the strike force’s authority allowed it to resolve confusion and ambiguities in the separate roles of TDEM and DSHS. The challenges involved in their coordination were understandable.

DSHS oversees public health, a huge task in a pandemic, while TDEM is responsible for the logistics of any emergency response, which in this case are statewide and particularly challenging.

Furthermore, response to a full-fledged pandemic of the scope and characteristics of COVID-19 was a new undertaking for both organizations — what several interviewees called “building the airplane while they were flying it.”

■ Chapter 4 / Supply Chain Logistics

Exhibit 4.3

Exhibit 4.4

Third-Party Assistance Provided to the Strike Force

Company

Role Description

E2Open

Order and inventory management

Visionworks

Quality control at TDEM warehouse

Horne

Data analytics and visualization

Palantir

Allocation methodology; data and demand modeling

Valkyrie

Forecast modeling

Texas 2036

Industry and coronavirus data reporting and analytics

McKinsey & Company

Supply-chain strategy and demand modeling

Boston Consulting Group

Policy support and strategy

Source: Supply Chain Strike Force

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■ STRIKE FORCE OPERATIONS PPE and medical supply markets: Predictably, the strike force faced delays in acquiring supplies manufactured primarily in Asia.

The federal government offered the state only limited support from the national stockpile, and allocated its supplies to states most in need at any particular time, making it unreliable. Further complicating the problem was the fact that Texas state government had very few pre-existing supplier relationships it could turn to in an emergency.

The strike force used its supply chain expertise to source PPE and medical supplies from nontraditional sources around the world. It also developed partnerships with local manufacturing suppliers and other entities that could assist. Local arrangements of this nature have helped reduce the state’s reliance on offshore manufacturers.8 Strategic reserve: The strike force noted the state’s lack of a strategic PPE reserve, an aspect of pandemic planning it considered critically important. “The thing I worry about most is the state not having an effective stockpile strategy going forward,” said Keith Miears, director of the strike force and senior vice president of Worldwide Procurement for Dell Technologies. "We never want to be in this shortage situation again in the next pandemic."

The group recommended creation of a state reserve and developed preliminary plans for a reserve that could last for about three to 30 weeks, depending on the item.

Quality control: At the beginning of the pandemic, TDEM didn’t have a large-scale quality control system in place to check the massive influx of PPE and medical supplies arriving at its warehouse in San Antonio. Experience confirmed the need for such a system, given the number of product deliveries that failed to meet specifications; some were intended to defraud the state. The strike force coordinated the development of quality-control procedures along with DSHS and the assistance of a third-party provider.

2014 RECOMMENDATION The Texas Task Force on Infectious Disease Preparedness and Response proposed a strategic PPE stockpile in 2014. Then-Governor Rick Perry established this group by executive order after the Ebola scare of that year.

Acting on this recommendation, Senator Charles Schwertner introduced Senate Bill 538 in the 2015 legislative session. This bill would have required DSHS to “establish a stockpile, or regional stockpiles, of personal protective equipment to support responses to infectious disease emergencies in the state” if funds were appropriated for that purpose.

The bill passed the Senate but failed in the House.9

During the pandemic, some companies unsuccessfully attempted to sell the state PPE that either failed to meet specifications or was misrepresented by the manufacturer.

This TDEM display features examples of both approved and unapproved PPE the agency received. (Texas Division of Emergency Management)

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Business information: Another issue the strike force noted was a lack of detailed information about materials ordered and available inventories.

The group developed a system to track and report this information. Basic business information of this kind, part of a “business intelligence system,” gives management the data needed to support sound decisions.

Distribution system: The pandemic’s scale far exceeds that of a hurricane or fire; emergency systems must respond across the entire state. To accommodate the statewide demand for PPE and medical supplies, DSHS, the strike force and TDEM ultimately strengthened the distribution network by using eight regional advisory councils serving as DSHS’ Hospital Preparedness Program (HPP) providers supplemented by eight regional National Guard armories as major distribution centers. The HPP providers offered an existing structure for the regional and local distribution of state-acquired PPE and medical supplies — a new role for the HPP partners. As of December 2020, they remained actively engaged in the weekly distribution of PPE from TDEM’s warehouse.

One task of the strike force was estimating the future demand for PPE and medical supplies — a major challenge in the face of a pandemic.

Modeling: Effective infection modeling would prove to be essential in estimating future needs. The strike force found multiple models in various stages of development; their differences prompted it to create a model of its own with third-party consulting expertise.

Material Requirements Plan: The scale, rapid spread and duration of COVID-19 created an urgent need for a tool that could predict requirements for each item over time and by location. The strike force established a material requirements plan to show the types and estimated amounts of PPE and medical supplies needed for distribution several weeks in advance, which helped to define purchasing and distribution schedules. With modeling and the material requirements plan, the strike force could predict, for example, that the Southwest Texas Regional Advisory Council was likely to need a certain number of N-95 masks, gloves and surgical gowns in three weeks. The tool was handed off to TDEM for use in future emergencies.

■ Chapter 4 / Supply Chain Logistics

■ PLANNING FOR SUPPLY AND DEMAND

State of Texas Assistance Request (STAR) Process: STAR is the system used in the state’s emergency management process to take requests for supplies such as PPE, medical equipment, personnel and other needs. As such, STAR requests can be used to help determine and predict demand. The strike force found, however, that its usefulness in this role was limited. Some requests, for instance, may be for immediate use while others are intended to meet future needs. Still others fail to accurately describe the types of materials needed.

The strike force recommended that the state revise and improve the STAR system, in part to provide better information for distribution and planning.

Gov. Abbott thanks military and TDEM personnel after touring the TDEM warehouse in San Antonio for their hard work and tireless effort during the COVID-19 response, August 4th, 2020. (Texas Division of Emergency Management)

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■ OTHER ISSUES Warehouse upgrade: TDEM’s San Antonio warehouse is near its capacity and in need of repairs.

The strike force recommended that the agency invest in a new warehouse with electric forklifts and climate control to protect expensive and perishable supplies.

TDEM has developed an “exceptional item request” for legislative consideration in 2021. The request seeks funding for the 2022–2023 biennium to develop regional storage and staging areas for emergency purposes. It explains that additional regional facilities of this nature would speed emergency response, reduce transportation costs and provide areas for staging.10

Digital business processes: TDEM uses various business systems, some of them manual, to manage inventory and other business processes.

These systems are poorly suited to efficient management. The strike force recommended that the state implement digital business systems to integrate purchase orders with inventory management.

Data integration: The strike force found that the data it needed to manage the pandemic response — including testing results, epidemiological models and real-time data on hospital capacity — were “siloed” in different entities and difficult to integrate.

Integrated data streams would help ensure the state is ready to respond to the next pandemic or emergency.

COVID-19 patient reports are stacked in a pile after being processed by the Northeast Texas Public Health District office in Tyler. (Shelby Tauber for The Texas Tribune)

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6 Require TDEM to submit a plan to the Texas Legislature concerning the adoption of improvements recommended by the Supply Chain Strike Force.

These improvements could help reduce the state’s need to compete for scarce, high-cost PPE and medical supplies during a pandemic; reduce competition within the state for scarce PPE; and provide the tools needed to acquire, manage and distribute PPE efficiently.

Key innovations and recommendations of the strike force included: • a local provider network to supply the state with PPE and medical supplies; • a revolving strategic reserve (a “strategic stockpile”) of these supplies; • additional quality control measures for PPE, medical supplies and other items; • a system to track and report on materials ordered and inventory on hand; • a distribution system for emergency goods and services that could be scaled according to need; • modeling to help predict future PPE needs;

■ Chapter 4 / Supply Chain Logistics

■ RECOMMENDATIONS

• a “material requirements plan” showing the types and estimated amounts of PPE and medical supplies needed for distribution several weeks in advance; • an update to the State of Texas Assistance Request (STAR) system or any future resource request system; • increased warehousing space (TDEM included an exceptional-item request for warehouse upgrades in its 2022-2023 legislative appropriations request); and • updated TDEM business processes.

In addition to these improvements, the plan should address the use of private- and public-sector expertise in implementation.

TDEM should review this plan with DSHS and other members of the Texas Emergency Management Council to ensure its alignment with statewide public health and other activities, including coordination with the federal government on the Strategic National Stockpile.

The plan should be submitted to the Legislature no later than November 1, 2022, in time for consideration during the 2023 legislative session.

7 TDEM should create a permanent partnership with the private sector that could assist it in response and recovery operations as the Supply Chain Strike Force did during the pandemic.

The governor’s creation of the Supply Chain Strike Force was an important innovation in the state response to COVID-19. This concept could be continued by a permanent Business Emergency Operations Center (BEOC). TDEM already uses similar methods to assemble experts in various functional areas, such as its Air Operations Center for coordinating the use of aircraft and its Communications Coordination Group for managing communication resources during disasters.

The BEOC framework is permanent, but private partners should be selected according to the needs of the disaster response. A host agency activates the BEOC when needed. FEMA already uses BEOCs to gain the assistance of business partners with specific expertise.

TDEM already is considering the development of a BEOC and a new annex to the state emergency management plan outlining its functions and operations. The division should complete this effort, which would provide the state with the benefits of private-sector expertise similar to those realized from the innovative work of the Supply Chain Strike Force.

n

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A worker prepares a sample at a state COVID-19 testing site. (Texas Military Department)

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CHAPTER 5 CHAPTER 5

THE PUBLIC H E A LT H R E S P O N S E The COVID-19 pandemic highlighted challenges in Texas’ ability to respond to a public health crisis of COVID-19’s size and scope. While Texas’ public health system responds well to “normal” events such as hurricanes or salmonella outbreaks, a deadly worldwide pandemic represents a new and more serious challenge.

To meet the early days of a pandemic, our public health system must be able to: • deploy mass diagnostic testing; • rapidly expand the public health workforce for case investigation; and • provide the public and decision makers with timely and accurate information on the disease’s spread.

A NOTE ON VACCINE DISTRIBUTION Vaccine distribution in Texas had just begun as this report was being prepared for publication, creating yet another large-scale logistical challenge for the state to tackle.

The timing of our report didn’t allow us to evaluate the unique issues surrounding vaccine distribution in any depth, but the recommendations do consider the need to improve all aspects of pandemic planning and interagency coordination for the future.

■ TESTING Widespread diagnostic testing with rapid, reliable results provides the information needed both to treat patients and to monitor and ultimately control the spread of a new and unpredictable disease.

From the beginning of the pandemic, however, our public health system struggled to ramp up testing in the face of a worldwide supply shortage and early missteps from federal agencies. The demand for diagnostic tests reached an unprecedented scale during the COVID-19 pandemic. Humankind simply has never attempted to test this many people for a new disease at once.

Neither the states nor the federal government could respond with the speed or scale needed during the early days of this event. Ultimately, the rapid expansion of testing required an historic effort from many sectors, including private and nontraditional labs such as university research centers.

Texas’ emergency management plans assumed the Texas Department of State Health Services (DSHS) and local public health departments would take the lead for communicable disease monitoring and collaborate with the healthcare system and private entities for testing and developing disease prevention activities. But their logistical capabilities weren’t designed for a worldwide pandemic and couldn’t provide the scale or speed needed for COVID-19. Early missteps by federal agencies didn’t help matters; initially faulty tests, delayed

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Exhibit 5.1

Coronavirus Test Results Reported to the State Each Day The state testing program required intensive coordination by the Texas Division of Emergency Management (TDEM), DSHS and the Texas National Guard. Dozens of other public and private entities were involved as well, including regional advisory councils, local health and fire departments, Texas A&M University’s Engineering and Texas A&M AgriLife Extension Services, the Texas Department of Public Safety, the Texas Parks and Wildlife Department, commercial laboratories and many others who worked with one another day after day, on the fly and without prior plans in place.

The massive logistical operation to provide testing materials, pick up samples and return them to laboratories with available capacity became known among emergency responders as “The Pony Express.”

State did not classify the type of test Viral tests were not broken down by molecular or antigen

Molecular tests Antigen tests Antibody tests

Source: The Texas Tribune, based on data from the Texas Department of State Health Services.10

approvals for expanding testing options, and lack of coordination to boost supply manufacturing slowed test distribution nationwide.1 On March 10, as community spread of COVID-19 was taking hold in Texas and private testing was not yet widely available, the state’s entire public health lab network could process only 252 COVID-19 tests per day.2 Texas was forced to improvise.

In March and April, Gov. Abbott directed the creation of a state testing program, first piloted in San Antonio on March 13 and rolled out statewide in late April.3 The federal government also began supporting testing sites in Texas starting on March 23.4 The governor’s overall goal, as announced in his Report to Reopen Texas on April 27, was to reach 30,000 total daily tests in Texas by mid-May, through sites run by a combination of federal, state and local entities as well as the private sector.5 The state testing program initially provided about a third (up to 11,000) of those daily tests. By the end of September, state-run sites alone had run more than 627,000 tests in total.6

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By December 31, various public and private entities in Texas were testing about 100,000 people per day (Exhibit 5.1).7 At that point, about 13.6 million COVID-19 tests had been conducted in Texas, the fourth-highest number among states.8 On a per capita basis, however, the state has persistently ranked in the bottom quarter of states throughout the pandemic.9

TESTING THE MOST VULNERABLE TEXANS On May 11, Gov. Abbott directed TDEM, DSHS and the Texas Health and Human Services Commission (HHSC) to test all residents and staff in Texas’ 1,200 nursing homes.11 From May 11 through June 11, these agencies worked with the National Guard, regional advisory councils, local public health and fire departments and private contractors to conduct more than 188,000 tests for residents and staff in facilities throughout the state. The use of local fire departments to provide manpower was particularly innovative — 113 voluntarily participated through the existing Texas Intrastate Fire Mutual Aid System, mobilized by the Texas A&M Forest Service, to coordinate testing sites and perform the sample collection.12 And the mission didn’t end in June; state testing assistance continued at nursing homes and other facilities throughout the year.13

Coordinating this testing during rapid deployment was difficult at best, with many problems along the way. Local officials sometimes didn’t know who was running various testing sites in their jurisdictions; people often didn’t have clear information about which entities were providing tests or how to obtain their results.14 On April 24, Governor Abbott, TDEM and DSHS announced an online COVID-19 test collection map to help Texans better navigate the various testing options available.15 In the earlier weeks of the pandemic, moreover, laboratory capacity was in short supply. Public health laboratories couldn’t support the volume of tests needed, but the state had no way to determine the capacities and run rates of private labs to direct the flow of samples and supplies. The labs cooperated to provide the needed information, but their efforts had to be coordinated through daily phone calls.16 Some high-capacity Texas laboratories, such as the Texas A&M Veterinary Medical Diagnostic Laboratory (TVMDL), could have provided more assistance, but were blocked by federal requirements. On March 31, 2020, TVMDL applied for a federal waiver to allow its personnel to perform as many as 1,200 human tests a day.17 The lab received permission to perform human testing, but with staffing requirements it generally couldn’t meet, requiring outside staff to run the tests. TVMDL was limited to using only about 10 percent of its potential capacity for human COVID-19 testing and only about 28,500 human tests were processed in TVMDL facilities from March to September 15, days of critical need.18

state’s 254 counties, most of them rural.20 The state was woefully understaffed to track the explosion of cases in this pandemic; it also has a shortage of epidemiologists, the “detectives” who investigate the spread of infectious diseases.21

COMMON PUBLIC HEALTH FOLLOW-UP ACTIVITIES • Disease management in people who are infected • Case investigation, contact tracing and confidential notification of contacts • Testing • Support for isolation/quarantine recommendations

■ Chapter 5 / The Public Health Response

COORDINATION

• Other social service needs Source: Department of State Health Services

■ THE PUBLIC HEALTH WORKFORCE Labor-intensive case investigations and follow-up, often called contact tracing, are essential to the effective control of infectious disease.19 As COVID-19 spread, a national public health workforce that has been declining for more than a decade quickly became overwhelmed. Since 2008, the public health workforce has declined by 16 percent across the country. While Texas’ large urban areas have their own locally operated public health departments, many Texas counties have only a handful of public health employees or have no local health department at all, requiring DSHS to fill in. DSHS operates regional offices around the state and provides direct public health services in 194 of the

Texas Department of Public Safety aircraft coordinated by the Emergency Medical Task Force prepare to transport COVID-19 test samples to labs across the state, May 23, 2020. (Jordan Ghawi, Southwest Texas Regional Advisory Council)

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TEXAS’ PUBLIC HEALTH SCHOOLS Public health schools are particularly well suited to providing surge support during a pandemic, including case investigations as well as technical support, training and analytics. Texas' schools provided important emergency staffing during the pandemic. The Texas A&M Health Science Center, for instance, partnered with the Brazos County Health District to handle its case investigations and contributed staff to support DSHS' statewide contact tracing program. The UTHealth School of Public Health also supplied contact tracers for several local health departments across the state, including San Antonio's as well as DSHS. Other public health schools and university departments outside of public health also contributed resources to the state's response.22 Arranging for this help, however, proved difficult.

Human resource issues became stumbling blocks; in some cases, schools still were working through contract and other legal issues as late as September.

Volunteers for contact tracing, moreover, required time-consuming training and supervision to handle the sensitive and technical nature of contact tracing work. Data sharing arrangements also had to be worked out to ensure proper access to patient information.23 The state and its partners now have an opportunity to translate these hard-learned lessons into a better prepared system for the future.

ACCREDITED PUBLIC HEALTH SCHOOLS AND PROGRAMS IN TEXAS Fully Accredited Public Health Schools • Texas A&M Health Science Center • University of North Texas Health Science Center • University of Texas Health Science Center at Houston

Accredited Public Health Programs • Baylor University • University of Texas at El Paso • University of Texas Medical Branch at Galveston • Texas Tech University Health Sciences Center Source: Council on Education for Public Health

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FUNDING The U.S. Centers for Disease Control and Prevention (CDC) once provided funding to schools of public health for emergency preparedness but largely discontinued it in 2015. For example, Texas A&M’s USA Center for Rural Public Health Preparedness received about $10 million from the CDC between 2005 and 2015. Though the center still exists, its activities are now greatly reduced.24 In 1999, the Texas Legislature created a program to support schools of public health in providing training and assistance to the state’s public health workforce, but it was never funded at the level originally envisioned.25 Even so, DSHS has entered into smaller-scale partnerships with public health schools; in 2018, for example, it partnered with a group of them to pilot a “Public Health 101” training curriculum for local health departments.26 Further investment in such efforts could expand and improve the public health workforce while strengthening Texas’ public health disaster response abilities. While pandemics have been rare, Texas has many disaster events that regularly require significant public health support such as hurricane evacuations, where potentially infectious conditions must be monitored and tracked in mass care shelter environments. Students and faculty also benefit from real-world opportunities to assist, which become valuable recruitment and learning tools to continue building the state’s public health workforce.

■ PUBLIC HEALTH DATA COVID-19 exposed fundamental weaknesses in the state's ability to collect and report real-time public health information. Throughout the pandemic, responders, decision makers and the public sought real-time public health data that existing systems simply couldn’t deliver on such an unprecedented scale.

Texas’ decentralized public health system created significant challenges for fast and reliable data collection and reporting in the pandemic (Exhibit 5.1). Public and private labs, local emergency responders, private hospitals and providers, county vital statistics units, regulatory agencies and many other players gather and organize information on COVID-19. They report critical information through multiple systems, many of which cannot communicate with one another and some of which aren’t under state control. Many of these systems,

The extreme nature of the challenge faced by DSHS and local health departments can’t be overstated. No infectious disease event has ever demanded the level or speed of reporting required for this pandemic.

NO INFECTIOUS DISEASE EVENT HAS EVER DEMANDED THE LEVEL OR SPEED OF REPORTING REQUIRED FOR THIS PANDEMIC. Before COVID-19, the average daily number of electronic laboratory reports (ELRs) DSHS received per day was about 2,000 for all reportable disease conditions. By mid-January 2021, the average ELRs processed had increased to about 100,000 to 150,000 each day.27 The agency’s reporting system simply couldn’t handle this extreme surge in reporting, resulting in backlogs, delays and questionable data quality throughout the pandemic’s early months. Federal, state and local agencies constantly struggled with data standards, reporting requirements and interpretation. Multiple system updates and federal changes to reporting requirements caused several major data revisions during the event, sowing confusion. Several reporting and calculation changes, most notably concerning the testing “positivity rate” (the share of tests coming back positive), caused a great deal of uncertainty about data quality.28 The efforts of DSHS and other entities to improve and update their data systems during the crisis were admirable, and jurisdictions around the world have encountered similar challenges. To its credit, DSHS updated and modernized its system for accepting COVID-19 lab results during the event to increase daily results processing from 2,000 to 200,000 per day, and eventually received a rating of “A” from the COVID-19 Tracking Project for data transparency.29 DSHS also developed and launched a new system called Texas Health Trace to support the volume of COVID-19 case investigations and

contact notifications needed statewide, along with a dedicated data analytics team.30 Of course, as soon as these processes stabilized, new challenges with reporting real-time vaccination numbers and demographics through the state’s centralized immunization database began unfolding in late December.31 COVID-19 has underlined Texas’ need for better public health information systems. A bipartisan coalition of state auditors in other states have begun a multi-state COVID-19 data audit process.32 The Delaware state auditor, for example, released a report evaluating the state’s COVID-19 data dashboard and noting available best practices in other states.33 Considering that data reported during a major outbreak have a direct impact on decisions to restrict movement, businesses and schools, timely, accurate and transparent reporting of this information is critical.

■ Chapter 5 / The Public Health Response

moreover, are governed by federal requirements and would need federal involvement to improve.

All of these stakeholders and systems must be considered together when considering future improvements.

DATA AUTHORITY During a public health disaster, the DSHS commissioner can require additional disease reporting from healthcare providers.34 This authority, however, doesn’t cover other healthcare information the department may need to manage the response, such as information about hospital or laboratory capacity. In March, Gov. Abbott issued an executive order to require and expedite additional reporting from private labs and hospitals.35 Similarly, many local entities requested data from DSHS to help understand the virus’s spread in their communities, but state law doesn’t provide a clear process for DSHS to share confidential health information with local jurisdictions, even in a pandemic. The law does allow DSHS to release confidential information during a public health emergency to protect first responders who are called to a home where a known infectious disease is present. It doesn’t, however, provide clear authority for DSHS to share information intended to aid local officials such as county judges in understanding a disease’s spread in their communities.36

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NURSING HOMES Public information about the spread of COVID-19 in nursing homes became a particularly sensitive issue. Statutory ambiguity delayed the release of information about one of the most highly vulnerable populations for nearly four months.

HHSC, which regulates long-term care facilities, didn’t believe it could release such information due to provisions of Texas’ Health and Safety Code and the federal Health Insurance Portability and Accountability Act (HIPAA) meant to protect individual health care information.37 On May 4, 2020, HHSC submitted an open records opinion request to the Attorney General’s Office seeking guidance on what information it could release.

On July 6, the attorney general ruled that HHSC could release any relevant information related to the presence of COVID-19 in long-term care facilities so long as personal information about individuals wasn’t divulged.38 On July 27, HHSC finally released information to the public related to the prevalence of COVID-19 in the care facilities it regulates.

Exhibit 5.1

Key Public Health Information Challenges During COVID-19

Affected Information Systems/Entities

Official test result reporting Key System: National Electronic Disease Surveillance System (NEDSS) Affected Entities: • DSHS

Challenges During COVID-19 • Segregating and reporting results from different test types, when the type (molecular, antigen or antibody) can change the meaning of the result • A much higher number of results due to reporting both positive and negative results (a first in public health reporting) • Incomplete patient information from new testing sites

• Public and private labs

• Lengthy delays in communicating test results to patients and local health departments

• Healthcare providers

• Data backlogs and delayed and/or misleading reporting

• Local health departments • CDC

• Lack of interoperable systems requiring faxes, phone calls and manual entry

• Supply Chain Strike Force

• Hundreds of new reporting entities requiring technical assistance

• Regulatory agencies

• Technical issues causing data entry backlogs and data quality problems

• Congregate settings: schools, jails, prisons, etc.

• Lack of initial data validation process (since added); no external audit process

• Individuals

• Changing federal reporting requirements during event • Limited DSHS authority over reporting entities; no ability to require specific data formats or to ensure complete and timely reporting • Many local health departments without electronic medical record systems • DSHS required to post “real-time” data without the ability to review and investigate cases for accuracy • Conflicting state and local case data • Confusion concerning how the state would report positive cases in congregate settings (nursing homes, prisons, schools, childcare facilities, etc.)

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Hospital capacity Key Systems: WebEOC and EMResource Affected Entities:

Challenges During COVID-19 • Systems designed for short-term bed management during disasters; cannot capture information such as length of stay and equipment or staffing levels • Prior to the pandemic, facility-level data in these systems never analyzed for purposes or to extent as used today

• Hospitals

• Rapidly changing federal reporting requirements

• Regional advisory councils

• Unclear authority of DSHS commissioner to require additional reporting

• DSHS • Supply Chain Strike Force

Mortality reporting Key system: Texas Electronic Vital Events Registrar (TxEver) Affected Entities:

• Discrepancies in reporting COVID-19 death locations and demographic information due to multiple processes (during the event, DSHS changed mortality reporting to rely only on official certificates reported through TxEver)

■ Chapter 5 / The Public Health Response

Affected Information Systems/Entities

• Lack of integrated/automated disease surveillance systems

• DSHS • County vital statistics • Local health departments

Analytics Affected Entities: • DSHS • Supply Chain Strike Force

• Multiple disease models circulating from various sources; no “official” state models or tools, leading to conflicting and confusing information • Ad-hoc and changing metrics and thresholds to monitor status of disease spread; local jurisdictions set their own standards and benchmarks that varied considerably across state

• University/private scientists • Private organizations • News media

Information sharing Affected Entities: • DSHS • Case investigation and contact tracing partners • News media • Local health departments • Agencies

• Constant challenge in communicating meaningfully with the public through dashboards and other web tools; all data noted as provisional and constantly changing • Secure data sharing to facilitate case investigation • Difficulties in sharing accurate information on high-risk congregate settings • Constant requests for information from media, researchers and the public for public information such as infection rates in nursing facilities and schools

• Researchers Note: The intent of this chart is to illustrate the wide scope of data challenges experienced during COVID-19. Some of these issues have been reduced or resolved since the early days of the pandemic.

Sources: Multiple interviews with state and local officials, press reports and internal documents

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■ RECOMMENDATIONS DISEASE TESTING 8 Require DSHS and TDEM to develop and regularly update a detailed state pandemic testing deployment plan.

In the pandemic, public health systems everywhere struggled to support the ramp up of testing in the face of a worldwide supply shortage. In March and April, Gov. Abbott called for the creation of a state testing program, which required intensive coordination among TDEM, DSHS, the Texas National Guard and dozens of other public and private entities.

This plan would allow the state to make formal preparations for large-scale testing in the event of a pandemic and should be considered as a key element of broader state pandemic planning (see Recommendation 30).

This plan should include: • DSHS-led public health testing strategy guidance, including rapid methods for prioritizing populations and geographic locations for testing and transmitting test results; • a TDEM-led logistics and deployment plan, including communications for local site coordination; • an “early warning” trigger that requires DSHS and TDEM to begin assembling resources; • planning participation by public and private laboratories, local health departments, RACs, the Texas Military Department and other entities that may be involved in deploying testing sites; • coordination with state strategic stockpile planning to ensure testing needs are considered; and • a public and local government communications strategy and plan for testing sites.

9 Require DSHS to conduct a regular survey of Texas laboratory capacity.

In the earlier portion of the pandemic, laboratory capacity was in short supply. Public health laboratories couldn’t support the volume of tests needed, but the state had to rely on daily phone calls to determine the capacities and run rates of other labs.39 Texas should establish a system to obtain lab capacity information as part of its preparedness activities.

DSHS should be required to conduct a survey, updated biennially, of major commercial, hospital and public labs to understand their diagnostic capacity. The labs, in turn, should be required to report information to DSHS for the survey and during an actual public health disaster.

Labs surveyed should include those managed by university entities such as the Texas A&M Veterinary Medical Diagnostic Laboratory (TVMDL) and the University of Texas Medical Branch at Galveston.

The survey also should identify funding sources that could be used in an emergency to support testing at nontraditional labs and to collect information on changing technologies and testing innovations. DSHS should complete the first survey by November 1, 2022 and should share the results with TDEM.

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On March 31, 2020, TVMDL applied for a waiver from federal regulations under the Clinical Laboratory Improvement Amendments (CLIA) that would have allowed its personnel to perform as many as 1,200 human tests a day.40 The lab received permission to perform human testing, but with staffing requirements it generally couldn’t meet. TVMDL was limited to using only about 10 percent of its potential capacity for human COVID-19 testing and only about 28,500 human tests were processed in TVMDL facilities from March to September 15, days of critical need.41 Congress should consider amending the Public Health Service Act to waive CLIA personnel requirements in an emergency, so that TVMDL and similar facilities can perform human testing. An amendment of this kind has been supported by the Association of American Veterinary Medical Colleges, the American Veterinary Medical Association and the American Association of Veterinary Laboratory Diagnosticians.42

PUBLIC HEALTH WORKFORCE 11 Require DSHS to develop a Texas public health workforce surge plan in partnership with the state’s public health schools.

■ Chapter 5 / The Public Health Response

10 The Texas congressional delegation should work with Congress and federal agencies to waive federal requirements that prevent the Texas A&M Veterinary Medical Diagnostic Laboratory from using its full capacity for emergency human diagnostic testing.

As COVID-19 spread, a public health workforce that had been declining for more than a decade quickly became overwhelmed. Many Texas counties have only a handful of public health employees or no local health department at all, requiring DSHS to fill in. Texas’ public health schools provided important emergency staffing during the pandemic, but their help was slowed by bureaucratic obstacles such as contract negotiations and human resources onboarding.

Public health schools are particularly well-suited to provide surge support during such emergencies, including case investigations as well as technical support, training and analytics. Their students and faculty, in turn, would benefit from real-world experience that also might become a valuable recruitment tool for the state’s public health workforce.

DSHS should develop a plan and advance agreement with the state’s public health schools that could be activated quickly in a public health emergency. The planning process should include a working group of the schools, DSHS, local health departments and relevant stakeholders such as hospitals.

The plan should establish the types and amount of assistance schools could provide; reimbursement arrangements; and the data-sharing agreements required for investigations and other support activities.

This plan also could include other appropriate public- and private-sector partners, including other university departments outside of public health.

DSHS should seek TDEM’s feedback on the plan to ensure its alignment with the State Emergency Management Plan. TDEM, in turn, should update its state plan to reflect this new resource. DSHS should complete the plan no later than November 1, 2022.

12 The Texas Legislature should fund a consortium of the state’s public health schools to bolster the state’s public health and disaster response surge capacity.

To address critical public health workforce gaps and better employ the expertise of the state’s public health institutions in a disaster, the Legislature should fund a consortium of public health schools to develop the training, technical assistance and research needed to support public health preparedness and response. The U.S. Centers for Disease Control and Prevention (CDC) previously provided funding for such efforts, but largely discontinued it in 2015.43 Between $5 million and $10 million in annual funding for this effort should be managed through DSHS. The consortium should present detailed plans and performance metrics for the use of this funding. A portion of the funding should directly support degree or certification programs that further specific disaster needs such as rapid-response case investigations.

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The planning process to develop this consortium should include a working group of public health schools, DSHS, local health departments and other stakeholders such as hospitals and other university departments outside of public health. DSHS should seek TDEM feedback on the funding plan and objectives to ensure its alignment with the State Emergency Management Plan. TDEM, in turn, should update the state plan to reflect this new resource.

PUBLIC HEALTH DATA ISSUES 13 Require DSHS to convene a multi-disciplinary taskforce to recommend improvements in the processes and systems used to collect, analyze and report key public health data during a widespread infectious disease event.

No infectious disease event has ever demanded the level or speed of reporting required for the coronavirus. The efforts of DSHS and other entities to improve and update their data systems during the crisis were admirable, and jurisdictions around the world have encountered similar challenges. Even so, COVID-19 underlined Texas’ need for better public health information. Texas’ decentralized public health system creates significant challenges for fast and reliable data collection and reporting in a pandemic.

The collaboration of many stakeholders and partners will be needed to make lasting improvements to these processes. The DSHS commissioner should appoint the members of the task force, which could be organized into subgroups by topic area, to include representatives from: • DSHS headquarters and regional offices, including vital statistics expertise • TDEM • the Governor’s Office • RACs serving as Hospital Preparedness Program regions • Local public health departments • Public and private laboratories and pharmacies • Hospitals and emergency medical services entities • Long-term care facilities • Texas-based experts in infectious disease modeling and biostatistics • The Texas Health and Human Services Commission (HHSC), including regulatory program staff • Representatives of other appropriate state and federal agencies, including member agencies of the Texas Emergency Management Council as well as CDC and the U.S. Department of Health and Human Services • Private industry representatives, such as various healthcare associations • Public health schools • Pharmacies and other providers involved in vaccine distribution • The Texas Department of Information Resources (DIR) The task force should review and address key challenges and recommendations relating to testing data, hospital capacity reporting, vital statistics, vaccine registry data, data analytics (such as modeling) and information sharing. In addition, it should address and balance the need for information during a pandemic with the burden it places on healthcare providers. Similarly, it should consider and balance the right to public information with personal privacy requirements.

The task force also should address data quality concerns and propose an ongoing process to test and improve data accuracy, including an audit process or “stress testing.”

The task force should make its recommendations no later than November 1, 2022, for consideration in the 2023 legislative session. Its recommendations should include a clear appropriations strategy for funding improvements proposed in its report, as well as requests for appropriate federal changes.

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The Legislature, either by statute or by direction of the Legislative Audit Committee, should direct SAO to conduct a COVID-19 data quality audit using guidelines recently developed by a consortium of several state auditors with assistance from the National State Auditor’s Association.

The audit should be conducted as quickly as possible to inform the multi-disciplinary task force (see Recommendation 13). This work should be completed no later than May 1, 2022. The audit should be conducted as part of SAO’s work plan and should not have a significant fiscal impact on the state.

15 Clarify portions of the Health and Safety Code concerning the DSHS commissioner’s authority to make decisions on data reporting and data sharing during a pandemic.

During a public health disaster, the DSHS commissioner currently has two authorities under Chapter 81 of the Health and Safety Code that would benefit from clarification.

While the DSHS commissioner can require additional disease reporting from health care providers during a public health disaster, the law doesn’t cover other healthcare information DSHS may need to manage the response, such as information about hospital and laboratory capacity.44 During the current event, the governor issued executive orders requiring such information.45 While hospitals and private laboratories collaborated well with the state throughout the pandemic, in a public health disaster the DSHS commissioner should have clearer authority to require timely reporting in specific formats from a wide range of health care entities.

■ Chapter 5 / The Public Health Response

14 Require the Texas State Auditor’s Office (SAO) to conduct a COVID-19 data quality audit to identify necessary public health data system improvements.

Furthermore, Chapter 81 allows the release of information to local health authorities that otherwise would be considered confidential. It requires release of the “minimum necessary” information, but doesn’t clarify which entity ultimately decides on the format and appropriateness of these releases.46 The law should clarify that, during a public health disaster, DSHS can specify the format and contents of such information while preserving confidentiality to the extent possible.

State law also should allow DSHS to provide such information to other local entities managing frontline response, such as county judges and other local officials, as the commissioner deems appropriate. DSHS should work with local health authorities, first-responder groups and emergency managers to develop a process for implementing this authority during future infectious disease events.

16 HHSC should suggest statutory modifications addressing the timely reporting of infectious disease in long-term care facilities.

Statutory ambiguity delayed the release of information about one of the state’s most vulnerable populations for nearly four months. HHSC should suggest statutory changes needed to clarify how the agency can release such data quickly while satisfying confidentiality requirements. While the Texas Attorney General’s Office ruled on these issues during the pandemic to allow such releases, statutory changes would ensure a clear process for providing this information in a timely manner for a population highly vulnerable to infectious disease.47 HHSC should submit its proposed statutory changes to the Legislature no later than November 1, 2022, for consideration in the 2023 legislative session.

n

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A teacher gives a student a name tag on the first day of school at Johnson Elementary, August 20, 2020. (BryanCollege Station Eagle)

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CHAPTER 6 CHAPTER 6

KEY SUPPORT FUNCTIONS In the early days of the COVID-19 emergency, almost all government functions had significant roles to play in addressing the pandemic, but not all could be addressed in this report. We selected the following support functions that had significant and addressable policy implications for the state as the need for social distancing grew.

Child care services, especially for essential workers, became a critical issue for the economy. Information technology (IT) infrastructure, always a concern, suddenly came into sharp focus as we charted new remote approaches to meet our needs. Telework and telemedicine became essential methods for helping meet two of these needs: workforce productivity, a key to the state’s economic viability; and medical services, always important but even more so in a medical emergency such as the COVID-19 pandemic.

Improving policies in these areas is critical to becoming more resilient to future pandemics and can provide everyday benefits as well.

IMPROVING CHILD CARE SERVICES, IT INFRASTRUCTURE, TELEWORK AND TELEMEDICINE IS CRITICAL TO BECOMING RESILIENT TO FUTURE PANDEMICS.

■ CHILD CARE SERVICES The Texas Health and Human Services Commission (HHSC) is primarily responsible for overseeing the state’s child care industry. It licenses, regulates and inspects child care operations; educates parents and the public about minimum standards of care; and provides technical assistance and training for child care providers.1 In addition, the Texas Workforce Commission (TWC) administers the federal Child Care and Development Block Grant, which provides child care subsidies for low-income parents to allow them to work or attend workforce training or educational classes.2 Local workforce development boards administer the program in their areas; lengthy waitlists are common.

Before the pandemic, nearly 60 percent of U.S. children under age five participated in weekly care arrangements with a non-parental provider, typically child care facilities or relatives. For older children, school is the most common care arrangement, but many also participate in care programs after school and during breaks.3 As shelter-in-place orders began in March 2020, daycares and schools across Texas closed and child care became a critical issue for working parents — and the economy.

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FEDERAL ACTIONS On March 27, the federal government passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which included billions in assistance for child care providers (Exhibit 6.1).4 Yet a majority of Texas providers didn’t receive CARES Act funds.

Before the pandemic, just 47 percent of Texas licensed child care providers received ongoing federal subsidies for low-income parents through TWC, and only they received CARES Act support.5 Inadequate finances contributed to many closures of child care facilities during the pandemic; 20 percent of licensed Texas providers closed between February and September 2020. According to HHSC, unsubsidized providers accounted for 69 percent of closures.6 Exhibit 6.1

CARES Act Child Care Provisions The federal CARES Act provided: • $3.5 billion for the Child Care and Development Block Grant program for providers who accept subsidies to provide care to lower-income families, as well as those who care for the children of essential workers; • additional funding to allow programs to operate at lower enrollment ratios when providing care for essential workers’ children, regardless of income; • cleaning and sanitation supplies, regardless of subsidy status; • income support for small and midsized child care businesses, including loans through the act’s Paycheck Protection Program (PPP); and • waivers or partial coverage of child care tuition to alleviate costs for families who might not be able to continue child care without assistance.

Sources: Child Trends and First Five Years Fund.

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STATE ACTIONS Gov. Abbott made child care a priority in the state’s early response to the pandemic. One focus of the governor’s Supply Chain Strike Force was creating a statewide child care infrastructure for essential workers.7 The strike force consolidated child care-related information and directives from various state, local and federal entities through a new web portal, Frontline Child Care, which allows parents to look for child care openings near their home or office.8 Abbott expanded child care capacity for essential workers and supported the creation of free, COVIDspecific online training for providers. The governor’s initiatives rolled out as follows: March 27: Established new processes to preserve and extend child care capacity for essential workers.9 April 6: Announced a partnership with Care.com to increase in-home child care access for frontline workers.10 April 10: Announced development of the Frontline Child Care website.11 April 29: Announced free online training for child care providers during the COVID-19 response.12 May 18: Announced child care centers could reopen immediately to all, not just essential workers, with enhanced safety, disinfection and social distancing guidelines.13 June 3: Exempted child care services from business occupancy limits.14 June 23: Directed HHSC to enact emergency rules to increase safety at child care centers.15

CHILD CARE PROVIDERS One analysis estimated that school and daycare closures during the pandemic could cost the nation $700 billion in lost revenue and productivity, about 3.5 percent of the gross domestic product.16 Even before the pandemic, affordable child care had been a long-time concern in Texas and other states.

According to HHSC, the number of Texas child care operators declined from 20,882 in fiscal year 2015 to 17,546 in fiscal year 2019.17 The pandemic is likely to close many more. By October, the U.S. child care industry faced an overall net loss of 177,900 jobs due to the pandemic — 17 percent of its workforce.18

Temporary financial assistance through the CARES Act, moreover, wasn’t enough to sustain some providers beyond the initial lockdown.19 As noted earlier, fewer than half of Texas’ licensed providers received CARES Act funding; only 21 percent received PPP loans.20 A June 2020 survey of child care programs released by the National Association for the Education of Young Children (NAEYC) found that nearly half of Texas respondents expected to close within six months if they continued to operate at lower capacity without additional financial support.21 A December NAEYC survey found that 56 percent of child care centers across the U.S. said they were still losing money each day they remained open.22 While the federal government provided CARES Act funding for child care support, the states were responsible for its distribution and oversight. TWC stopped taking applications for subsidies to Texas’ essential workers in May and ended all payments in August. Another temporary TWC program, covering the share of expenses low-income parents normally pay when receiving child care subsidies, ended on June 1.23 Advocates asserted that ending these subsidies prematurely could make child care unavailable for many essential workers and lowincome parents.24 Some local governments attempted to fill the gap.

By August, for instance, the city of Austin had distributed $900,000 in loans and grants to child care providers.25 On December 9, the city announced it would distribute an additional $5 million in relief grants for child care providers; these grants of up to $60,000 each could be used for “payroll, rent relief, operational costs and other eligible COVID-19 related expenses.”26 As the research for this report was being finalized, Congress passed the Consolidated Appropriations Act of 2021 in late December. The act allocated $10 billion to states in pandemic aid for the child care sector. Funds may be used to support child care providers faced with lower enrollment and higher operating costs; subsidize parents’ co-payments; cover staff salaries; provide child care for essential workers regardless of income; and facilitate reopening by supporting related expenses. Texas is anticipated to receive an estimated $1.08 billion, in addition to the $371 million the state received through the CARES Act in 2020, to respond to the child care impacts of COVID-19.27 It’s not clear at the time of this writing how the state intends to allocate these funds.

To meet the increased need for child care, particularly for essential workers, Texas and other states requested waivers from various federal requirements, such as waivers that would allow them to fund short-term relief programs instead of the required 12-month grant period. The slow federal response to these requests, however, hampered the state’s response. Texas agencies reported that federal approvals for child care waivers were slow during this critical time, with some requiring up to three months.28

DATA LIMITATIONS Data limitations posed an additional challenge.

HHSC collects data on licensed providers’ capacity and the number of providers in each county, but doesn’t track point-in-time availability. The Frontline Child Care website helped the situation. Providers could register on the portal, list their spots and other program details; essential workers could look for providers with openings in their areas. Due to the website’s success, the state intends to convert it into a “one-stop-shop” for all Texas families and providers.29

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FEDERAL WAIVERS

Delays in the public reporting of COVID-19 case data for schools and day cares also proved problematic.

State agencies didn’t begin publicly publishing information on COVID-19 rates for public schools and child care operations until August 20, 2020, well into the pandemic.30 This information is essential to determining incidence rates across Texas — and the risks of child care and in-person education.

COORDINATION OF EARLY CHILDHOOD EDUCATION PROGRAMS The Bipartisan Policy Center has developed a scoring system for how well states integrate Early Childhood Education (ECE) programs. This integration matters because it makes it easier for families to access services and promotes better oversight and resource allocation by the state. In December 2018, this system ranked Texas last nationally for its integration of ECE.31 The center noted that Texas’ administration of ECE programs was highly fragmented. Lowerscoring states typically had more agencies involved; in Texas, five state agencies administer ECE funding.

Only one other state involved this many entities.32

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Since this ranking was issued, Texas has made improvements in this area. In 2018, an interagency work group, the state interagency early education collaboration, representing the Texas Education Agency (TEA), TWC, HHSC and the Texas Department of Family and Protective Services (DFPS) jointly created and funded the position of interagency deputy director of early childhood. The partners say this initiative has proven useful in coordinating information-sharing and implementing joint strategies during the pandemic.33

■ INFORMATION TECHNOLOGY AND RELATED POLICIES IT plays a critical role in every governmental agency. During the state’s response to COVID-19, IT services supported the tracking and monitoring of the pandemic’s spread; the coordination of emergency workers across the state; telecommuting, telemedicine and virtual learning; the location and purchase of medical supplies; and critical public information regarding safety protocols.

Each Texas state agency oversees its own IT system with varying levels of support from the Texas Department of Information Resources (DIR).34 While state agencies rely on DIR for some services and expertise, it doesn’t have direct authority to oversee or coordinate state agencies’ IT operations. Despite this limitation, DIR has played a critical role during the pandemic, assisting agencies with application development and telework, expanding their IT capacities and advising them on topics including video conferencing, procurements and use of the “cloud.”35

TRANSITION TO TELEWORK Texas also lacks a centralized human resources (HR) agency. State law provides standards for some benefits, such as leave time and certain payment provisions, but each agency develops its own policies and procedures in compliance with these guidelines.

The state doesn’t prescribe comprehensive HR policies for emergencies and has no central oversight authority to ensure agencies comply with state law during an emergency.

This decentralization became an issue during the state government’s move to widespread telework.

Chapter 658 of the Texas Government Code authorizes but does not require state agencies to offer telecommuting from alternative work locations; each agency can use its own discretion in developing telework policies.36 An April 2019 Legislative Budget Board report included a survey of 13 large state agencies that found 11 offered some level of telecommuting during fiscal 2017. Participation rates varied from 0.5 percent at the Texas Department of Agriculture (TDA) to 27.4 percent at the Texas Comptroller of Public Accounts.37 In survey comments, TDA stated its telecommuting options were limited largely to “extraordinary circumstances.”

Gov. Abbott’s March 13 statewide disaster declaration, however, directed all state agencies to provide flexible work and telework policies while continuing to provide necessary services.38 Agencies such as the Comptroller’s office, which already had formal telework programs, expanded them relatively easily, but others faced significant challenges including equipment issues, security policies and procedures, training and the monitoring of employee performance.

EQUIPMENT Depending on their roles, telework employees may require laptops, headsets, mobile phones and related software and support. While the March 13 disaster declaration allowed agencies to use an emergency exemption to buy IT equipment directly, these purchases occurred at a time of significantly increased demand, limiting their options.39 In a presentation to state agencies, DIR stressed the reality of the phrase “while supplies last.”40 DIR estimates that state entities purchased more than 14,000 mobile computing devices through bulk purchase agreements and other DIR cooperative contracts in the first 60 days of the pandemic.

Agencies made an unknown number of additional purchases under the emergency exemption.41 HHSC alone ordered about 10,000 laptops plus additional equipment. These purchases and activation of the equipment required about 10 days.42 Outdated IT equipment and limited staffing were especially troublesome for TWC.43 Between March 15 and September 19, more than 3.5 million Texans filed for unemployment.44 The agency simply was overwhelmed. Before the pandemic, TWC received

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TWC acted quickly to expand its capacity. In March, the agency had 400 employees at four call centers;

by September, it had 1,500 workers at eight call centers. Call-center hours were expanded to 12 hours a day, seven days a week. TWC also used its website to post information on how to apply for COVID-19 benefits, as well as an FAQ and resources for the news media.47 Even so, callers continued to report problems in getting through or finding answers to their questions. The agency urged people to submit applications online. One legislator said the problem wasn’t with staff but with equipment, noting the agency was “operating with a very old, 1980s, 1990s style technology.”48

SECURITY Widespread telework requires effective cybersecurity. The state has strict requirements related to information security and confidentiality, but expanded telework and higher usage of mobile and digital applications increase the opportunities for cyberattacks. Without a comprehensive plan, agencies face increased vulnerabilities as they rush to adapt in an emergency.

In its 2020 Biennial Performance Report, DIR noted that state agencies identified the increasing sophistication of threats as the top barrier to cybersecurity.49 In a 2019 survey, 90 percent of state agency technology leaders and executives ranked cybersecurity as “highly relevant” in the next two years, scoring it significantly higher than any other issue.50

MORE THAN A MILLION TEXAS HOUSEHOLDS CAN'T ACCESS THE SPEEDS NEEDED FOR MANY TELEWORK AND REMOTE LEARNING ACTIVITIES.

BROADBAND ACCESS Broadband internet access has been called “a foundation for economic growth, job creation, global competitiveness and a better way of life.”51 Millions of Texans lack the broadband connectivity needed for remote work, online education, telemedicine and access to information during an emergency.

According to Connected Nation Texas, more than a million Texas households can’t access the speeds needed for many telework and remote learning activities.52 In 2019, the Texas Legislature created the Governor’s Broadband Development Council to identify barriers to broadband deployment in unserved areas and study potential solutions.53 This council began holding monthly meetings in May 2020 and issued its first annual report in November.

In examining the main barriers to broadband development, it cited factors such as inadequate infrastructure, low profitability and lacking coordination among stakeholders. The council noted that Texas is one of only six states without a statewide broadband plan.

■ Chapter 6 / Key Support Functions

an average of about 13,000 phone calls a day.

After it began, TWC sometimes received up to 3 million calls in a single day.45 One Houston woman reported spending 30 hours a week for three weeks trying to reach a live TWC operator.46

Based on its research, the council recommended that the Legislature create a state broadband plan and a state broadband office, and consider creating a state funding program to incentivize deployment in unserved areas.54 The Texas Medical Association (TMA) supports the Broadband Development Council’s recommendations and has become an avid proponent of broadband improvements based on doctors’ experiences with telemedicine during the pandemic.55 During the pandemic, doctors often have been forced to help patients work through connectivity issues with computers and cell phones, especially in rural areas.56 In August, Gov. Abbott announced the creation of Operation Connectivity to address the immediate challenges students have faced during the pandemic. Under this program, TEA and local education agencies purchased more than a million personal devices and internet WiFi hotspots for Texas students with federal funding and matching funds from school districts.57 On September 11, 2020, a bipartisan group of 88 Texas legislators sent a letter to Gov. Abbott urging him to develop an immediate state plan for expanding broadband access. The letter

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lauded Operation Connectivity but stated “rural communities are continuing to be left behind,” and recommended that the governor charge the Broadband Development Council with developing a state broadband plan including a timeline and clear goals. They also suggested the creation of regional plans to address unique challenges across the state.58

7 MILLION TEXANS LIVE IN PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREAS. POLICIES AND PROCEDURES Telework required state agencies to develop accompanying policies and procedures for issues such as sick leave and vacation time. The resulting decisions sometimes generated confusion.

One HHSC employee, for example, reported being told she would be required to take paid time off if she didn’t come into the office, even though she could perform her work remotely.59 In another example, following Gov. Abbott’s order on telework policies, the Texas Department of Agriculture told its employees that teleworking would be available only to “high-risk individuals or those living with high-risk individuals,” staff members with children in a closed school and those with a physician’s recommendation to engage in social distancing.60 The agency later revised its policy to be consistent with the governor’s order.

Hazardous-duty payments also raised consistency questions. KXAN News reported that on March 13, 2020, the Texas Department of Transportation (TxDOT) began making these payments to more than 7,600 workers, totaling more than $1.3 million per week. These payments were made until June 1. Yet inquiries at other state agencies with frontline workers (including HHSC, DSHS, the Texas Department of Criminal Justice [TDCJ], DFPS, Texas Facilities Commission and the Texas Department of Public Safety) found that none had offered hazardous-duty pay related to COVID-19.61 As of December 29, TDCJ reported that 30 employees had died in connection with the COVID-19 pandemic.62

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■ TELEMEDICINE AND TELEHEALTH Telemedicine and telehealth refer to services provided through a range of tools that allow health care providers to advise and examine patients remotely rather than face to face.

As COVID-19 spread, telemedicine became an obvious solution to providing safe access to health care.65 It’s particularly helpful to the more than 7 million Texans who live in areas identified by the federal government as Primary Care Health Professional Shortage Areas.66 The State Office of Rural Health Care reports that 63 Texas counties lack a hospital and 35 counties have no primarycare physicians.67 For some rural Texans, the nearest hospital is more than 100 miles away. For them, telemedicine can be especially important, particularly if they have chronic medical conditions or communicable illnesses.

DEFINING TERMS While often used interchangeably, Texas defines telemedicine and telehealth as different types of services subject to different state regulatory provisions. In 2017, the Legislature amended the state’s legal definition of telemedicine to include health care services delivered remotely by a Texas physician or a health professional acting under the supervision of a Texas physician.

Telehealth means a health service “other than a telemedicine medical service” provided remotely by a licensed/certified professional acting within the scope of his or her license.63 Such services might include health education or the remote monitoring of vital signs.

To others, however, telehealth is a broader term that includes telemedicine as well as other, non-clinical services. The U.S. Centers for Medicare and Medicaid Services (CMS) and the Federal Office of Rural Health Policy, for instance, generally employ the term in this way.64 For the purposes of this report, we use the terms “telemedicine” or “telehealth” when discussing Texas-specific regulatory requirements, but note that the terms may not have the same meaning for non-Texas programs.

In Pottsboro near Sherman, the community library played a role in providing telemedicine during the pandemic. After COVID-19 hit, residents called the library looking for telemedicine access. The library director, Dianne Connery, offered her office, the only private room in the building, for video consultations.

Soon, she applied for and received a $20,000 grant from the Network of the National Library of Medicine to develop a formal telemedicine program, and partnered with the University of North Texas Health Science Center to provide services. The library created a soundproof room with computer monitors, improved lighting and an enhanced internet connection. For patients who need more information after a telemedicine visit, the library assists them with their research.68

The pandemic has revealed the complexity and variability of telemedicine benefits in Texas. As with other health benefits, coverage varies by plan, whether it’s Medicare, Medicaid or commercial insurance. Consumers often found it difficult to understand their benefits, their costs and their plan requirements, particularly since regulators continued to announce changes. While state law requires health plans to provide policies and payment practices for telemedicine on their websites, the information can be difficult to find.69 Doctors also struggled to understand changing insurer requirements as well as Texas Medical Board (TMB) regulations that were revised during the pandemic.70

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TELEMEDICINE AT A COMMUNITY LIBRARY

REGULATORY OVERSIGHT HHSC, TMB and the Texas Department of Insurance (TDI) oversee various aspects of Texas telemedicine.

• HHSC regulates Texas Medicaid and the Children’s Health Insurance Program (CHIP) and determines coverage for telemedicine services and requirements for health care providers who offer them.

The OnMed station was delivered in July to the Milam County Sheriff’s Office.

(Texas A&M Health Science Center)

TELEMEDICINE KIOSK IN MILAM COUNTY In August 2020, the Texas A&M Health Science Center opened a telemedicine kiosk at the Milam County Sheriff’s Office in Cameron. The station includes a high-definition camera and equipment for measuring basic vital signs such as height, weight and blood pressure; thermal imaging to provide body temperature and diagnose infections; and a remote stethoscope to allow the clinician to evaluate the patient’s heart and lung function. The station also can dispense hundreds of common prescription medications and prints paper prescriptions for pharmacies. After each visit, the booth is cleaned with ultraviolet sanitization.

• TMB regulates the practice of medicine and licensed health care providers including physicians and other licensed professionals and entities.72 Its rules govern how licensees can provide telemedicine services, including the type of technology to be used, minimum care standards and privacy requirements.73 • TDI regulates fully insured health insurance programs and monitors their compliance with state laws and regulations on benefits for telemedicine services.

In addition, the U.S. CMS oversees both Medicare and Medicaid in coordination with state insurance departments and Medicaid agencies. While CMS delegates significant oversight authority to states, certain benefits and services must be covered under Medicare and Medicaid.

Texas A&M and local officials note that Milam County has lost two hospitals in the past two years and describe the station as a “game changer.” It charges a flat fee of $65 and accepts most credit and debit cards, Medicare and major insurance plans.71

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TELEMEDICINE COVERAGE IN TEXAS Before the pandemic, some of Texas’ key telemedicine requirements were:

Texas Medicaid • HHSC must reimburse Medicaid providers that provide covered telemedicine or telehealth services and encourage but not require providers to offer telemedicine or telehealth services.

• Approved telemedicine services must receive the same rate Medicaid pays for a comparable in-person service.

• Medicaid managed care organizations must provide coverage for telemedicine or telehealth on the same basis as for an in-person service.

• HHSC must ensure Medicaid reimbursement for telehealth services provided through a school district or charter school, including those provided by social workers, occupational therapists, speech-language pathologists, licensed professional counselors and licensed specialists in school psychology.74

Texas Department of Insurance • Regulated health benefit plans must cover approved telemedicine and telehealth services on the same basis as for in-person service. This requirement excludes services provided by audio-only telephone conversations, text-only email messages and faxes.

• Plans are not required to reimburse telemedicine/telehealth services at the same rate used for in-person services, but must post their policies and payment practices for telemedicine on the plan’s website “in a conspicuous manner.”

• Health plans cannot deny payment based on the provider’s choice of technology platform.75

REGULATORY CHANGES DURING COVID-19 Many Texas physicians have been reluctant to offer telemedicine services due to lower reimbursement rates than those paid for in-person services; varying and often burdensome documentation requirements; and constant uncertainty about the requirements of different health plans.

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Even so, provider participation has increased significantly during 2020 due in large part to regulatory changes made in response to the pandemic, including a “payment parity” requirement — reimbursement at the same rate as for inperson services — for commercial insurance plans.

Directives issued by the governor, HHSC, TMB, TDI and CMS also reduced administrative burdens associated with telemedicine/telehealth.76 The U.S. Health and Human Services Office of Civil Rights temporarily waived its enforcement of federal privacy provisions to allow providers to use any private remote communication product to communicate with patients.77 This significantly expanded access to technologies not typically authorized for telemedicine/telehealth, such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video and Skype.

Other actions taken to improve access to telemedicine/telehealth include:

Centers for Medicare and Medicaid Services Before COVID-19, Medicare telehealth benefits were limited to persons living in rural areas. CMS temporarily expanded these benefits and is working on new rules that would make some changes permanent.78 Recent Medicare changes have: • waived federal licensing regulations to permit out-of-state physicians to treat patients via telehealth in states with large COVID-19 outbreaks; • lifted geographical restrictions so that any enrollee can access covered services; • expanded the list of approved providers to include doctors, nurse practitioners, clinical psychologists, physical therapists, occupational therapists, speech language therapists and licensed social workers; • allowed providers to offer telehealth services from Federally Qualified Health Centers (FQHCs) and rural health centers; • allowed enrollees to receive coverage for audioonly services; and • expanded the list of approved Medicare and Medicaid telemedicine services.79

Self-Funded Commercial Plans

In March 2020, Gov. Abbott waived certain regulations and directed TDI to issue an emergency rule concerning telemedicine/telehealth services for patients with stateregulated insurance.80 For Texans enrolled in stateregulated, fully insured, non-ERISA plans (that is, plans not subject to rules of the federal Employee Retirement Income Security Act), this waiver:

Most Texans with private health insurance are covered under self-funded plans. These are offered by an employer that generally contracts with an insurance company to administer the program. The insurer processes the claims, but the money for claims is provided —“self-funded” — by the employer rather than the insurer.87 The U.S. Department of Labor regulates self-funded plans and state insurance departments have very limited authority.

• required payment parity for in-network, covered services, including mental health; • required insurers to cover telemedicine services using any platform allowed by state law, including audioonly phone calls; and • allowed providers to establish a physician-patient relationship by telephone during the initial call.81 The emergency rule initially was set to expire on July 14 but was extended through September 12, 2020.82 On September 25, Abbott announced that major health insurers had agreed to continue providing payment parity through the end of 2020.83

Because self-funded plans are exempt from most government regulations, there’s no central data source or reporting mechanism for tracking changes adopted in response to COVID-19. These plans cover more than 70 percent of Texans with commercial insurance, so the impact of such policy changes is significant.

Because TDI’s rules don’t apply to state-funded state employee and teacher insurance plans, Abbott also directed the Employees Retirement System and the Teachers Retirement System to extend the same telemedicine benefits to the 1.25 million state employees, teachers, retirees and dependents they serve.84

In March, Gov. Abbott asked self-funded health insurers and managed care plans to waive costs associated with testing and telemedicine visits for COVID-19; waive consumer cost-sharing and expand access to telemedicine services; waive requirements for preauthorization; and authorize payments to pharmacies for up to a 90-day supply of any prescription medication.88 Abbott cannot compel any of these actions, however. In May, TDI announced that some self-funded insurers voluntarily complied with at least some of these requests.89

Texas Medicaid

Expanded Telemedicine

In the course of the emergency, CMS issued blanket waivers for Medicaid and CHIP that allow states to take certain steps to ensure enrollees continue to receive covered services. In addition, Texas received a Section 1135 waiver that:

CMS reported a 4,300 percent increase in telehealth usage for Medicare primary care visits between February and April, from less than 1 percent to 43.5 percent of all such visits.90 In late March, one Austin clinic with 28 offices reported that nearly half of its patient visits were virtual.91 An April TMA survey found that 80 percent of surveyed Texas physicians either already offered or intended to offer telemedicine.92

• authorizes payments for Texas Health Steps visits provided via telemedicine for persons older than 24, under specific conditions, when exams cannot be completed in person; • expands allowable telemedicine services to cover telephone-only visits for certain evaluation and management services; • authorizes payments for certain behavioral health services provided via audio-only telephone calls; • allows temporary reimbursement for out-of-state services if the provider is enrolled in Medicare or another state’s Medicaid program; and • pay FQHCs as telemedicine and telehealth service distant site providers.85

■ Chapter 6 / Key Support Functions

Texas Department of Insurance

Both patients and providers are encouraging CMS and states to make telemedicine/telehealth regulatory changes permanent, stating that many have come to prefer its convenience and safety when medically appropriate. As part of its legislative agenda for 2021, TMA intends to push for permanent payment parity and other regulatory changes that have allowed telemedicine to expand in the pandemic, including support for expanded broadband access.93 Some changes to Medicare and Medicaid would require federal approval.

These changes will continue until the public emergency ends.86

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RECOMMENDATIONS CHILD CARE 17 The Texas Workforce Commission (TWC) should consider allocating additional federal child care funds to a wider range of child care programs.

Economic recovery and the return to work are dependent on adequate access to child care. At the end of 2020, Congress passed the Consolidated Appropriations Act of 2021, which includes an estimated $1 billion in additional relief funds for Texas child care providers through the Child Care and Development Block Grant.94 TWC determines how to allocate this funding in Texas. TWC should consider including unsubsidized child care programs (which aren’t already a part of TWC’s existing program) along with subsidized programs when distributing this new funding. Unsubsidized programs appear to be closing at a higher rate and did not receive allocations in the first round of relief passed in the CARES Act earlier in 2020.

18 The Texas congressional delegation should advocate for changes to the Child Care and Development Block Grant to give federal agencies more flexibility to issue blanket waivers to program requirements during emergencies.

To meet the increased need for child care, particularly for essential workers, Texas requested waivers from various federal requirements, such as permission to fund short-term relief programs instead of the normally required 12-month grant period. The slow federal response to these requests hampered the state’s response. Texas agencies reported that federal approvals for child care program waivers took up to three months. Many other states also requested similar flexibility, but were told that current block grant rules don’t allow the issuance of such waivers.95

19 The Texas Legislature should support the ongoing collection and transparent reporting of infection rates in child care settings essential to policymaking and family decisions.

HHSC should continue to collect and publish COVID-19 infection rates from public schools and child care centers, in collaboration with DSHS and TEA. The agencies should plan to report this information in a timelier manner in any future pandemic.

20 The governor should consider expanding child care options earlier in a pandemic to reduce the economic impact on families and the state.

In a pandemic, the governor should consider directing TWC to open subsidized child care slots to all workers as soon as capacity allows.

For future pandemic planning, relevant state agencies including the Governor’s office, HHSC, TWC and TEA should consider how to expand child care options if schools must be closed for extended periods.

For example, the child care industry is shifting to provide support for online schooling, but such changes would require regulatory flexibility from HHSC and additional coordination between school districts and child care providers.

21 The Supply Chain Strike Force’s early and ongoing emphasis on child care responsiveness is a best practice that should be included in future planning for pandemic response.

A focus on child care needs should be institutionalized as part of future pandemic planning efforts (see Recommendation 30). The Frontline Child Care website in particular filled a void at a crucial moment by supplying data on available child care seats through a central information resource. It should be continued and expanded as part of the existing interagency early childhood collaboration.

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22 The Legislature should provide guidance on state agency policies regarding sick leave, vacation time, overtime payments or accrual and hazardous-duty pay for eligible state employees working during a pandemic.

The Legislature should appoint a work group of human resource representatives, employees and executive staff members from agencies of varying sizes to develop recommendations for legislative consideration. The Legislature could use the existing State Agency Coordinating Committee as a forum for this effort or appoint a separate committee.

Agencies with varying degrees of employee risk during a pandemic should be represented, including those with health care and public safety workers and other staff required to interact face to face with the public during a health crisis. The report should be submitted to the Legislature no later than November 1, 2022, and should include recommendations for improvements.

23 Require the Department of Information Resources (DIR) to develop a long-term plan for improving the state’s information technology infrastructure for future pandemics and other emergencies.

■ Chapter 6 / Key Support Functions

INFORMATION TECHNOLOGY AND STATE TELEWORK ISSUES

DIR should establish a work group to inform the plan’s development including representation from a range of state agencies and members of the Information Technology Council for Higher Education. The plan should include an overview of the challenges agencies and higher education institutions encountered during the pandemic, including the transition to remote work, customer service and interactions with service providers and vendors. It should assess technology modernization plans and requirements to support secure remote work; changes needed to allow agencies to collect and share information in real time; and any other recommendations that can help ensure that state government and institutions of higher education are prepared to continue operations during emergency events. DIR should submit the plan to the Legislature no later than November 1, 2022, for consideration in the 2023 legislative session.

24 Require all state agencies to develop a telework policy and implementation plan for both normal business operations and emergencies.

State law authorizes but does not require state agencies to offer telecommuting. The law should be amended to require state agencies to develop telecommuting policies and implementation plans.

These plans should account for varying scenarios including both pandemics and weather-related events.

Each should be reviewed and updated at least annually, with the first plans due November 1, 2022. All employees should complete training to ensure they are prepared to work remotely when necessary. A test run should be conducted at least annually.

State agencies should develop an inventory of their IT needs for remote work to enable the state to develop a long-term strategy for equipment upgrades, thus avoiding costly emergency purchases. All agencies should be required to include associated costs in their budget proposals to the 88th Legislature for the 2024-25 biennium.

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25 Require the state’s Broadband Development Council to develop a detailed statewide broadband expansion plan.

High-speed internet access became a critical lifeline during the pandemic, and it will continue to be increasingly important to the state as a whole. Given the importance of this service and the recommendations made in the Broadband Development Council’s November 2020 report, the Legislature should direct the council to develop a statewide broadband expansion plan that includes specific expansion goals, timelines and cost estimates.96 The council should submit the plan to the Legislature no later than November 1, 2022, for consideration in the 2023 legislative session. As part of this process, the council should: • evaluate approaches other states have used to spur broadband development, particularly those with extensive rural areas; • regularly collect broadband access and usage data to evaluate progress and prioritize areas for expansion; • incorporate best practices in planning and implementation used by other states;97 • identify funds available to assist broadband expansion, including federal funds and grants; • identify eligibility requirements that may prevent the state from accessing such funds and recommend ways to address them; • recommend entities that should apply for funding; • identify interim steps to improve broadband access until permanent solutions can be achieved; and • provide specific deadlines and detailed expectations for ongoing reports to the Legislature.

26 The Legislature and TWC should continue to prioritize modernization of the Unemployment Insurance system to support higher volumes and quicker processing of claims during an emergency.

TWC should include the development of a detailed plan to employ artificial intelligence to quickly increase call-center capacity as well as the creation of a pre-approved list of vendors that could be used to provide additional technology and staffing.

TELEMEDICINE 27 Require HHSC to convene a work group to make recommendations on the permanent expansion of the list of services eligible for telehealth/telemedicine in Medicaid and the Children’s Health Insurance Program as well as the types of providers who should be allowed to deliver these services.

During the pandemic, HHSC temporarily expanded the list of telehealth and telemedicine services available for Medicaid enrollees. This list should be evaluated for permanent adoption to aid in future emergencies and address longstanding provider shortages across the state. The work group should be appointed by HHSC and include providers, health plans, consumers and other stakeholders.

The group’s review should recommend whether HHSC should permanently offer those services recently made eligible during the pandemic; whether HHSC should include other telehealth/telemedicine services typically allowed in the commercial market or Medicare; and any other recommendations for adding additional services.

In particular, this evaluation should consider services for which HHSC receives the most complaints about availability, as well as those services for which the state’s managed care organizations cannot meet current network adequacy requirements.

The work group also should identify additional services that could be provided temporarily via telehealth/ telemedicine in an emergency; HHSC could immediately authorize these when necessary. It also should

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28 The Legislature should establish a telemedicine work group to review innovative telemedicine programs throughout the state and identify long-term strategies for their sustainability, expansion and growth.

Given the critical importance of telemedicine services during the pandemic and the successful rollout of additional services, the state should make a thorough review of the best ways to expand these services responsibly in normal times.

In addition to HHSC staff, the working group should include representatives from state-funded medical schools engaged in telemedicine programs, healthcare and industry associations, regulatory agencies and consumers. The work group should include a wide variety of provider types and consider all types of services that could be delivered effectively via telemedicine. Its efforts should involve an evaluation of current Texas telemedicine projects, including projects funded through HHSC’s Delivery System Reform Incentive Payment program and more recent models developed during the pandemic.

■ Chapter 6 / Key Support Functions

consider whether and how HHSC should revise applicable Medicaid regulations to allow health plans to count in-network telehealth/telemedicine providers, as well as the issue of parity in reimbursement rates for telemedicine versus face-to-face services. HHSC should submit the results of the work group to the Legislature no later than November 1, 2022, for consideration in the 2023 legislative session.

The group should recommend strategies for continuing support of existing projects as well as future expansion and growth, and the regulatory and statutory changes necessary for their support. It also should evaluate and issue recommendations for the development of the technology infrastructure needed to expand access to telemedicine, including broadband. HHSC should submit the results of the work group to the Legislature no later than November 1, 2022, for consideration in the 2023 legislative session.

29 The Texas Department of Insurance (TDI) should conduct regular reviews of health-plan websites to ensure their compliance with the state’s requirement that information on telemedicine must be displayed prominently.

Access to information on telemedicine benefits and providers is critical for consumers in a pandemic.

While state regulations require regulated health-plan web sites to “display in a conspicuous manner” their telemedicine policies and payment practices, a review of a sample of websites found that information on telemedicine often was either difficult or impossible to locate. To ensure ongoing compliance with this requirement, TDI should visit managed-care plan websites to confirm their compliance with this requirement at least annually. Plans not in compliance should be subject to appropriate enforcement action.

n

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A crossing guard greets children on the first day of school for College Station ISD, August 18, 2020. (Bryan-College Station Eagle)

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CHAPTER 7 CHAPTER 7

P R E PA R I N G FOR THE FUTURE COVID-19 isn’t the first serious infectious disease Texas has faced. In 2009, novel influenza A H1N1, known informally as the “swine flu,” set off alarm bells around the world, perhaps in part because the virus initially showed high mortality among young, healthy individuals, similar to the 1918 H1N1 virus. In 2014, the deadly Ebola virus broke out in West Africa; the first diagnosis of a U.S. Ebola patient occurred in Dallas in that same year. As it turned out, the swine flu caused less severe infections than anticipated, and Ebola was quickly contained in Dallas.1 Yet such events were harbingers of future threats, and Texas took some actions to prepare for the next outbreak. After the Ebola crisis, for instance, the state created the Infectious Disease Response Unit, part of its medical disaster system, to deal with such threats.2 Still, nothing prepared Texas or the nation for an infectious disease of COVID-19’s scope and characteristics.

Previous chapters have suggested ways to improve our response to future pandemics through better preparation for activities such as disease testing and the “surging” of public health personnel. This chapter takes a broader view of preparedness, focusing on planning, funding and training for infectious disease emergencies in the future.

■ PANDEMIC PLANNING While federal, state and local government entities have planned for various aspects of pandemic response, COVID-19 has demonstrated a need for Texas and the nation to focus on developing a comprehensive overarching implementation plan and strategy.

This isn’t surprising; the drive to plan loses steam in the often-lengthy intervals between serious infectious disease events. The involvement of every level of government as well as private entities in pandemic response, moreover, makes planning challenging at best. Overcoming this challenge probably requires a common sense of urgency to create the will and momentum for better preparation.

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This moment of urgency has arrived. We’ve seen and continue to see the devastating consequences of COVID-19.

The increasing possibility of pandemics in the future lends another dimension to this urgency. Densely populated urban centers, global trade and travel, and increasing demand for agricultural products all make more frequent contact with infected people and animals almost certain.3 These factors underline the need for all governments to become better prepared for a future pandemic — and to plan for it.

■ FEDERAL PLANNING EFFORTS Different federal agencies have been involved in a variety of pandemic-related planning efforts, including high-level strategy documents, operational plans and “playbooks” setting out steps to take depending on various emerging virus scenarios.

The sheer number of such plans caused at least one observer to comment that any failure in the federal response to coronavirus hasn’t been due to a lack of plans, but to the proliferation of such plans without clear strategies or a clearly identified central authority.4 Some plans have garnered more attention than others. In 2005, then-President George W. Bush initiated a major pandemic planning effort when he became concerned with the possibility of pandemic threats such as the 1997 outbreak of “bird flu.”5 His action resulted in the publication of the 2005 National Strategy for Pandemic Influenza, followed by a document to implement that strategy in 2006.6 Other plans have addressed a broader range of biological threats, such as the 2017 Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans.7

■ STATE AND LOCAL PLANNING In Texas, pandemic planning has been going on for at least 15 years, prompted by virus outbreaks such as the swine flu of 2009. The state hasn’t entirely incorporated such planning in its emergency management system, probably due to the attention that must be devoted to more frequent disasters such as hurricanes, floods, wildfires and other weather-related events.8

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STATE AND LOCAL PUBLIC HEALTH AGENCIES The Department of State Health Services (DSHS) and local health departments are the key public health entities involved in planning for public health and medical emergencies of all types in the state.

Available resources suggest that the pandemic planning efforts of the state’s public health system as a whole often focused on pandemic influenza due in part to the availability of federal funding for this purpose.9 Planning for pandemic influenza also yields benefits for responding to COVID-19, both being respiratory viruses with certain similar characteristics, perhaps the most obvious being the means of transmission.10 DSHS’ experiences with the 2009 swine flu and its evolving interest in expanding its planning beyond influenza resulted in its preparation of a 2015 “public health preparedness, surveillance and response plan,” Respiratory Viruses Having Pandemic Potential.

The document was principally intended to guide DSHS’ actions, but could serve as a guide to local jurisdictions.11 Local health departments have created their own pandemic influenza plans. Interviews suggest that most of them received federal funding for their development. Information about the current status of such plans, however, or associated planning documents, proved hard to find.12

STATE AND LOCAL EMERGENCY MANAGEMENT PLANS As described in Chapter 3, the Texas Division of Emergency Management (TDEM) is responsible for coordinating the state response to disasters of all types, while local emergency management organizations (cities, counties and interjurisdictional entities) manage disaster efforts in their regions.

State law requires TDEM to prepare a state emergency management plan and local jurisdictions to prepare local emergency management plans.

One component of these plans, typically called a plan “annex,” addresses public health and medical emergencies. TDEM establishes the format and approves the plans of local jurisdictions, which generally follow the basic structure of the state plan (Exhibit 7.1).

State of Texas Emergency Management Plan The State of Texas Emergency Management Plan is part of TDEM’s charge to coordinate a “comprehensive, allhazards emergency management program for the state and for assisting cities, counties and state agencies in planning and implementing their emergency management programs.” 13 The state plan consists of a basic plan and various annexes further detailing emergency responses in specific circumstances or emergency events.14

Component

Description

Basic Plan

Describes the state's emergency management organization and a statewide system of coordination.

Emergency Support Function (ESF) Annexes

Outline the objectives, policies, concepts of operations and responsibilities of state agencies relative to unique functional activities before, during and after disaster incidents that exceed the capacities of local jurisdictions. These annexes may be augmented by other supporting plans.

Support Function Annexes

Describe essential supporting aspects that are common to all incidents and serve as the primary mechanism for providing assistance at the operational level. These annexes may be augmented by other supporting plans.

Hazard Specific Annexes

Address how Texas responds to specific types of incidents and may be referenced by other annexes. Hazard annexes may be augmented by other supporting plans.

■ Chapter 7 / Preparing for the Future

Exhibit 7.1

Source: Texas Division of Emergency Management

The state plan includes the public health and medical “emergency support function” annex, called ESF-8, as one of 15 emergency support functions. This annex organizes a coordinated response for incidents with public health and medical impacts, whatever the cause. While many agencies support a disaster response, TDEM has designated DSHS as the primary entity assisting it in ESF-8 planning. DSHS and local health departments support TDEM and local emergency agencies in planning for and responding to public health and medical emergencies.

DSHS began revising and updating its internal system for responding to public health and medical emergencies in 2014. As part of this effort, the agency is revising its 2015 publication, Respiratory Viruses Having Pandemic Potential, to guide its response.15

Some local public health authorities have added pandemic-related plans to their health and medical plans, but information on how many have done so isn’t readily available.16 Given the past availability of federal funding, however, these plans probably focus primarily on influenza.

STATE HAZARD ANNEXES As Exhibit 7.1 above shows, the state emergency management plan contains “hazard-specific” annexes addressing threats of major concern such as droughts, nuclear threats, terrorism, wildland fires and hurricanes.17 TDEM has not yet completed development of an annex for pandemics.18

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■ OTHER PANDEMIC PLANNING ACTIONS

■ CHALLENGES IN STATE PANDEMIC PLANNING

State responses to COVID-19 so far have included elements that could make valuable contributions toward a comprehensive pandemic plan. Some of these follow.

Texas begins with two advantages in any emergency planning effort, including pandemic planning: a viable emergency management framework and extensive experience with disaster, primarily hurricanes. State planners can draw on strengths learned from these events in preparing for any future emergency.

On March 22, Gov. Abbott created the Supply Chain Strike Force, a public-private partnership with highly specialized skills including supply chain and inventory management as discussed in Chapter 4. The strike force helped plan and execute a beginning-to-end supply chain process, spearheading the distribution of millions of pieces of personal protective equipment (PPE) and medical supplies in its 12-week life span. It left the state with innovations and information that could become part of state planning for the sourcing of critical supplies.19

THE SUPPLY CHAIN STRIKE FORCE'S INNOVATIONS COULD BECOME PART OF STATE PLANNING FOR SOURCING CRITICAL SUPPLIES. Gov. Abbott issued The Governor’s Report to Open Texas on April 27, 2020. This report laid out goals for expanding diagnostic testing and contact tracing and included health protocols for individuals, employers and employees to follow as steps to reopen Texas.

It also described a COVID-19 mitigation plan for the state and long-term care facilities.20 DSHS issued a draft COVID-19 vaccine distribution plan on October 16, 2020. The plan addressed an important milestone in the coronavirus timeline, given the key importance of a vaccine.21 As part of the distribution process, DSHS also created the Expert Vaccine Allocation Panel, comprising subject-matter experts and key decision-makers, to recommend vaccine allocation strategies.22 At the time of this writing, the vaccination process has just begun. Experience gained from the process should inform future detailed pandemic planning.

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Yet planning for and responding to COVID-19 has presented many new challenges, and planning for a future pandemic response must address them.

Some of these unique properties of COVID-19 include: • Duration. COVID-19 has demonstrated that a pandemic can linger. At this writing, the state and nation are fast approaching a year-long effort to get COVID-19 under control. In addition, the virus has come in waves, requiring ongoing bursts of intensity in response. Long duration causes fatigue and burnout among health care professionals and first responders, presenting ongoing staffing challenges. These factors also contribute to virus “fatigue,” causing some to become less cautious about safety protocols.

• Statewide impact. A hurricane affects a subset of Texas' counties; a pandemic affects the entire state, creating enormous demand for medical and emergency resources. There are no “safe” areas that can send help.

• “Whole-of-government” involvement. The involvement of every level of government in pandemic response raises jurisdictional questions. In the earlier days of COVID-19, some communities wanted greater control over the virus’ local management than state leaders wanted to grant. Due to the extent of the disaster, moreover, DSHS had to share some of its normal responsibilities with TDEM and other agencies; the confusion that sometimes resulted should be recognized and addressed in future planning.

Then-Gov. Rick Perry created the Task Force on Infectious Disease Preparedness and Response by executive order in October 2014, after the first diagnosis of a U.S. Ebola patient in Dallas.23 Members included representatives from pertinent state agencies and experts in infectious disease, emergency management and public health preparedness and response.24 The task force assessed the evolving emergency and provided real-time support to front-line workers in Dallas. Its December 2014 report included many recommendations to improve the state’s response to future threats from infectious disease. One recommendation called for establishing the task force as a permanent advisory body available to the governor and state leadership during future emergencies.25 Following this suggestion, the Legislature codified the task force into law in 2015 as an advisory panel to the governor (Exhibit 7.2).26 State law directs the task force to provide expert, evidence-based assessments and recommendations for the state response to infectious disease and to serve as an information source for the state’s leadership and citizens.27 As of December 21, 2020, the task force includes the chief of TDEM and the DSHS commissioner, representatives of major state agencies, and universities and officials involved in various aspects of the health professions. The DSHS commissioner is the current director.

The task force includes a “rapid assessment subcommittee,” currently comprising eight members, that can quickly address and offer recommendations on evolving health issues. This subcommittee has served as a sounding board for DSHS during COVID-19 and other infectious disease threats.29

Exhibit 7.2

Current Statutory Membership, Task Force on Infectious Disease Preparedness and Response • The governor may appoint members of the task force as necessary, including members from relevant state agencies, persons with expertise in infectious diseases and members from institutions of higher education.

• Members include: - at least two county judges, one from a county with a population under 100,000 and one from a county with a population of 100,000 or more; - at least two representatives of a local health authority, one from a rural area and one from an urban area;

■ Chapter 7 / Preparing for the Future

TASK FORCE ON INFECTIOUS DISEASE PREPAREDNESS AND RESPONSE

- at least one licensed nurse; and - at least one member defined by statute as emergency medical services personnel.

• The governor shall appoint a director from among its members and may appoint additional members as needed.

• Members serve at the pleasure of the governor.28 Source: Texas Health and Safety Code §81.404.

GOVERNOR RICK PERRY CREATED THE TASK FORCE TO HELP RESPOND TO THE EBOLA CRISIS IN 2014.

The full task force hasn’t met frequently in recent years. Since its four meetings in 2016, the group has met only five times, twice in 2018 and three times in 2020.30 Agendas show a variety of topics were discussed, from updates of a general but informative nature to discussions of specific types of infectious diseases.

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■ FUNDING ISSUES Pandemic preparedness requires a coordinated state network of public, private and nonprofit public health and medical providers. Such a network requires enough funding to support the complex planning, coordination and training required in a state as decentralized and diverse as Texas.

According to the University of Minnesota’s State Health Access Data Assistance Center, in fiscal 2019 Texas ranked 11th from the bottom in state funding for public health, spending about $17 per person in that year.31 This funding has fluctuated in the last decade, reaching an inflation-adjusted high of $30 per person in 2015 and declining thereafter (Exhibit 7.3).

Two important federal funding sources for public health agencies and related entities are the Public Health Emergency Preparedness (PHEP) program administered by the U.S. Centers for Disease Control and Prevention (CDC); and the Hospital Preparedness Program (HPP) administered by the U.S. Department of Health and Human Services.

Congress created both in response to the terrorist attacks of September 11, 2001.32 DSHS receives federal PHEP and HPP funds, distributes them to eligible providers and oversees compliance with program requirements. No direct state funds flow into the programs. PHEP and HPP both support important emergency preparedness initiatives in the state, but have seen significant funding declines in the past 18 years.

18+18.519+19.5 +2224+2021+2430+2923+17.517

Exhibit 7.3

State Per Person Public Health Funding in Texas by Fiscal Year (Adjusted to 2019 Dollars)

$30

$18

$19

$19

$19

$22

$24

$20

$21

$24

$29

$23

$17

$17

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Note: Data not available for 2006.

Source: University of Minnesota State Health Access Data Assistance Center. Adjusted for inflation according to the Consumer Price Index.

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Federal Funding for the Texas Public Health Emergency Preparedness Program and the Hospital Preparedness Program (millions) Fiscal Years 2004 through 2020 (Adjusted to 2020 Dollars) $90 $80 $70 $60 $50 $40 $30 $20 $10 $0

84.7+69.148.444.8+76.443.8+77.947.7+67.536.6+52.134.9+50.631.1+49.832.9+42.428.8+41.629.3+3827.1+40.817.3+40.717.1+36.117.3+39.216.7+38.416.5+39.115.5

■ Chapter 7 / Preparing for the Future

Exhibit 7.4

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

PHEP $84.7

$69.1

$76.4

$77.9

$67.5

$51.1

$50.6

$49.8

$42.4

$41.6

$38.0

$40.8

$40.7

$36.1

$39.2

$38.4

$39.1

HPP $48.4

$44.8

$43.8

$47.7

$36.6

$34.9

$31.1

$32.9

$28.8

$29.3

$27.1

$17.3

$17.1

$17.3

$16.7

$16.5

$15.5

Source: Texas Department of State Health Services. Adjusted for inflation according to the Consumer Price Index.

Funding for PHEP in Texas fell from an inflationadjusted $84.7 million in fiscal year 2004 to $39.1 million in fiscal year 2020, a decline of 54 percent.

HPP funding decreased from an inflation-adjusted $48.4 million in fiscal year 2004 to $15.5 million in fiscal year 2020, a 68 percent decrease (Exhibit 7.4).

PHEP provides funds to state and local health departments to help them prepare for and recover from public health emergencies.33 It supports statewide staffing and funding to coordinate and plan for bioterrorism; surveillance and epidemiology capacity for local health departments; capacity and diagnostic capabilities for public health laboratories; communication networks; and education and training for bioterrorism preparedness.34 HPP funds hospitals and other organizations in the health care system to prepare for and respond to bioterrorism and other large-scale public health emergencies. The program emphasizes the use of health care coalitions to encourage diverse and often competitive health care organizations to work together during disasters and emergencies.

These coalitions include hospitals, long-term care

providers, public health agencies, emergency medical services and others. HPP is the only source of federal funding specifically intended to support health-care system readiness and support.35 DSHS currently contracts with eight of the 22 regional advisory councils to serve as the HPP providers and coordinate the Emergency Medical Task Force (EMTF) teams within their regions.

The EMTF comprises eight regional teams and a statewide coordinating entity that can deploy medical resources on a state mission assignment.

These eight regional teams, strategically located throughout the state, align with the DSHS public health regions. The teams leverage existing relationships with EMS, fire departments, hospitals and healthcare entities to provide personnel and essential resources available to respond throughout the state when needed. The EMTF program is funded by HPP.36

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T H E LON G Y EAR EMERGENCY MEDICAL TASK FORCE DSHS, the regional advisory councils, emergency medical services (EMS) units and hospital stakeholders created the Emergency Medical Task Force in 2009 to respond to critical requests for emergency health care during disasters and other emergencies. These teams can rapidly deploy to provide EMS in partnership with local EMS departments, fire departments, hospitals and other health care entities.37 The Southwest Texas Regional Advisory Council in San Antonio currently serves as the EMTF state coordination office for the eight regional EMTF teams. DSHS competitively bids out the lead for this coordinating entity every five years.38 EMTF has been active in the state’s coronavirus response. The task force and its organizational units, including the Infectious Disease Response Unit, helped ensure the safe transport and medical oversight of the first passengers being repatriated to Lackland Air Force Base near San Antonio in the early days of the pandemic.

■ TRAINING The coronavirus has emphasized the need for additional training to address infectious disease outbreaks.

HIGH-RISK SETTINGS

Controlling infectious diseases such as COVID-19 requires the cooperation and participation of the general public, whether through mask-wearing, social distancing or proper handwashing.44 To ensure their cooperation, the public has to understand these techniques — and their importance.

“Congregate settings” such as nursing facilities and prisons have been hotspots in the spread of COVID-19. According to the New York Times, about 38 percent of all U.S. deaths from the virus — more than 106,000 fatalities — occurred among residents and staff of nursing homes and other long-term care facilities.39 As of December 4, 2020, the Texas Health and Human Services Commission (HHSC) reported a total of about 6,400 COVID-19 deaths among residents of Texas nursing homes and assisted-living facilities, about a quarter of all Texas fatalities from the disease.40

Texas A&M AgriLife Extension Service is in a unique position to offer health literacy education through its Family and Community Health agents.45 These agents, with backgrounds in education, science, family consumer science, public health, nutrition science or dietary science, live in the community and draw upon their detailed knowledge of their areas to determine local health literacy priorities.

They promote health literacy activities through local advisory committees and other community partners such as physicians, clinics, libraries, school districts and local health departments.46

According to a November 2020 University of Texas report, the Texas prison system — the nation’s largest — had experienced more COVID-19 infections and deaths than any other state’s. Even after adjusting for population size, Texas’ prison system ranks very high among states in its rates of COVID-19 infections and deaths.41 As of the ending days of December 2020, the Texas Department of Criminal Justice reported that about 177 Texas inmates and 30 prison employees had died (or were presumed to have died) of COVID-19; 45 more inmate deaths were “pending cause.”42

AgriLife recently partnered with the Texas A&M Health Science Center on a successful health literacy initiative in South Texas. The program, called Healthy South Texas, seeks to provide families in rural and underserved communities “with knowledge and resources to take control of their health.”47 Focusing on “high-impact diseases” such as diabetes, asthma and infectious diseases, the program employs a multidisciplinary team of county extension agents, community allies and volunteers to engage with families and promote healthy behaviors.48

Administrators, staff and guards need to be well educated on the role of PPE, sanitation and basic health practices in preventing the spread of serious infectious diseases. Training needed includes the proper use and conservation of PPE; appropriate methods of maintaining proper sanitation; and basic health practices such as proper handwashing and covering the mouth if coughing or sneezing.43

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HEALTH LITERACY

The South Texas pilot, covering 27 counties, has proven effective in improving the health of program participants.49 AgriLife has agents operating in 181 counties available to provide such education, but doesn’t have the staffing necessary to provide health literacy services to all 254 Texas counties. Texas A&M plans to expand the program to other parts of the state as funding becomes available.

For example, DSHS offers a training and certification program for “community health workers.” These are non-medical public health workers whose job is to improve health outcomes in their communities.

City and county local health departments, clinics, hospital systems, and non-profits all employ community health workers for various activities such as community outreach and chronic disease health management education.50

TRAINING FOR EMERGENCY MANAGERS COVID-19 has demonstrated that emergency managers must be well-versed in pandemic response. State law currently requires personnel carrying out emergency management functions, such as county judges or emergency management coordinators, to receive at least three hours of emergency management training upon assuming their roles.51 Specific pandemic training, however, is not required.

Amendments to state law made in 2019 specify that the instruction must include training based on a “Disaster Response Guide” developed by TDEM. The guide must provide a comprehensive approach to disaster recovery for local officials, including information on various disaster topics, but serious infectious disease isn’t included in the list.52

TRAINING FOR TEXAS EMERGENCY MANAGEMENT COUNCIL MEMBERS COVID-19 has required intense coordination and communication among state agencies and other entities represented on the Texas Emergency Management Council. The regular occurrence of billion-dollar disasters in Texas and the chance of more frequent infectious disease outbreaks both argue for more extensive training for council members, particularly on topics related specifically to pandemics and on the operations of the council itself.53 At present, no training on these topics is required.

TRAINING FOR PUBLIC HEALTH AND MEDICAL EMERGENCY RESPONDERS The intense public health and medical response to COVID-19 revealed that public health and medical personnel don’t always understand one another’s roles.

Local health departments and DSHS regional and state offices comprise one major group of responders answering public health and medical emergencies. Another group includes hospitals, EMS units and other members of the medical community.

The state's 22 regional advisory councils help coordinate the activities of such entities concerning trauma care and various other services.

Both public health and medical personnel obviously are essential in any emergency, but the two groups don’t necessarily work together routinely. They’re not always familiar with each other’s procedures, which can slow down an emergency response. In addition, some interviewees suggested that the public health and medical responses would benefit by a more widespread understanding of the structure and operation of the state emergency management system. In the current emergency, many had to learn and adjust to new conditions as best they could.

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In addition to Texas A&M AgriLife, other entities also could be considered for greater roles in promoting health literacy. One of DSHS’ functions is to help advance the training and skills of the public health workforce, and to coordinate and leverage partnerships with academia and other external partners to help improve the health of Texans.

These factors all point to a need for training so that each group understands the role of the other in a disaster, an essential ingredient of emergency management preparedness.

In 2018, the Governor’s Commission to Rebuild Texas, formed to suggest ways to “future-proof” Texas after the devastation of Hurricane Harvey, highlighted the need to raise the overall level of preparedness among emergency management personnel. The report suggested, and the Legislature subsequently approved, the creation of a group of stakeholders to study a scheme to train personnel based on their various areas of responsibility and other criteria.54 That study has been completed and proposals submitted for consideration during the legislative session convening in January 2021.55

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RECOMMENDATIONS PLANNING 30 Require development of a response strategy, associated implementation plan and biennial pandemic preparedness “report card” to prepare for and evaluate the state’s readiness for major public health disasters.

Our recent experience with the coronavirus exposed a national lack of preparedness to deal with such a large-scale public health crisis. All levels of government have an urgent need to become better prepared for the next major public health disaster.

The Legislature should enact laws to implement an overarching strategy and an implementation plan to accomplish this objective. In addition, the Legislature should mandate the preparation of a biennial pandemic “report card.” It should be clear, however, that these documents don’t bind the governor’s actions if events dictate a departure.

The Strategy The strategy should be a high-level plan identifying the elements that should be addressed to prepare for the next pandemic. The Legislature should require DSHS and TDEM, in consultation with the Texas Emergency Management Council and the Task Force on Infectious Disease Preparedness and Response, to develop the strategy. (The role of the task force is discussed at greater length in Recommendation 31.)

As a possible model, DSHS, TDEM and its partners should consider the 2005 National Strategy for Pandemic Influenza prepared by the Homeland Security Council.56 This strategy, developed at the request of the White House, identified key actions that should be taken to properly plan for, monitor and respond to a pandemic.

Topics considered in Texas’ strategy could include, for example, the development of state and local pandemic action plans; strategies for testing, case investigation, hospital capacity, staffing surge and vaccine distribution; public messaging; and development of community mitigation guidelines such as social distancing and the closure and opening of businesses and schools.

The governor should review and approve this strategy document after TDEM and DSHS agree on a final product. It should be updated each biennium or more frequently as needed.

The Implementation Plan TDEM then should lead the development of an operational implementation plan to implement the strategy in partnership with DSHS and the emergency management council and with the advice of the task force. This plan should not in any way preclude DSHS from carrying out its day-to-day public health planning, preparedness and response duties for more localized issues such as foodborne illness, tuberculosis and other day-to-day infectious disease response in which TDEM and the council may or may not be involved.

TDEM, with the help of its partners and the advice of the task force, should develop a new hazard annex for declared public health disasters and other documents it thinks necessary to make the strategy operational. TDEM also should recommend legislation needed to implement the strategy. Statutes should be written flexibly to give TDEM and its partners the freedom to adjust as needed in carrying out this challenging task.

TDEM, with DSHS as its primary partner, should report periodically to the task force on progress toward implementation of the strategy.

The federal 2006 pandemic influenza implementation plan, published after the 2005 National Strategy for Pandemic Influenza mentioned above, provides one example of implementation planning.57

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The Legislature should direct HHSC to publish a state pandemic preparedness “report card” before each regular session of the Legislature. The report would grade the state’s readiness for a future large-scale public health emergency and be distributed to the Legislature, the governor, state entities and the public.

HHSC would judge the state’s readiness based on metrics established by the Task Force on Infectious Disease Preparedness and Response, as described in Recommendation 31. Responsible agencies and entities should provide data on metrics to HHSC in a manner and on a timeline it prescribes.

The executive commissioner of HHSC would certify in the biennial report card the state’s overall level of readiness based on its analysis of the information submitted. The certification should specify areas in which the state’s level of preparedness is deemed adequate and those where improvements are needed.

The report card should display results in easily understood graphics.

HHSC would staff preparation of the report card, but could reach out for assistance or additional information to TDEM, DSHS, the task force and other relevant entities.

31 Require the Task Force on Infectious Disease Preparedness and Response to advise state leaders on pandemic planning and develop metrics for evaluating the state’s level of pandemic preparedness.

■ Chapter 7 / Preparing for the Future

The Pandemic Preparedness Report Card

Then-Governor Rick Perry created the task force in 2014 to assist in the response to the Ebola emergency occurring in Texas. In 2015, the Legislature placed the task force in state law to advise the governor on infectious disease. State law also directs the task force to “provide expert, evidence-based assessments, protocols and recommendations related to state responses to infectious diseases … and serve as a reliable and transparent source of information and education for Texas leadership and citizens.”58 The task force thus provides a ready-made entity to assist the state in improving future pandemic planning. Specific requirements and structural changes needed to accomplish this purpose follow.

Pandemic Planning Duties These specific duties would be added to the task force’s other activities required by law.

Pandemic advice: The task force would advise and assist in the preparation of the high-level pandemic strategy and implementation plan recommended above. In keeping with its current statutory duties, the task force would assist the governor in matters concerning pandemic planning and response as well as other matters related to infectious diseases.

Metrics for the report card: As discussed in the prior recommendation, the task force would develop metrics for HHSC’s use in assessing the state’s level of pandemic preparedness. Metrics would be based on elements identified in the state strategy to the extent possible. They would be founded on the task force’s collective judgement and on the best available professional information from the state and national public health community. The task force should fashion the metrics keeping in mind and adjusting for the level of difficulty associated with collecting required data.

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Task Force Structure and Operation Membership: The task force would maintain the positions currently identified in state law (see below).59 In addition, the executive commissioner of HHSC, commissioner of DSHS and chief of TDEM should be added to the list, codifying their current appointments to the task force.

CURRENT STATUTORY MEMBERSHIP TASK FORCE ON INFECTIOUS DISEASE PREPAREDNESS AND RESPONSE • The governor may appoint members of the task force as necessary, including members from relevant state agencies, persons with expertise in infectious diseases and members from institutions of higher education.

• Members include: - at least two county judges, one from a county with a population under 100,000 and one from a county with a population of 100,000 or more, - at least two representatives of a local health authority, one from a rural area and one from an urban area, - at least one licensed nurse, and - at least one member defined by statute as emergency medical services personnel.

• The governor shall appoint a director from among its members and may appoint additional members as needed.

• Members serve at the pleasure of the governor.

Source: Texas Health and Safety Code §81.404.

State law authorizes the governor to appoint other members to the task force as necessary. Given the task force’s expanded pandemic planning role, the governor may wish to consider appointing representatives of RACs, health-related associations such as hospital associations, public health schools and the private sector, as well as a public health communications expert and other public members.

Operations: The task force should be authorized to consult with external groups. State law should require the task force to meet at least twice a year or more frequently as determined by the director.

State law should specify that the task force could form subcommittees as necessary, as it has done with the current Rapid Assessment Subcommittee.60 As already permitted, the task force could hold a closed meeting when discussing matters confidential under state or federal law or to meet public security or law enforcement needs. Members would continue to serve without compensation and would not be eligible for travel expenses, as statute currently stipulates.61

32 TDEM, in coordination with its partners, should update the State Emergency Management Plan to incorporate changes reflecting lessons learned from the COVID-19 pandemic.

These updates should align with planning efforts resulting from the previous recommendations. The Public Health and Medical Annex (Emergency Support Function 8) would be the major annex in line for updates. As noted above, TDEM also should develop a hazard annex for public health disasters in the same vein as TDEM’s other five hazard annexes, which address hurricanes, drought, nuclear, terrorism and wildland fire.

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33 The Texas Legislature should provide general revenue to restore key public health and medical preparedness funding to previous levels.

Two important federal funding sources for public health agencies and medical entities are the Public Health Emergency Preparedness (PHEP) program administered by CDC and the Hospital Preparedness Program (HPP) administered by the U.S. Department of Health and Human Services. Congress created both in response to the terrorist attacks of September 11, 2001.62 Annual funding for PHEP in Texas fell from an inflation-adjusted $84.7 million in fiscal year 2004 to $39.1 million in fiscal year 2020, a 54 percent decline. HPP funding decreased from an inflation-adjusted $48.4 million in fiscal year 2004 to $15.5 million in fiscal year 2020, a 68 percent decline.63 In view of the dramatic economic consequences of COVID-19, and the cost of the improvements suggested in this report, Texas should restore funding for these two critical programs to their fiscal year 2004 levels — an inflation-adjusted $78.5 million annually in state funding on top of federal funds. This would allow the state to proceed with preparedness activities while retaining key partnership links with the federal agencies critical to pandemic preparedness.

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FUNDING FOR PUBLIC HEALTH AND MEDICAL PREPAREDNESS

DSHS should continue to administer PHEP and HPP grants but should increase its coordination for these two programs with TDEM and the Texas Emergency Management Council. The Legislature should allocate a portion of the funding to DSHS programs to support DSHS state-level planning and administration.

As part of this coordination, the Legislature should require DSHS, as a condition of funding, to seek feedback from TDEM on grant distribution priorities and goals for the two programs to ensure alignment with the State of Texas Emergency Management Plan and other disaster preparedness priorities. As a further condition, DSHS should be required to provide regular reports to the Legislature on how the funding has been used for the two programs and its impacts on advancing preparedness goals. These reports also should be provided to the Task Force on Infectious Disease Preparedness and Response to assist them in assessing the state’s level of pandemic readiness and identifying any remaining funding gaps.

TRAINING 34 Require administrators and staff of nursing facilities and Texas Department of Criminal Justice (TDCJ) prison facilities to be trained in the use of personal protective equipment, sanitation techniques and basic health-related practices.

HHSC would oversee the development and implementation of this training for nursing facility administrators and staff, while TDCJ would do so for the prison system. These agencies should determine the frequency of training sessions.

The Texas A&M Engineering Extension Service could provide assistance with this training, given its past experience with the development of similar courses.

This recommendation would entail a minor cost that would vary depending on the design of the training.

35 The Texas A&M AgriLife Extension Service should seek exceptional-item funding to provide health literacy education in all Texas counties.

AgriLife Extension has about 160 family and community health agents operating in 181 Texas counties who can provide such education; at present, it has no agents in 73 counties.

The pandemic has underlined the need for health literacy education to help mitigate COVID-19 as well as future infectious diseases. AgriLife Extension’s family and community health agents could serve all 254 Texas counties for about $4.2 million annually, as well as additional administrative costs for purposes such as office space, travel and materials.

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36 Add information about serious infectious diseases to the topics listed in statute to be covered in TDEM’s Disaster Response Guide.

Instruction based on the Disaster Response Guide already is required for public officers such as county judges and mayors. Adding infectious diseases to the guide ensures these key individuals receive information on this important topic.

37 Require the leaders of the state agencies and other entities represented on the Texas Emergency Management Council to receive training on the state’s emergency management system.

State law should be amended to direct the chief of TDEM to develop this program with the advice and collaboration of the affected state agencies and entities.

The training program should encompass basic emergency management training as well as response to public health disasters. It should include different tiers appropriate to the trainees’ varying levels of responsibility or involvement. Distance learning or other electronic means could be employed to deliver the training. Successful completions should be noted in TDEM’s records.

TDEM should, to the best of its ability, notify individuals periodically about their training requirements and encourage them to successfully complete training within 180 days of being appointed to the council.

38 The Legislature should establish a disaster training and certification program for key state, regional and local personnel involved in public health and medical responses to disasters.

This training should be directed to individuals staffing local, regional and state medical operations centers and all RACs. This would include, for example, city and county centers, regional operations centers and the DSHS State Medical Operations Center.

The training should provide key personnel with a shared understanding of roles and procedures involving a public health and medical disaster response, thus improving their preparedness for pandemics or other significant disasters with public health and medical components.

State law should direct TDEM in consultation with the Texas Emergency Management Council to convene an appropriate work group of local, regional and state stakeholders to develop a proposal for a training and certification program to be developed jointly by DSHS and TDEM. This proposal should include sample legislation drafted flexibly enough to allow DSHS and TDEM to adjust the resulting program as needed. Drafters of this sample legislation should consider: • the types or classes of personnel who would receive the training; • the use of tiers indicating levels of accomplishment; • the organization or organizations that would provide certification; • whether training certification would be provided to the individuals being trained, the entity they represent or both; and • whether training or certification would be optional or required for participation in the emergency-related activities of RACs and medical operations centers.

In addition to these stipulations, the proposal should suggest possible funding sources for the training, such as the Hospital Preparedness Program and other sources identified by the work group. The work group should submit the proposal and sample legislation to the governor and Legislature by November 1, 2022, for consideration in the 2023 legislative session.

n

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ENDNOTES

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INTRODUCTION 1 U.S. Federal Emergency Management Agency, “Declared Disasters,” https://www.fema.gov/disasters/ disaster-declarations/; and Carly Dodd, “The US States Most Prone To Natural Disasters,” WorldAtlas (October 19, 2020), https://www.worldatlas.com/articles/the-10-states-most-prone-to-natural-disasters.html.

2 Legislative Budget Board, “Hurricane Harvey’s Fiscal Impact on State Agencies,” October 2017, p. 2, https:// www.lbb.state.tx.us/Documents/Publications/Presentation/4569_LBB_HAC_Presentation_Hurricane.pdf.

3 National Institute of Allergy and Infectious Disease, “COVID-19, MERS & SARS,” August 18, 2020, https://www. niaid.nih.gov/diseases-conditions/covid-19; and U.S. Centers for Disease Control and Prevention, “About COVID-19,” September 1, 2020, https://www.cdc.gov/coronavirus/2019-ncov/cdcresponse/about-COVID-19.html.

4 Lawrence Wright, “The Plague Year,” The New Yorker (December 28, 2020), https:// www.newyorker.com/magazine/2021/01/04/the-plague-year.

5 World Health Organization, “Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV),” January 30, 2020, https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-healthregulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov).

6 World Health Organization, “WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19,” March 11, 2020, https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-on-COVID-19---11-march-2020.

7 World Health Organization, “WHO Coronavirus Disease (COVID-19) Dashboard,” https://covid19.who.int/.

8 U.S. Centers for Disease Control and Prevention, “First Travel-related Case of 2019 Novel Coronavirus Detected in United States,” January 21, 2020, https://www.cdc.gov/media/releases/2020/p0121-novel-coronavirustravel-case.html; and Roni Caryn Rabin, “First Patient With Wuhan Coronavirus Is Identified in the U.S.,” New York Times (January 21, 2020), https://www.nytimes.com/2020/01/21/health/cdc-coronavirus.html.

9 Texas Department of State Health Services, “DSHS Announces First Case of COVID-19 in Texas,” March 4, 2020, https://www.dshs.texas.gov/news/releases/2020/20200304.aspx.

10 Texas Department of State Health Services, COVID-19 Tracker, https://txdshs.maps.arcgis. com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83.

11 Vaclav Smil, Global Catastrophes and Trends: The Next Fifty Years, Cambridge, Massachusetts: The MIT Press, 2008.

12 Michael Osterholm, “Preparing for the Next Pandemic,” Foreign Affairs (July/August 2005), https://www.foreignaffairs.com/articles/2005-07-01/preparing-next-pandemic.

13 Bryan Walsh, “The World Is Not Ready for the Next Pandemic,” TIME (May 4, 2017), https:// time.com/magazine/us/4766607/may-15th-2017-vol-189-no-18-u-s/.

14 Texas Department of State Health Services, Respiratory Viruses Having Pandemic Potential (Austin, Texas, March 2015), https://dshs.texas.gov/IDCU/disease/influenza/Respiratory_Virus_ Plan_FINAL_V-1-2_03-20-15-fixed.doc; and interviews with staff of the Texas Department of State Health Services, October 5, 2020, November 4, 2020, and December 29, 2020.

15 Texas Department of State Health Services, “COVID-19 Update,” Presentation to the Senate Committee on Health and Human Services, December 7, 2020, https://www.dshs.texas.gov/legislative/86th/SenateHHS_COVID_Data.pdf.

16 Texas Department of State Health Services, “Task Force on Infectious Disease Preparedness and Response,” updated December 18, 2020, https://www.dshs.state.tx.us/TaskForceID/; and Tex. Health and Safety Code §81.403(b)(1), https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.403.

17 World Health Organization, “Coronavirus Disease (COVID-2019) Press Briefing,” December 28, 2020, https:// www.who.int/emergencies/diseases/novel-coronavirus-2019/media-resources/press-briefings#.

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1 World Health Organization, “Chapter 1: Smallpox — Eradicating an Ancient Scourge,” in Bugs, Drugs, and Smoke: Stories From Public Health (2011), https:// www.who.int/about/bugs_drugs_smoke_chapter_1_smallpox.pdf?ua=1.

2 U.S. Centers for Disease Control and Prevention, “1918 Pandemic (H1N1 Virus),” https://www.cdc.gov/ flu/pandemic-resources/1918-pandemic-h1n1.html; and Joint United Nations Programme on HIV/AIDS, “Global HIV & AIDS Statistics — 2020 Fact Sheet,” https://www.unaids.org/en/resources/fact-sheet.

3 Michael McCarthy, “A Century of the US Army Yellow Fever Research,” The Lancet 357 (June 2, 2001), https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04943-6/fulltext.

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CHAPTER 1

4 Kate E. Jones et al, “Global Trends in Emerging Infectious Diseases,” Nature 451: 990-993 (February 21, 2008), https://www.nature.com/articles/nature06536?source=post_page.

5 Mary C. Brucker, “Novel Viruses, Zoonotic Infections, and Travel Health,” Nursing for Women’s Health 24(2) (April 2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7128288/.

6 Rafael Sanjuán and Pilar Domingo-Calap, “Mechanisms of Viral Mutation,” Cellular and Molecular Life Sciences 72(23): 4433-4448 (July 08, 2016), https://link.springer.com/article/10.1007/s00018-016-2299-6.

7 Siobain Duffy, “Why Are RNA Virus Mutation Rates So Damn High?” PLOS Biology 16(8): e3000003 (August 13, 2018), https://doi.org/10.1371/journal.pbio.3000003.

8 Rafael Sanjuán and Pilar Domingo-Calap, “Mechanisms of Viral Mutation”; and José A. Campillo-Balderas et al, “Viral Genome Size Distribution Does Not Correlate with the Antiquity of the Host Lineages,” Frontiers in Ecology and Evolution 23 (December 2015), https://www.frontiersin.org/articles/10.3389/fevo.2015.00143/full.

9 Santiago F. Elena and Rafael Sanjuan, “Adaptive Value of High Mutation Rates of RNA Viruses: Separating Causes from Consequences,” Journal of Virology 79(18): 11555-11558 (2005), https://jvi.asm.org/content/79/18/11555.short.

10 Rafael Sanjuán and Pilar Domingo-Calap, “Mechanisms of Viral Mutation.”

11 U.S. Centers for Disease Control and Prevention, “Emerging SARS-CoV-2 Variants,” January 28, 2021, https://www.cdc.gov/coronavirus/2019-ncov/ more/science-and-research/scientific-brief-emerging-variants.html.

12 U.S. Centers for Disease Control and Prevention, “SARS Basic Fact Sheet,” December 6, 2017, https://www.cdc.gov/sars/about/fs-sars.html; World Health Organization, Middle East Respiratory Syndrome Coronavirus (MERS-CoV),” https://www.who.int/emergencies/ mers-cov/en/; and Johns Hopkins University, “COVID-19 Dashboard,” https://www.arcgis. com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6.

13 Johns Hopkins Coronavirus Resource Center, “Mortality Analyses,” December 16, 2020, https://coronavirus.jhu.edu/data/mortality.

14 Mark R. Denison et al, “Coronaviruses: An RNA Proofreading Machine Regulates Replication Fidelity and Diversity,” RNA Biology 8(2): 270-279 (March 01, 2011), https://www.tandfonline. com/doi/full/10.4161/rna.8.2.15013; and José A. Campillo-Balderas et al, “Viral Genome Size Distribution Does Not Correlate with the Antiquity of the Host Lineages.”

15 William C. Shiel, Jr., “Medical Definition of Cluster,” MedicineNet, https:// www.medicinenet.com/script/main/art.asp?articlekey=38210.

16 World Health Organization, “Disease Outbreaks,” https://www.who.int/ environmental_health_emergencies/disease_outbreaks/en/.

17 U.S. Centers for Disease Control and Prevention, “Lesson 1: Introduction to Epidemiology,” from Principles of Epidemiology in Public Health Practice (November 2011), https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html.

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18 World Health Organization, “COVID-19 Public Health Emergency of International Concern (PHEIC) Global Research and Innovation Forum,” February 12, 2020, https://www.who.int/publications/m/item/covid19-public-health-emergency-of-international-concern-(pheic)-global-research-and-innovation-forum.

19 World Health Organization, “Coronavirus Disease 2019 (COVID-19) Situation Report 67,” March 27, 2020, https://www.who.int/docs/default-source/coronaviruse/ situation-reports/20200327-sitrep-67-covid-19.pdf?sfvrsn=b65f68eb_4.

20 Johns Hopkins Center for Health Security, “Clade X Exercise,” May 15, 2018, https:// www.centerforhealthsecurity.org/our-work/events/2018_clade_x_exercise/.

21 Quiang Ding et al, “The Clinical Characteristics of Pneumonia Patients Coinfected With 2019 Novel Coronavirus and Influenza Virus in Wuhan, China,” Journal of Medical Virology (March 20, 2020), https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25781.

22 Johns Hopkins University, “Coronavirus Resource Center, COVID-19 Dashboard,” https://coronavirus.jhu.edu/map.html.

23 Hussin A. Rothan and Sidappa N. Byrareddy, “The Epidemiology and Pathogenesis of Coronavirus Disease (COVID-19) Outbreak,” Journal of Autoimmunity 109 (May 2020), https://www. sciencedirect.com/science/article/pii/S0896841120300469?casa_token=KsU6RhNQz9oAAAAA:gXEPoW8k9T6bUXfrjZcHE7zNWRtQrI-WVB9OXbQ0_FPFhaPmpHHc3VnuXbG_OGZYRW1vtIJvA. 24 Lisa Schnirring, “Japan Has 1st Novel Coronavirus Case; China Reports Another Death,” CIDRAP News (January 16, 2020), https://www.cidrap.umn.edu/news-perspective/2020/01/ japan-has-1st-novel-coronavirus-case-china-reports-another-death.

25 Roni C. Rabin, “First Patient With Wuhan Coronavirus Is Identified in the U.S.,” New York Times (January 21, 2020), https://www.nytimes.com/2020/01/21/health/cdc-coronavirus.html.

26 Texas Department of State Health Services, “COVID-19 Dashboard,” https://txdshs.maps. arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83.

27 Johns Hopkins University Coronavirus Resource Center, “New Cases of COVID-19 in World Countries: Daily Confirmed New Cases (7-Day Moving Average),” https://coronavirus.jhu.edu/data/new-cases.

28 John Henley, “Global Report: France ‘Could Lose Control of Covid-19 at Any Time,’” The Guardian (August 4, 2020), https://www.theguardian.com/world/2020/ aug/04/global-report-france-could-lose-control-of-covid-19-at-any-time.

29 Texas Department of State Health Services, “COVID-19 in Texas Dashboard,” https://txdshs. maps.arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83.

30 World Health Organization, “WHO Coronavirus Disease (COVID-19) Dashboard,” https://covid19.who.int/.

31 Colm Quinn, “Europe Embraces Tighter Measures as Coronavirus Cases Surge,” Foreign Policy (December 15, 2020), https://foreignpolicy.com/2020/12/15/ europe-embraces-tighter-measures-as-coronavirus-cases-surge/.

32 Marc Santora and Isabella Kwai, “U.K. Increasingly Isolated as U.S. Restricts Travel,” The New York Times (December 25, 2021), https://www.nytimes.com/2020/12/25/world/europe/covid-19-uk-travel-us.html.

33 U.S. Centers for Disease Control and Prevention, “Symptoms of Coronavirus,” https:// www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.

34 U.S. Centers for Disease Control and Prevention, “People with Certain Medical Conditions,” https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html.

35 Ahmed S. Abdulamir and Rand Hafidh, “The Possible Immunological Pathways for the Variable Immunopathogenesis of COVID-19 Infections among Healthy Adults, Elderly, and Children,” Electronic Journal of General Medicine 17(4) (March 2020), https://www.researchgate.net/profile/ Ahmed_Abdulamir/publication/340136238_The_Possible_Immunological_Pathways_for_the_Variable_ Immunopathogenesis_of_COVID-19_Infections_among_Healthy_Adults_Elderly_and_Children/ links/5e7b7dc9a6fdcc139c016909/The-Possible-Immunological-Pathways-for-the-VariableImmunopathogenesis-of-COVID-19-Infections-among-Healthy-Adults-Elderly-and-Children.pdf.

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37 Andrea T. Cruz and Steven L. Zeichner, “COVID-19 in Children: Initial Characterization of the Pediatric Disease,” Pediatrics 145(6) (June 2020), https://pediatrics.aappublications.org/content/145/6/e20200834.

38 Young J. Park et al, “Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020,” Emerging Infectious Diseases 26(10) (October 2020), https://wwwnc.cdc.gov/eid/article/26/10/20-1315_article.

39 Rebecca L. Laws et al, “Symptoms and Transmission of SARS-CoV-2 Among Children — Utah and Wisconsin, March-May 2020,” Pediatrics 146(6) (December 3, 2020), https://doi.org/10.1542/peds.2020-027268.

■ ENDNOTES / Chapter 1

36 Zintis Inde et al, “Age-Dependent Regulation of SARS-CoV-2 Cell Entry Genes and Cell Death Programs Correlates with COVID-19 Disease Severity,” bioRxiv (September 13, 2020), http://doi.org/10.1101/2020.09.13.276923.

40 Mark Hicar, “A Mysterious Illness Is Striking Children Amid the Coronavirus Pandemic — But Is It Kawasaki Disease?” The Conversation (May 6, 2020), https://theconversation.com/a-mysteriousillness-is-striking-children-amid-the-coronavirus-pandemic-but-is-it-kawasaki-disease-137986.

41 National Cancer Institute, “Definition: Cytokine Storm,” https://www.cancer.gov/search/ results?swKeyword=cytokine+storm; and Temima Waltuch et al, “Features of COVID-19 PostInfectious Cytokine Release Syndrome in Children Presenting to the Emergency Department,” The American Journal of Emergency Medicine (May 23, 2020), https://doi.org/10.1016/j.ajem.2020.05.058.

42 U.S. Centers for Disease Control and Prevention, “Multisystem Inflammatory Syndrome,” October 30, 2020, https://www.cdc.gov/mis-c/cases/index.html.

43 Ricardo J. Jose and Ari Manuel, “COVID-19 Cytokine Storm: The Interplay Between Inflammation and Coagulation,” The Lancet Respiratory Medicine 8(6) (April 27, 2020), https:// www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30216-2/fulltext.

44 Thomas J. Oxley et al, “Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young,” The New England Journal of Medicine (April 28, 2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207073/.

45 Jennifer Couzin-Frankel, “The Mystery of The Pandemic’s ‘Happy Hypoxia,’” Science 368(6490) (May 1, 2020), https://science.sciencemag.org/content/368/6490/455.summary?casa_token=0ZlXJmlPj64AAA AA:TDpN0myYgmtRjxHXxuiGF31yH7FjkpeyF1evoOuESjkoH8gLkp-6h8ciuL94KUj5jDOSs6UFSKZNow. 46 Meredith Wadman et al, “A Rampage Through the Body,” Science 368(6489) (April 24, 2020), https:// science.sciencemag.org/content/368/6489/356.summary?casa_token=0_R86KeSSuMAAAAA:BnXU8eCXoM6J5IxUjHKjAKUd_Ds1k1Vz7rVuXYhkVwdOm9xic-VgtGFZ9Pmic1aQfQ3adBFEkKrKQ. 47 Jennifer Couzin-Frankel, “The Mystery of The Pandemic’s ‘Happy Hypoxia.’”

48 Heather Wood, “New Insights Into the Neurological Effects of COVID-19,” Nature Reviews Neurology 16 (June 26, 2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317889/; and Megan Brooks, “COVID-19 Neurologic Fallout Not Limited to the Severely Ill,” Medscape (December 14, 2020), https://www.medscape.com/viewarticle/942571.

49 Aravinthan Varatharaj et al, “Neurological and Neuropsychiatric Complications of COVID-19 in 153 Patients: A UK-Wide Surveillance Study,” The Lancet Psychiatry 7(10) (June 25, 2020), https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30287-X/fulltext.

50 Koy Chong Ng Kee Kwong et al, “COVID-19, SARS, and MERS: A Neurological Perspective,” Journal of Clinical Neuroscience 77 (July 2020), https://www.sciencedirect.com/science/article/pii/S0967586820311851.

51 Ray Perrin et al, “Into the Looking Glass: Post-Viral Syndrome Post COVID-19,” Medical Hypotheses 144 (June 27, 2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320866/.

52 U.S. Centers for Disease Control and Prevention, “What is ME/ CFS?” https://www.cdc.gov/me-cfs/about/index.html.

53 Chuck Goudie et al, “Coronavirus Symptoms: Mysterious, Scary Symptoms Persist Long After Initial COVID-19 Infection,” ABC 7 Eyewitness News (July 27, 2020), https:// abc7chicago.com/covid-symptoms-19-coronavirus-signs-and/6337918/.

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54 U.S. Food and Drug Administration, “Coronavirus (COVID-19) Update: FDA Revokes Emergency Use Authorization for Chloroquine and Hydroxychloroquine” (June 15, 2020), https://www.fda.gov/news-events/press-announcements/coronavirus-covid19-update-fda-revokes-emergency-use-authorization-chloroquine-and.

55 National Institutes of Health, “NIH Halts Clinical Trial of Hydroxychloroquine,” June 15, 2020, https://www.nih.gov/news-events/news-releases/nih-halts-clinical-trial-hydroxychloroquine.

56 U.S. Food and Drug Administration, “Investigational COVID-19 Convalescent Plasma,” September 2020, https://www.fda.gov/regulatory-information/searchfda-guidance-documents/investigational-covid-19-convalescent-plasma.

57 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, “ASPR’s Portfolio of COVID-19 Medical Countermeasures,” https:// www.phe.gov/emergency/events/COVID19/investigation-MCM/Pages/default.aspx.

58 U.S. Food and Drug Administration, “Remdesivir EUA Letter of Authorization,” May 1, 2020, https://www. fda.gov/media/137564/download; and “FDA Approves First Treatment for COVID-19,” October 22, 2020, https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-covid-19.

59 Megan Schmidt, “What is Remdesivir, the First Drug That Treats Coronavirus?”

Discover Magazine (May 6, 2020), https://www.discovermagazine.com/health/ what-is-remdesivir-the-first-drug-that-treats-coronavirus.

60 Owen Dyer, “Covid-19: Remdesivir Has Little or No Impact on Survival, WHO Trial Shows,” The BMJ (October 19, 2020), https://doi.org/10.1136/bmj.m4057; and John H. Beigel et al, “Remdesivir for the Treatment of Covid-19 — Final Report,” The New England Journal of Medicine 10.1056 (November 5, 2020), https://www.nejm.org/doi/full/10.1056/NEJMoa2007764.

61 World Health Organization, “Q&A: Dexamethasone and COVID-19,” June 25, 2020, https://www.who.int/news-room/q-a-detail/q-a-dexamethasone-and-covid-19.

62 The RECOVERY Collaborative Group, “Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report,” New England Journal of Medicine (July 17, 2020), https://www.nejm. org/doi/full/10.1056/NEJMoa2021436?casa_token=aY6YUOO2bq8AAAAA:5EE0KSJYGtn_ iL9zThfO60vJQBEXgQ4KwpOmh1kNvDOMR49secwYfOjHaoOJ89eVZ4LwK0enc35t3g.

63 U.S. Centers for Disease Control and Prevention, “Polio Elimination in the United States,” https://www.cdc.gov/polio/what-is-polio/polio-us.html.

64 Catherine I. Paules, et al, “Measles in 2019: Going Backward,” New England Journal of Medicine 10.1056 (June 6, 2019), https://www.nejm.org/doi/full/10.1056/NEJMp1905099.

65 U.S. Food and Drug Administration, “Pfizer-BioNTech COVID-19 Vaccine,” December 17, 2020, https://www.fda.gov/emergency-preparedness-and-response/ coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine.

66 Heidi Ledford et al, “The UK Has Approved a COVID vaccine – Here’s What Scientists Now Want to Know,” Nature (December 3, 2020), https://www.nature.com/articles/d41586-020-03441-8.

67 Pfizer, “Pfizer and BioNTech to Supply the U.S. with 100 Million Additional Doses of COVID-19 Vaccine,” December 23, 2020, https://www.pfizer.com/news/press-release/ press-release-detail/pfizer-and-biontech-supply-us-100-million-additional-doses.

68 U.S. Food and Drug Administration, “Moderna COVID-19 Vaccine,” https://www.fda.gov/emergencypreparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine.

69 U.S. Department of Health and Human Services, “Trump Administration purchases additional 100 million doses of COVID-19 investigational vaccine from Moderna,” December 11, 2020, https://www.hhs.gov/about/news/2020/12/11/trump-administration-purchasesadditional-100-million-doses-covid-19-investigational-vaccine-moderna.html.

70 Centers for Disease Control and Prevention, “Principles of Epidemiology in Public Health Practice, Lesson 1, Introduction to Epidemiology, Section 11, Epidemic Disease Occurrence,” May 18, 2012, https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html.

71 Gavi, the Vaccine Alliance, “Is COVID-19 Here to Stay?” (May 22, 2020), https://www.gavi.org/vaccineswork/covid-19-here-stay.

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1 World Health Organization, “Timeline of WHO’s response to COVID-19,” September 9, 2020, https://www.who.int/news/item/29-06-2020-COVID-19timeline.

2 World Health Organization, “Timeline of WHO’s response to COVID-19,” September 9, 2020, https://www.who.int/news/item/29-06-2020-COVID-19timeline.

3 U.S. Centers for Disease Control and Prevention, “First Travel-related Case of 2019 Novel Coronavirus Detected in United States,” January 21, 2020, https://www.cdc.gov/ media/releases/2020/p0121-novel-coronavirus-travel-case.html and Roni Caryn Rabin, “First Patient With Wuhan Coronavirus Is Identified in the U.S.,” New York Times (January 21, 2020), https://www.nytimes.com/2020/01/21/health/cdc-coronavirus.html.

■ ENDNOTES / Chapter 2

CHAPTER 2

4 U.S. Department of Health and Human Services, “Secretary Azar Declares Public Health Emergency for United States for 2019 Novel Coronavirus,” January 31, 2020, https://www.hhs.gov/about/ news/2020/01/31/secretary-azar-declares-public-health-emergency-us-2019-novel-coronavirus.html.

5 Andrew Joseph, “WHO Declares Coronavirus Outbreak a Global Health Emergency,” STAT Public Health (January 30, 2020), https://www.statnews.com/2020/01/30/ who-declares-coronavirus-outbreak-a-global-health-emergency/.

6 Megan Thielking, “CDC Confirms First Known Person-to-Person Spread of New Coronavirus in U.S.,” STAT Public Health (January 30, 2020), https://www.scientificamerican.com/article/ cdc-confirms-first-known-person-to-person-spread-of-new-coronavirus-in-u-s/.

7 Associated Press, “Lackland AFB in San Antonio Named as Quarantine Site Amid Coronavirus Outbreak,” Spectrum News 1 (February 1, 2020), https://spectrumlocalnews.com/tx/san-antonio/news/2020/02/02/ lackland-afb-in-san-antonio-named-as-potential-quarantine-site-amid-coronavirus-outbreak.

8 Austin Ramzy and Tiffany May, “Philippines Reports First Coronavirus Death Outside China,” New York Times (February 2, 2020), https://www.nytimes. com/2020/02/02/world/asia/philippines-coronavirus-china.html.

9 Information on the official activation date of the State Medical Operations Center provided by the Texas Department of State Health Services, January 2021.

10 Daniel Victor et al, “Deaths in China Rise, With No Sign of Slowdown,” New York Times (February 4, 2020), https://www.nytimes.com/2020/02/04/world/asia/coronavirus-china.html#link-658f6486.

11 U.S. Food & Drug Administration, “FDA Takes Significant Step in Coronavirus Response Efforts, Issues Emergency Use Authorization for the First 2019 Novel Coronavirus Diagnostic,” February 4, 2020, https://www.fda.gov/news-events/press-announcements/fda-takessignificant-step-coronavirus-response-efforts-issues-emergency-use-authorization-first.

12 U.S. Centers for Disease Control and Prevention, “About COVID-19,” September 1, 2020, https://www.cdc.gov/coronavirus/2019-ncov/cdcresponse/about-COVID-19.html.

13 U.S. Centers for Disease Control and Prevention, “Transcript for CDC Telebriefing: CDC Update on Novel Coronavirus,” February 23, 2020, https://www.cdc. gov/media/releases/2020/t0212-cdc-telebriefing-transcript.html.

14 Elian Peltier, “France Confirms First Death in Europe From Coronavirus,” New York Times (February 15, 2020), https://www.nytimes.com/2020/02/15/world/europe/france-coronarivus-death.html.

15 Jason Horowitz et al, “Italy, Pandemic’s New Epicenter, Has Lessons for the World,” New York Times (March 21, 2020), https://www.nytimes.com/2020/03/21/world/europe/italy-coronavirus-center-lessons.html.

16 Bonnie Petrie, “Total Confirmed COVID-19 Cases At Lackland Rises To 6,” Texas Public Radio (February 24, 2020), https://www.tpr.org/biosciencemedicine/2020-02-24/total-confirmed-COVID-19-cases-at-lackland-rises-to-6.

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17 Bryan Pietsch and Katie Canales, “Here’s Everything We Know About How San Francisco is Battling the Coronavirus Pandemic,” Business Insider (April 18, 2020), https://www.businessinsider. com/san-franciscos-state-of-emergency-coronavirus-COVID-19-city-impact-2020-2.

18 Stephanie Soucheray, “Coroner: First US COVID-19 Death Occurred in Early February,” CIDRAP News (April 22, 2020), https://www.cidrap.umn.edu/news-perspective/2020/04/ coroner-first-us-COVID-19-death-occurred-early-february.

19 Andrew Selsky, “Washington Governor Declares State of Emergency Over Virus,” ABC News (February 29, 2020), https://abcnews.go.com/US/wireStory/coronavirus-cases-unknown-origin-found-west-coast-69301250.

20 U.S. Food & Drug Administration, “Coronavirus (COVID-19) Update: FDA Issues New Policy to Help Expedite Availability of Diagnostics,” February 29, 2020, https://www.fda.gov/news-events/press-announcements/ coronavirus-COVID-19-update-fda-issues-new-policy-help-expedite-availability-diagnostics.

21 Sig Christenson and Lauren Caruba, “San Antonio Takes Federal Government to Court Over Control of Quarantine,” Houston Chronicle (March 2, 2020), https://www.houstonchronicle.com/news/ houston-texas/texas/article/San-Antonio-coronavirus-panic-evacuation-health-15099395.php.

22 State of California Executive Department, “Executive Order N-33-20,” March 19, 2020, https://www. gov.ca.gov/wp-content/uploads/2020/03/3.19.20-attested-EO-N-33-20-COVID-19-HEALTH-ORDER. pdf; Office of the Florida Governor, “Executive Order Number 20-52,” March 9, 2020, https://www. flgov.com/wp-content/uploads/orders/2020/EO_20-52.pdf; and Office of the New York Governor, “Executive Order No. 202: Declaring a Disaster Emergency in the State of New York,” March 7, 2020, https://www.governor.ny.gov/news/no-202-declaring-disaster-emergency-state-new-york.

23 Texas Department of State Health Services, “DSHS Announces First Case of COVID-19 in Texas,” March 4, 2020, https://www.dshs.texas.gov/news/releases/2020/20200304.aspx.

24 Naomi Andu, “Coronavirus Concerns Prompt Austin Officials to Cancel SXSW,” The Texas Tribune (March 6, 2020), https://www.texastribune.org/2020/03/06/sxsw-texas-coronavirus-fears/.

25 Edgar Walters and Sami Sparber, “Texas’ First Case of Possible Community Spread of Coronavirus Highlights Lack of Testing,” The Texas Tribune (March 11, 2020), https://www.texastribune. org/2020/03/11/coronavirus-texas-community-spread-may-be-montgomery-county/.

26 Mike Morris et al, “Rodeo Cancelled After Visit by Montgomery County Man Who Tested Positive for Coronavirus,” Houston Chronicle (March 11, 2020), https://www.houstonchronicle.com/news/houstontexas/houston/article/rodeo-cancel-coronavirus-montgomery-county-close-15124793.php.

27 World Health Organization, “WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19,” March 11, 2020, https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-on-COVID-19---11-march-2020.

28 Adam Samson et al, “US Stocks Fall 10% in Worst Day Since 1987 Crash,” Financial Times (March 12, 2020), https://www.ft.com/content/454b7bb2-6405-11ea-a6cd-df28cc3c6a68.

29 Office of the White House, “Memorandum on Authorizing the Other Needs Assistance Program for Major Disaster Declarations Related to Coronavirus Disease 2019,” August 8, 2020, https://www.whitehouse.gov/presidential-actions/memorandum-authorizing-needsassistance-program-major-disaster-declarations-related-coronavirus-disease-2019/.

30 Reagan Roy, “Governor Greg Abbott Declares State of Disaster for Texas in Response to Coronavirus,” CBS19 (March 13, 2020), https://www.cbs19.tv/article/news/governor-greg-abbott-declares-state-ofdisaster-for-texas-in-response-to-coronavirus/501-c2860693-240e-4e24-85a6-15d002ced316.

31 Sami Sparber and Raga Justin, “Texas Gets Drive-Thru Coronavirus Testing in San Antonio, but It’s Not Open to the General Public,” The Texas Tribune (March 13, 2020), https://www. texastribune.org/2020/03/13/drive-through-coronavirus-testing-comes-san-antonio-texas/.

32 Eliza Shapiro, “New York City Public Schools to Close to Slow Spread of Coronavirus,” New York Times (March 15, 2020), https://www.nytimes.com/2020/03/15/nyregion/nyc-schools-closed.html.

33 Ian Millhiser, “The Dow Jones Had its Biggest Point Drop in History Monday,” Vox (March 16, 2020), https://www.vox.com/2020/3/16/21182341/dow-jones-biggest-point-drop-coronavirus-3000.

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35 Texas Department of State Health Services, “Texas Confirms First Death in COVID-19 Patient,” March 17, 2020, https://www.dshs.state.tx.us/news/releases/2020/20200317. aspx#:~:text=March%2017%2C%202020,County%20and%20had%20been%20hospitalized.

36 “All 50 States Now Have Virus Cases: West Virginia the Last,” WSLS 10 (March 17, 2020), https:// www.wsls.com/news/2020/03/17/all-50-states-now-have-virus-cases-west-virginia-the-last/.

37 Texas Health Commissioner John W. Hellerstedt, “Declaration of a Public Health Disaster in the State of Texas,” March 19, 2020, https://lrl.texas.gov/scanned/govdocs/ Greg%20Abbott/2020/declaration03192020_public_health_disaster.pdf.

38 Office of the Texas Governor, “Executive Order No. GA-08 Relating to COVID-19 Preparedness and Mitigation,” March 19, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-11.pdf.

■ ENDNOTES / Chapter 2

34 Office of the White House, “15 Days to Slow the Spread,” March 16, 2020, https://www.whitehouse.gov/articles/15-days-slow-spread/.

39 State of California Executive Department, “Executive Order N-33-20.”

40 Office of the Texas Governor, News Archive, press releases for March 2024, 2020, https://gov.texas.gov/news/archive/2020/03.

41 Office of the Texas Governor, “Gov. Abbott Issues Executive Order Increasing Hospital Capacity, Announces Supply Chain Strike Force For COVID-19 Response,” March 22, 2020, https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-increasinghospital-capacity-announces-supply-chain-strike-force-for-COVID-19-response.

42 Associated Press, “More Big Texas Cities Order Residents to Stay Home,” U.S. News & World Report (March 24, 2020), https://www.usnews.com/news/best-states/texas/ articles/2020-03-24/houston-harris-county-issue-stay-at-home-order.

43 Staff, “Coronavirus in Texas 3/24: Quarantine Ending for Cruise Ship Evacuees at Lackland Air Force Base,” The Texas Tribune (March 24, 2020), https://www.texastribune. org/2020/03/24/coronavirus-updates-texas-stay-at-home-hospitals/.

44 Office of the Texas Governor, “Gov. Abbott Announces Approval Of Major Disaster Declaration,” March 25, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press03252020_disaster.pdf.

45 Staff, “Coronavirus in Texas 3/25: Unemployment Claims Surge,” The Texas Tribune (March 25, 2020), https://www.texastribune.org/2020/03/25/coronavirusupdates-texas-austin-mayor-says-city-needs-more-tests/.

46 Donald G. McNeil Jr., “The U.S. Now Leads the World in Confirmed Coronavirus Cases,” New York Times (March 26, 2020), https://www.nytimes.com/2020/03/26/health/usa-coronavirus-cases.html.

47 Office of the Texas Governor, “Executive Order No. GA-11 Relating to Airport Screening and Self-Quarantine During the COVID-19 Disaster,” March 26, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-11.pdf.

48 Claudia Grisales, “President Trump Signs $2 Trillion Coronavirus Rescue Package Into Law,” NPR (March 27, 2020), https://www.npr.org/2020/03/27/822062909/houseaims-to-send-2-trillion-rescue-package-to-president-to-stem-coronavirus-cr.

49 Michael D. Shear, “Trump Extends Social Distancing Guidelines Through End of April,” New York Times (March 29, 2020), https://www.nytimes.com/2020/03/29/us/politics/trump-coronavirus-guidelines.html.

50 Office of the Texas Governor, “Proclamation,” March 30, 2020, https://gov.texas.gov/ news/post/governor-abbott-issues-executive-order-mandating-14-day-quarantinefor-travelers-arriving-from-ca-la-wa-atlanta-chicago-detroit-and-miami.

51 U.S. Food & Drug Administration, “Coronavirus (COVID-19) Update: Daily Roundup March 30, 2020,” March 30, 2020, https://www.fda.gov/news-events/pressannouncements/coronavirus-COVID-19-update-daily-roundup-march-30-2020.

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52 Office of the Texas Governor, “Executive Order No. GA-08,” March 31, 2020, https://gov.texas.gov/ news/post/governor-abbott-issues-executive-order-implementing-essential-services-and-activitiesprotocols, and “Executive Order No. GA-14 Relating to Statewide Continuity of Essential Services and Activities During the COVID-19 disaster,” March 31, 2020, https://gov.texas.gov/uploads/files/ press/EO-GA-14_Statewide_Essential_Service_and_Activity_COVID-19_IMAGE_03-31-2020.pdf; and Christopher C. Krebs, director of the Cybersecurity and Infrastructure Security Agency, U.S. Department of Homeland Security, “Advisory Memorandum on Identification of Essential Critical Infrastructure Workers During COVID-19 Response,” March 28, 2020, https://www.cisa.gov/sites/default/files/ publications/Version_3.0_CISA_Guidance_on_Essential_Critical_Infrastructure_Workers_1.pdf.

53 Naomi Andu, “The Number of Texans Filing for Unemployment Has Soared 1,600% in Two Weeks,” The Texas Tribune (April 2, 2020), https://www.texastribune.org/2020/04/02/ texans-filing-unemployment-increases-1600-over-two-weeks-ago/.

54 Office of the Texas Governor, “Gov. Abbott Waives Certain Regulations to Expand Health Care Workforce During COVID-19 Response,” April 5, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press04052020_health_care.pdf.

55 Office of the Texas Governor, “Gov. Abbott Announces Texas Military Department, Prestige Ameritech Partnership To Increase Mask Production,” April 8, 2020, https://lrl. texas.gov/scanned/govdocs/Greg%20Abbott/2020/press04082020_masks.pdf.

56 Office of the Texas Governor, “Gov. Abbott, HHSC Announce Emergency Rule to Increase Supply of Direct Care Providers in Nursing Facilities,” April 9, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press04092020_nursing.pdf.

57 Office of the Texas Governor, “Gov. Abbott Waives Regulations, Expands Telehealth Options,” April 9, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press04092020_telehealth.pdf.

58 Office of the Texas Governor, “Gov. Abbott Provides Update on COVID-19 In Texas, Announces Frontline Child Care Website for Essential Workers,” April 10, 2020, https://lrl.texas.gov/ scanned/govdocs/Greg%20Abbott/2020/press04102020_COVID-19_presentation.pdf.

59 Office of the Texas Governor, “Gov. Abbott Eases Regulations on Physicians-InTraining To Increase Health Care Capacity In Texas,” April 11, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press04112020_physicians.pdf.

60 City of Austin, “Order No. 20200413-009 by the Mayor of the City of Austin,” April 13, 2020, http://www.austintexas.gov/sites/default/files/files/document_96DEBEEC-E581-05E08A3D444404948A84.pdf; and Travis County Judge, “Order No. 2020-7: Relating to the Declaration regarding COVID-19-19,” April 13, 2020, http://www.austintexas.gov/sites/default/files/files/ Travis%20County%20-%20Stay%20Home-Work%20Safe%20Order%20-%2004-13-2020.pdf.

61 Derrick Bryson Taylor, “A Timeline of the Coronavirus Pandemic,” New York Times (August 6, 2020), https://www.nytimes.com/article/coronavirus-timeline.html.

62 Staff, “A Timeline of COVID-19 Developments in 2020,” American Journal of Managed Care (July 3, 2020), https://www.ajmc.com/view/a-timeline-of-COVID-1919-developments-in-2020.

63 Office of the Texas Governor, “Executive Order No. GA-17 Relating to the Establishment of the Governor’s Strike Force to Open Texas,” April 17, 2020, https://gov.texas.gov/uploads/ files/press/EO-GA-17_Open_Texas_Strike_Force_COVID-19_IMAGE_04-17-2020.pdf.

64 Office of the Texas Governor, “Gov. Abbott, Texas National Guard Announce COVID-19 Mobile Testing Sites,” April 20, 2020, https://lrl.texas.gov/scanned/ govdocs/Greg%20Abbott/2020/press04202020_testing.pdf.

65 City of San Antonio, “Addendum to Stay Home Work Safe Measures: Public Use of Face Coverings,” April 16, 2020, https://www.sanantonio.gov/Portals/0/Files/health/COVID-1919/Public%20 Info/2nd%20Addendum%20to%20EXH%201%20-%205th%20Declaration%20-%20Stay%20 Home%20Work%20Safe%20Measures%2004.16.20%20FINAL.pdf?ver=2020-04-16-175323-370.

66 Office of the Texas Governor, “Gov. Abbott Temporarily Waives Certain Testing Requirements For Advanced Practice Registered Nurses,” April 22, 2020, https://lrl. texas.gov/scanned/govdocs/Greg%20Abbott/2020/press04222020_APRN.pdf.

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68 Office of the Texas Governor, Texans Helping Texans: The Governor’s Report to Open Texas (Austin, Texas, April 27, 2020), https://open.texas.gov/uploads/files/organization/opentexas/OpenTexas-Report.pdf.

69 Office of the Texas Governor, “Gov. Abbott Announces Phase One to Open Texas, Establishes Statewide Minimum Standard Health Protocols,” April 27, 2020, https://gov.texas.gov/news/post/governor-abbottannounces-phase-one-to-open-texas-establishes-statewide-minimum-standard-health-protocols.

70 U.S. Food & Drug Administration, “FDA Approves First Treatment for COVID-19,” October 22, 2020, https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-covid19#:~:text=Veklury%20is%20the%20first%20treatment,to%20receive%20FDA%20approval.

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67 Zach Despart, “Hidalgo Orders Harris County Residents to Wear Masks in Public, Draws Fire from Police Unions, GOP,” Houston Chronicle (April 22, 2020), https://www.houstonchronicle.com/news/ houston-texas/houston/article/harris-county-mandatory-mask-order-coronavirus-15217911.php.

71 Office of the Texas Governor, “Executive Order No. GA-21 Relating to the Expanded Reopening of Services as Part of the Safe, Strategic Plan to Open Texas in Response to the COVID-19 Disaster,” May 5, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-21.pdf.

72 Office of the Texas Governor, “Gov. Abbott Expands Business Openings in Texas, Announces Surge Response Teams to Combat COVID-19,” May 5, 2020, https://lrl.texas.gov/scanned/ govdocs/Greg%20Abbott/2020/press05052020_presentation_graduation.pdf.

73 Peggy Fikac and David Green, “Pandemic Drives Record Unemployment: Texas Workforce Commission Flooded With Claims,” Fiscal Notes (May 20, 2020), https:// comptroller.texas.gov/economy/fiscal-notes/2020/may/unemployment.php.

74 Office of the Texas Governor, “Gov. Abbott Directs TDEM, DSHS, HHSC to Test All Nursing Home Residents, Staff in Texas,” May 11, 2020, https://lrl.texas.gov/scanned/ govdocs/Greg%20Abbott/2020/press05112020_nursing_homes.pdf.

75 Office of the Texas Governor, “Gov. Abbott, HHSC Announce Over $1 Billion in Pandemic Food Benefits for Texas Families,” May 12, 2020, https://lrl.texas.gov/ scanned/govdocs/Greg%20Abbott/2020/press05122020_food.pdf.

76 Office of the Texas Governor, “Gov. Abbott, DSHS Distribute Additional Cases of Antiviral Drug Remdesivir Across Texas,” June 23, 2020, https://lrl.texas.gov/ scanned/govdocs/Greg%20Abbott/2020/press06232020_remdesivir.pdf.

77 Office of the Texas Governor, “Gov. Abbott, TDEM Announce Extension of FederallySupported Community-Based Testing Sites in Texas,” May 13, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press05132020_testing.pdf.

78 Office of the Texas Governor, “Gov. Abbott, Texas National Guard Launch Disinfection Mission for Nursing Facilities,” May 13, 2020, https://lrl.texas.gov/scanned/ govdocs/Greg%20Abbott/2020/press05132020_nursing_homes.pdf.

79 U.S. Department of Health & Human Services, “Trump Administration Announces Framework and Leadership for ‘Operation Warp Speed,’” May 15, 2020, https://www.hhs.gov/about/news/2020/05/15/ trump-administration-announces-framework-and-leadership-for-operation-warp-speed.html.

80 Office of the Texas Governor, “Gov. Abbott, TDEM Announce Partnership With Local Fire Departments To Expand Testing in Nursing Homes,” May 15, 2020, https://lrl.texas.gov/ scanned/govdocs/Greg%20Abbott/2020/press05152020_nursing_homes.pdf.

81 Office of the Texas Governor, “Executive Order No. GA-23 Relating to the Expanded Opening of Texas in Response to the COVID-19 Disaster,” May 18, 2020, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-23.pdf.

82 Office of the Texas Governor, “Gov. Abbott, Lt. Governor Patrick, Speaker Bonnen Direct State Agencies to Reduce Budgets By Five Percent,” May 20, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press05202020_budgets.pdf.

83 Office of the Texas Governor, “Executive Order No. GA-24 Relating to the Termination of Air Travel Restrictions as Part of the Safe, Strategic Plan to Open Texas in Response to the COVID-19 Disaster,” May 21, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-24.pdf.

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84 Office of the Texas Governor, “Gov. Abbott, CVS Health Announce 44 New COVID-19 Drive-Thru Test Sites in Texas,” May 21, 2020, https://lrl.texas.gov/scanned/ govdocs/Greg%20Abbott/2020/press05212020_cvs_testing.pdf.

85 Office of the Texas Governor, “A Proclamation Expanding the Enumerated List of Covered Services in Executive Order No. GA-23,” May 26, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/proc05262020.pdf.

86 U.S. Centers for Disease Control and Prevention, “United States Coronavirus (COVID-19) Death Toll Surpasses 100,000,” May 28, 2020, https://www.cdc.gov/media/releases/2020/s0528-coronavirus-death-toll.html.

87 Office of the Texas Governor, “Gov. Abbott Provides Update on COVID-19 Surge Response In Amarillo,” May 27, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press05272020_amarillo.pdf.

88 Office of the Texas Governor, “Gov. Abbott, HHSC Announce $3.6 Million To Connect Nursing Facility Residents And Families,” May 27, 2020, https://lrl.texas.gov/scanned/ govdocs/Greg%20Abbott/2020/press05272020_nursing_facilities.pdf.

89 Office of the Texas Governor, “Gov. Abbott Announces Phase III To Open Texas,” June 3, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press06032020_phase3.pdf.

90 World Health Organization, “Advice on the Use of Masks in the Context of COVID-19-19: Interim Guidance,” June 5, 2020, https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-duringhome-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak.

91 Office of the Texas Governor, “Gov. Abbott, TDEM Announce Expanded Testing In Underserved Communities Disproportionately Impacted by COVID-19,” June 8, 2020, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press06082020_testing.pdf.

92 Testing mission data provided by the Southwest Texas Regional Advisory Council, October 6 and November 18, 2020.

93 Staff, “A Timeline of COVID-19 Developments in 2020,” American Journal of Managed Care (July 3, 2020), https://www.ajmc.com/view/a-timeline-of-COVID-1919-developments-in-2020.

94 Office of the Texas Governor, “Gov. Abbott Announces Phase III To Open Texas,” June 3, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press06032020_phase3.pdf.

95 U.S. Food & Drug Administration, “Coronavirus (COVID-19) Update: Daily Roundup March 30, 2020,” March 30, 2020, https://www.fda.gov/news-events/pressannouncements/coronavirus-COVID-19-update-daily-roundup-march-30-2020.

96 Office of the Texas Governor, “A Proclamation Amending Executive Order GA-26 Relating to the Expanded Opening of Texas During the Disaster Posed by the Novel Coronavirus,” June 23, 2020, https://gov.texas.gov/uploads/files/press/DISASTER_proclamation_amending_GA-26.pdf.

97 Office of the Texas Governor, “Gov. Abbott Expands Local Authority on Outdoor Gatherings, Directs HHSC To Enact Emergency Rules To Increase Safety At Child Care Centers,” June 23, 2020, https://lrl.texas.gov/ scanned/govdocs/Greg%20Abbott/2020/press06232020_proc_child_care.pdf; and Aliyya Swaby, “Texas Parents Face a Frightening Lack of Information on Coronavirus Risks in Child Care Centers,” The Texas Tribune (July 9, 2020), https://www.texastribune.org/2020/07/09/texas-day-care-coronavirus-risks/.

98 Hannah Knowles et al, “New Coronavirus Cases in the U.S. Soar to Highest Single-Day Total,” Washington Post (June 24, 2020), https://www.washingtonpost.com/nation/2020/06/24/coronavirus-live-updates-us/.

99 Stephanie Adeline et al, “Coronavirus Is Surging: How Severe Is Your State's Outbreak?,” NPR (November 11, 2020), https://www.npr.org/sections/healthshots/2020/09/01/816707182/map-tracking-the-spread-of-the-coronavirus-in-the-u-s.

100 Office of the Texas Governor, “Gov. Abbott Announces Temporary Pause of Additional Reopening Phases,” June 25, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press06252020_reopening_pause.pdf.

101 Office of the Texas Governor, “Executive Order No. GA-27 Relating to the Need for Increased Hospital Capacity During the COVID-19 Disaster,” June 25, 2020, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-27.pdf.

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103 Jay Croft, “The US Sees a Record Number of New Coronavirus Cases in a Single Day,” CNN (June 25, 2020), https://www.cnn.com/2020/06/25/health/us-coronavirus-thursday/index.html.

104 Office of the Texas Governor, “Executive Order No. GA-28 Relating to the Targeted Response to the COVID-19 Disaster as Part of the Reopening of Texas,” June 26, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-28.pdf.

105 Office of the Texas Governor, “Gov. Abbott, HHSC Announce $9 Million for Nursing Facility Infection Control Projects to Prevent COVID-19,” June 30, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press06302020_nursing_facility.pdf.

■ ENDNOTES / Chapter 2

102 Nicole Cobler, “Since Memorial Day, Texas Sees Month of Coronavirus Spread,” Austin American-Statesman (June 27, 2020), https://www.statesman.com/news/20200627/ since-memorial-day-texas-sees-month-of-coronavirus-spread.

106 Office of the Texas Governor, “A Proclamation Amending Executive Order GA-27 Relating to Increased Hospital Capacity in Texas During the Disaster Posed by the Novel Coronavirus (COVID-19),” June 30, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/proc06302020.pdf.

107 Office of the Texas Governor, “Executive Order No. GA-29 Relating to the Use of Face Coverings During the COVID-19 Disaster,” July 2, 2020, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-29.pdf.

108 Office of the Texas Governor, “A Proclamation Amending Executive Order GA-28 Relating to Mass Gatherings in Texas During the Disaster Posed by the Novel Coronavirus (COVID-19),” July 2, 2020,https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/proc07022020.pdf.

109 Christianna Silva, “U.S. COVID-19 Deaths Near 130,000; Florida And Texas Report Record Case Numbers,” NPR (July 5, 2020), https://www.npr.org/sections/coronavirus-live-updates/2020/07/05/887445479/ u-s-COVID-19-deaths-near-130-000-florida-and-texas-report-record-case-numbers.

110 Office of the Texas Governor, “Gov. Abbott, DSHS Distribute Additional Cases of Antiviral Drug Remdesivir Across Texas,” July 4, 2020, https://gov.texas.gov/news/post/governorabbott-dshs-distribute-additional-cases-of-antiviral-drug-remdesivir-across-texas-2.

111 Office of the Texas Attorney General, “Order 2020-16956,” July 6, 2020, https://www.kxan. com/wp-content/uploads/sites/40/2020/07/HHSC-AG-Response-Nursing-Homes-2.pdf.

112 Office of Texas Governor, press releases dated July 7-31, 2020, https://gov.texas.gov/news/archive/2020/07.

113 Maria Abi Habib et al, “U.S. Hits Another Record for New Coronavirus Cases,” New York Times (July 9, 2020), https://www.nytimes.com/2020/07/09/world/coronavirus-updates.html.

114 Office of the Texas Governor, “A proclamation Amending Executive Order GA-27 Relating to Increased Hospital Capacity in Texas During the Disaster Posed by the Novel Coronavirus (COVID-19),” July 9, 2020, https://gov.texas.gov/uploads/files/press/DISASTER_amending_GA-27_adding_more_counties.pdf.

115 Office of the Texas Governor, “Gov. Abbott, Omnicare Announce COVID-19 Testing For Patients, Staff At Assisted Living Facilities, Nursing Homes,” July 10, 2020, https://gov.texas.gov/news/post/governorabbott-omnicare-announce-COVID-19-testing-for-patients-staff-at-assisted-living-facilities-nursing-homes.

116 Texas Education Agency, “TEA Announces Additional Reopening Guidance, Including Local Option for an Online-Only Start to the 2020-21 School Year,” July 17, 2020, https://tea.texas.gov/ about-tea/news-and-multimedia/news-releases/news-2020/tea-announces-additional-reopeningguidance-including-local-option-for-an-online-only-start-to-the-2020-21-school-year.

117 Office of the Texas Governor, “Gov. Abbott, Lt. Governor Patrick, Speaker Bonnen, Senate Finance, House Appropriations Committee Chairs Announce eLearning Funding for Texas Students,” July 17, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press07172020_elearning.pdf.

118 U.S. Food & Drug Administration, “Coronavirus (COVID-19) Update: FDA Issues First Emergency Authorization for Sample Pooling in Diagnostic Testing,” July 18, 2020, https://www.fda.gov/news-events/press-announcements/coronavirus-COVID-19update-fda-issues-first-emergency-authorization-sample-pooling-diagnostic.

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119 Texas Department of State Health Services, COVID-19 Tracker, https://txdshs.maps.arcgis. com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83.

120 National Institutes of Health, “Phase 3 Clinical Trial of Investigational Vaccine for COVID-19 Begins,” July 27, 2020, https://www.nih.gov/news-events/newsreleases/phase-3-clinical-trial-investigational-vaccine-covid-19-begins.

121 Office of the Texas Governor, “Gov. Abbott Issues Proclamation Extending Early Voting Period For November 3rd Election,” July 27, 2020, https://gov.texas.gov/news/post/governor-abbott-issuesproclamation-extending-early-voting-period-for-november-3rd-election; and “Gov. Abbott Waives Grade Promotion Requirements For 2020-2021 STAAR Testing,” July 27, 2020, https://gov.texas.gov/ news/post/governor-abbott-waives-grade-promotion-requirements-for-2020-2021-staar-testing.

122 Sarah R. Champagne, “Coronavirus Cases in Texas Nursing Homes More Than Doubled in July. Families Say the State Still Isn’t Testing Enough,” The Texas Tribune (July 28, 2020), https://www.texastribune.org/2020/07/28/nursing-homes-texas-coronavirus/.

123 Texas Health and Human Services Commission, “HHSC to Allow Limited Visitation at Nursing Facilities and Long-Term Care Facilities,” August 6, 2020, https://hhs.texas.gov/about-hhs/communicationsevents/news/2020/08/hhsc-allow-limited-visitation-nursing-facilities-long-term-care-facilities.

124 Office of the Texas Governor, “Gov. Abbott, Houston Astros, TDEM Announce COVID-19 Testing Site At Minute Maid Park,” August 6, 2020, https://gov.texas.gov/news/post/governorabbott-houston-astros-tdem-announce-COVID-19-testing-site-at-minute-maid-park.

125 Office of the Texas Governor, “Gov. Abbott Announces Federally Funded COVID-19 Testing Sites In Harris County,” August 7, 2020, https://gov.texas.gov/news/post/governorabbott-announces-federally-funded-COVID-19-testing-sites-in-harris-county.

126 Hunter Marrow, “Baylor College of Medicine Announces Licensing Agreement for COVID-19 Vaccine Candidate,” Community Impact (August 13, 2020), https://communityimpact.com/ houston/bellaire-meyerland-west-university/coronavirus/2020/08/13/baylor-college-ofmedicine-announces-licensing-agreement-for-COVID-19-vaccine-candidate/.

127 Anna Novak and Mitchell Ferman, “Texans Have Filed Nearly 3.2 million Unemployment Claims During the Coronavirus Pandemic,” The Texas Tribune (as of August 15, 2020), https://apps.texastribune.org/ features/2020/texas-unemployment/?_ga=2.190848042.1090465580.1598120698-1992640142.1597351012.

128 Emma Platoff, “Texas Becomes Fourth State to Surpass 10,000 COVID-19 Deaths,” The Texas Tribune (August 17, 2020), https://www.texastribune.org/2020/08/17/texas-coronavirus-deaths/.

129 Aliyya Swaby and Emma Platoff, “In Shift, Texas Begins Publishing Some Data on Coronavirus Cases at Child Care Centers,” The Texas Tribune (August 20, 2020), https:// www.texastribune.org/2020/08/20/texas-child-care-centers-coronavirus/.

130 Aliyya Swaby and Emma Platoff, “Texas Will Start Posting Coronavirus Case Data from Public Schools, Education Commissioner Says,” Texas Tribune (August 20, 2020), https:// www.texastribune.org/2020/08/20/texas-schools-coronavirus-cases/.

131 Office of the Texas Governor, “Gov. Abbott Announces Procurement of Over 1 Million Devices, WiFi Hotspots Through Operation Connectivity,” August 20, 2020, https://gov.texas.gov/news/post/governorabbott-announces-procurement-of-over-1-million-devices-wifi-hotspots-through-operation-connectivity.

132 U.S. Food & Drug Administration, “Recommendations for Investigational COVID-19 Convalescent Plasma,” August 23, 2020, https://www.fda.gov/media/141477/download.

133 Sergio Hernandez et al, “Tracking COVID-19 Cases in the US,” CNN Health (August 24, 2020), https://www.cnn.com/interactive/2020/health/coronavirus-us-maps-and-cases/.

134 Shonda Novack and Lori Hawkins, “TABC Relaxes Rules, Allowing More Bars to Reopen and Operate as Restaurants,” Dallas Morning News (August 26, 2020), https://www.dallasnews.com/ news/politics/2020/08/26/tabc-relaxes-rules-allowing-more-bars-to-operate-as-restaurants/.

135 Office of the Texas Governor, “Executive Order No. GA-30 Relating to the Continued Response to the COVID-19 Disaster as Texas Reopens,” September 17, 2020, https://gov.texas.gov/ uploads/files/press/EO-GA-30_expanded_openings_COVID-19.pdf; and “Executive Order No. GA-31 Relating to Hospital Capacity During the COVID-19 Disaster,” September 17, 2020, https://gov.texas.gov/uploads/files/press/EO-GA-31_hospital_capacity_COVID-19.pdf.

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137 Julie McCullough, “Federal Court Orders Texas Prison System to Provide Hand Sanitizer for Some Geriatric Inmates During Pandemic,” The Texas Tribune (September 29, 2020), https://www.texastribune.org/2020/09/29/texas-prisons-coronavirus-protections/.

138 Office of the Texas Governor, “Gov. Abbott, HHSC Announce $3.5 Million For Nursing Facility Safety Projects,” October 2, 2020, https://gov.texas.gov/news/post/governorabbott-hhsc-announce-3.5-million-for-nursing-facility-safety-projects.

139 Office of the Texas Governor, “Executive Order GA 32 Relating to the Continued Response to the COVID-19 Disaster as Texas Reopens,” October 7, 2020, https://gov.texas.gov/uploads/ files/press/EO-GA-32_continued_response_to_COVID-19_IMAGE_10-07-2020.pdf.

■ ENDNOTES / Chapter 2

136 Office of the Texas Governor, “Gov. Abbott Announces Over $171 Million In CARES Act Funding For Rental Assistance, Texas Eviction Diversion Program,” September 25, 2020, https://gov.texas.gov/news/post/governor-abbott-announces-over-171-millionin-cares-act-funding-for-rental-assistance-texas-eviction-diversion-program.

140 Office of the Texas Governor, “Gov. Abbott Encourages Health Care Providers to Enroll in DSHS Immunization Program in Preparation for COVID-19 Vaccine,” October 7, 2020, https://gov.texas.gov/news/post/governor-abbott-encourages-health-care-providersto-enroll-in-dshs-immunization-program-in-preparation-for-COVID-19-vaccine.

141 Office of the Texas Governor, “Gov. Abbott, HHSC Announce More Than $20 Million For Disaster Crisis Counseling Services,” October 9, 2020, https://gov.texas.gov/news/post/governorabbott-hhsc-announce-more-than-20-million-for-disaster-crisis-counseling-services.

142 Office of Texas Governor, press releases dated October 1225, 2020, https://gov.texas.gov/news/archive/2020/10.

143 Office of the Texas Governor, “Gov. Abbott, TEA, TDEM Announce COVID-19 Rapid Testing Pilot Program for Texas School Systems,” October 14, 2020, https://gov.texas.gov/news/post/governorabbott-tea-tdem-announce-COVID-19-rapid-testing-pilot-program-for-texas-school-systems.

144 U.S. Food & Drug Administration, “FDA Approves First Treatment for COVID-19,” October 22, 2020, https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-covid19#:~:text=Veklury%20is%20the%20first%20treatment,to%20receive%20FDA%20approval.

145 Daniel Borunda et al, “‘A Growing State of Emergency:’ El Paso County Orders 2-Week Shutdown amid COVID-19 Surge,” El Paso Times (October 29, 2020), https://www.elpasotimes.com/story/news/ health/2020/10/29/el-paso-COVID-19-restrictions-update-after-coronavirus-cases-spike/6070587002/; Vic Kolenc, “Texas Court Judge Allows El Paso Shutdown Order to Remain in Place,” El Paso Times (November 6, 2020), https://www.elpasotimes.com/story/news/2020/11/06/el-paso-covid-19shutdown-update-judge-makes-decision-case/6177525002/; and Eleanor Dearman and Vic Kolenc, “Texas Appeals Court’s Final Order Allows El Paso Nonessential Businesses to Stay Open,” El Paso Times (November 13, 2020), https://www.elpasotimes.com/story/news/local/el-paso/2020/11/13/ el-paso-officials-await-court-ruling-whether-shutdown-can-continue/6278423002/.

146 Office of the Texas Governor, “Gov. Abbott Announces Surge of Department of Defense Resources to El Paso,” November 6, 2020, https://gov.texas.gov/news/post/governorabbott-announces-surge-of-department-of-defense-resources-to-el-paso.

147 U.S. Food & Drug Administration, “Coronavirus (COVID-19) Update: FDA

Authorizes Monoclonal Antibody for Treatment of COVID-19,” November 9, 2020, https://www.fda.gov/news-events/press-announcements/coronavirus-COVID19-update-fda-authorizes-monoclonal-antibody-treatment-COVID-19.

148 Office of the Texas Governor, “Governor Abbott, DSHS Announce Distribution of COVID-19 Antibody Therapy to Hospitals Across Texas,” November 13, 2020, https://gov.texas.gov/news/post/ governor-abbott-dshs-announce-distribution-of-covid-19-antibody-therapy-to-hospitals-across-texas.

149 Jordan Rubio, “Texas Surpasses One Million COVID-19 cases, First State to Do So,” Houston Chronicle (November 9, 2020), https://www.houstonchronicle.com/coronavirus/ article/Texas-surpasses-one-million-COVID-19-cases-first-15714454.php.

150 Neil MacFarquhar and Nicholas Bogel-Burroughs, “U.S. Hospitalizations Reach a Record High as Medical Facilities are Under Strain,” New York Times (November 11, 2020), https://www.nytimes.com/live/2020/11/10/world/COVID-19-coronavirus-live-updates/ us-hospitalizations-reach-a-record-high-as-medical-facilities-are-under-strain.

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151 U.S. Centers for Disease Control and Prevention, “Scientific Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2,” November 2, 2020, https:// www.cdc.gov/coronavirus/2019-ncov/more/masking-science-sars-cov2.html.

152 National Institutes of Health, “Promising Interim Results from Clinical Trial of NIH-Moderna COVID-19 Vaccine,” November 16, 2020, https://www.nih.gov/news-events/news-releases/ promising-interim-results-clinical-trial-nih-moderna-covid-19-vaccine; and Pfizer Inc., “Pfizer and BioNTech Conclude Phase 3 Study of COVID-19 Vaccine Candidate, Meeting All Primary Efficacy Endpoints,” November 18, 2020, https://www.pfizer.com/news/press-release/ press-release-detail/pfizer-and-biontech-conclude-phase-3-study-covid-19-vaccine.

153 Baylor College of Medicine, “Biological E. Limited and Baylor COVID-19 Vaccine Begins Clinical Trial in India,” November 16, 2020, https://www.bcm.edu/news/ biological-e-limited-and-baylor-covid-19-vaccine-begins-clinical-trial-in-india.

154 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, “Casirivimab/Imdevimab,” https://www.phe.gov/ emergency/events/COVID19/investigation-MCM/cas_imd/Pages/default.aspx.

155 Office of the Texas Governor, “Gov. Abbott, DSHS Announce COVID-19 Vaccine Distribution Plan,” November 23, 2020, https://gov.texas.gov/news/post/governorabbott-dshs-announce-covid-19-vaccine-distribution-plan%22.

156 U.S. Food & Drug Administration, “FDA Takes Key Action in Fight Against COVID-19

By Issuing Emergency Use Authorization for First COVID-19 Vaccine,” December 11, 2020, https://www.fda.gov/news-events/press-announcements/fda-takes-key-actionfight-against-covid-19-issuing-emergency-use-authorization-first-covid-19.

157 Karen Brooks Harper et al, “COVID-19 Vaccine Doses are Arriving in Texas, Giving Weary Health Care Workers Hope after Months of Peril,” The Texas Tribune (December 14, 2020), https://www. texastribune.org/2020/12/14/texas-coronavirus-vaccines-arrive/; Aria Jones and Karen Brooks Harper, “Vaccinations are Underway for Texas’ Front-Line Health Care Workers: ‘I Can’t Believe This is Happening,’” The Texas Tribune (December 14, 2020), https://www.texastribune.org/2020/12/14/ covid-19-vaccinations-texas/; and MD Anderson Cancer Center, “Vaccination Clinic Begins Tuesday at MD Anderson,” December 15, 2020, https://www.mdanderson.org/newsroom/vaccinationclinic-begins-at-the-university-of-texas-md-anderson-cancer-center.h00-159387468.html.

158 U.S. Food & Drug Administration, “FDA Takes Additional Action in Fight Against COVID-19

By Issuing Emergency Use Authorization for Second COVID-19 Vaccine,” December 18, 2020, https://www.fda.gov/news-events/press-announcements/fda-takes-additionalaction-fight-against-covid-19-issuing-emergency-use-authorization-second-covid.

159 Patrick Svitek, “Gov. Greg Abbott Receives COVID-19 Vaccine, Saying He Wants to Serve as an Example to Texans,” The Texas Tribune (December 22, 2020), https:// www.texastribune.org/2020/12/22/greg-abbott-texas-vaccine/.

160 Texas Department of State Health Services, “Nearly 380,000 Doses Sent to Providers in Third Week of COVID-19 Vaccine Distribution,” December 28, 2020, https://dshs.texas.gov/news/releases/2020/20201228.aspx.

161 Karen Brooks Harper, “Texas’ Second Round of COVID-19 Vaccines Earmarked for Smaller Hospitals and Long-Term Care Facility Residents,” The Texas Tribune (December 18, 2020), https://www.texastribune.org/2020/12/18/texas-coronavirus-vaccine/.

162 Texas Department of State Health Services, COVID-19 in Texas (Dashboard), https://txdshs. maps.arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83.

163 U.S. Centers for Disease Control and Prevention, “Trends in Number of COVID-19 Cases in the US Reported to CDC, by State/Territory,” https://covid.cdc.gov/covid-datatracker/#trends_totalandratecases; and Texas Department of State Health Services, COVID-19 Data Tracker, https://dshs.texas.gov/coronavirus/additionaldata.aspx.

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1 Tex. Gov. Code §418.011, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.011.

2 Tex. Gov. Code §418.014, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.014.

3 Tex. Gov. Code §418.004(1), https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.004.

4 Tex. Health and Safety Code §81.003(7), https://statutes.capitol. texas.gov/Docs/HS/htm/HS.81.htm#81.003.

5 Tex. Health and Safety Code §81.082(d).

6 Tex. Health and Safety Code §81.082(e).

7 Texas Governor Greg Abbott, “Proclamation by the Governor of the State of Texas,” March 13, 2020, https://gov.texas.gov/uploads/files/press/DISASTER_covid19_disaster_proclamation_ IMAGE_03-13-2020.pdf; and Texas Commissioner of State Health Services John W. Hellerstedt, “Declaration of a Public Health Disaster in the State of Texas,” March 19, 2020, https://gov.texas. gov/uploads/files/press/DECLARATION_of_public_health_disaster_Dr_Hellerstedt_03-19-2020.pdf.

■ ENDNOTES / Chapter 3

CHAPTER 3

8 Tex. Gov. Code Chapter 418, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm.

9 Tex. Gov. Code §418.015(c), https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.015; and Tex. Gov. Code §418.012, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.012.

10 U.S. Department of Homeland Security, National Response Framework, Fourth Edition (October 28, 2019), p. 1, https://www.fema.gov/sites/default/files/2020-04/NRF_FINALApproved_2011028.pdf.

11 Tex. Gov. Code §418.1015, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.1015.

12 Tex. Gov. Code §418.1015, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.1015; and Tex. Gov. Code §418.108, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.108.

13 Tex. Gov. Code §418.102, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.102.

14 Tex. Gov. Code §418.106, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.106.

15 Tex. Health and Safety Code §117.001(5), https://statutes.capitol.texas.gov/Docs/ HS/htm/HS.117.htm#117.001; and Tex. Health and Safety Code §121.041, https:// statutes.capitol.texas.gov/Docs/HS/htm/HS.121.htm#121.041.

16 Descriptive material provided by the Texas Department of State Health Services, November 19, 2020.

17 Texas Department of State Health Services, “Texas Public Health Regions,” https://dshs. texas.gov/regions/state.shtm?terms=public%20health%20region%20map.

18 Tex. Health and Safety Code §121.021, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.121. htm#121.021; and interviews with staff of the Department of State Health Services.

19 Tex. Health and Safety Code §§121.007, 121.028, 121.033, and 121.045, starting at this link, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.121.htm#121.007.

20 Interviews with officials of the Texas Division of Emergency Management.

21 Texas Division of Emergency Management, State of Texas Emergency Management Plan: Basic Plan (February 2020), p. 9, https://tdem.texas.gov/wp-content/uploads/2019/08/2020State-of-Texas-Basic-Plan_WEBSITE_05_07_gs.pdf; and Tex. Gov. Code §418.041, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.041.

22 Tex. Gov. Code §418.013, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.013.

23 Texas Division of Emergency Management, Texas Emergency Management Executive Guide, FY 2019 Edition (Revised October 16, 2019), p. 23, https://tdem.texas.gov/ wp-content/uploads/2019/08/FY-2020-TDEM-Executive-Guide.pdf.

24 Texas Division of Emergency Management, Texas Emergency Management Executive Guide, FY 2019 Edition (Revised, October 16, 2019), p. 42, https://tdem.texas.gov/ wp-content/uploads/2019/08/FY-2020-TDEM-Executive-Guide.pdf.

25 Tex. Gov Code §418.113, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.113.

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26 Texas Division of Emergency Management, Texas Emergency Management Executive Guide, p. 22.

27 Texas Department of State Health Services, “Trauma Systems History,” https://www.dshs. texas.gov/emstraumasystems/Etrahist.shtm; and Texas Department of State Health Services, “What is a RAC?”, https://www.dshs.state.tx.us/emstraumasystems/etrarac.shtm.

28 Texas Department of State Health Services, “RAC Operation Guidelines: Regional Advisory Councils (History/Overview),” June 2008, https://www.dshs.state.tx.us/emstraumasystems/ RegionalAdvisoryCouncils_History_Overview06_2008.pdf; and “What Is a RAC?”.

29 U.S. Department of Health and Human Services, “Public Health Emergency,” https:// www.phe.gov/Preparedness/planning/hpp/Pages/about-hpp.aspx.

30 Interviews with staff of the Texas Department of State Health Services, November 19, 2020.

31 Texas Emergency Medical Task Force, “About,” http://txemtf.org/about/.

32 Texas Military Department, “Texas Military Department Covid-19 Response,” one-page graphic provided by the Texas Military Department.

33 Texas A&M Engineering Extension Service, Legislative Appropriations Request for Fiscal Years 2022 and 2023 (College Station, Texas, September 18, 2020), Administrator’s Statement, p. 3, https://www. lbb.state.tx.us/Agency_Docs.aspx; and internal documents of the Texas A&M University System.

34 Texas A&M Engineering Experiment Station, Legislative Appropriations Request for Fiscal Years 2022 and 2023, (College Station, Texas, September 18, 2020), Administrator’s Statement, p. 6, https://www. lbb.state.tx.us/Agency_Docs.aspx; and internal documents of the Texas A&M University System.

35 Texas A&M AgriLife Extension Service, Legislative Appropriations Request for Fiscal Years 2022 and 2023 (College Station, Texas, September 18, 2020), Administrator’s Statement, p. 2, https://www. lbb.state.tx.us/Agency_Docs.aspx; and internal documents of the Texas A&M University System.

36 Texas A&M Forest Service, Legislative Appropriations Request for Fiscal Years 2022 and 2023 (College Station, Texas, September 18, 2020), p. 1, https://www.lbb.state.tx.us/ Agency_Docs.aspx; and internal documents of the Texas A&M University System.

37 Tex. H.B. 1, Method of Financing, p. II-36, Acts of the 87th Legislature, Regular Session, 2019, https://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2020_2021.pdf.

38 Tex. Gov. Code §418.012, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.012; and Tex. Gov. Code §418.014, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.014.

39 Tex. Gov. Code §418.015(c).

40 Office if the State Governor, “Executive Order GA 05,” December 13, 2018, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2018/GA-05.pdf.

41 Tex. Gov. Code §418.042, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.042; and “Executive Order GA 05,” https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2018/GA-05.pdf.

42 Texas Division of Emergency Management, State of Texas Emergency Management Plan — Public Health and Medical Annex (ESF8) (Austin, Texas, March 2020), p. 1, https://tdem.texas.gov/ wp-content/uploads/2019/08/Texas-Public-Health-and-Medical-Annex-_May-2020.pdf.

43 Tex. Health and Safety Code Chapter 81.

44 Tex. Health and Safety Code §81.003(7).

45 Tex. Health and Safety Code §§81.081-81.085, https://statutes. capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.081.

46 Tex. Health and Safety Code §121.024(a), https://statutes.capitol. texas.gov/Docs/HS/htm/HS.121.htm#121.024.

47 Interviews with staff of the Southwest Texas Regional Advisory Council and the Texas Department of State Health Services conducted between April and mid-November 2020; and timeline information on early repatriations to Lackland Air Force Base.

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49 Letter from John Sharp, Chancellor of the Texas A&M University System, to the Honorable Lamar Alexander, Chairman, U.S. Senate Committee on Health, Education, Labor and Pensions, June 26, 2020.

50 Interview with staff of the Texas A&M Veterinary Medical Laboratory, September 15, 2020; and letter from John Sharp to Lamar Alexander.

51 Texas Division of Emergency Management, “Public Assistance Information for DR-4485TX: COVID-19,” https://tdem.texas.gov/covid-19/#1584884767024-4a025bba-5977.

52 Texas Division of Emergency Management, “CARES Act, Coronavirus Relief Fund,” https://tdem.texas.gov/crf/.

■ ENDNOTES / Chapter 3

48 Interviews with staff of the Southwest Texas Regional Advisory Council and the Texas Department of State Health Services conducted between April and late September 2020.

53 Information provided by staff of the Texas Division of Emergency Management.

54 U.S. Department of Health and Human Services, “Trump Administration Announces Framework and Leadership for ‘Operation Warp Speed’” May 15, 2020, https://www.hhs. gov/about/news/2020/05/15/trump-administration-announces-framework-and-leadershipfor-operation-warp-speed.html; and Noah Weiland and Katie Thomas, “Pfizer Applies for Emergency F.D.A Approval for COVID-19 Vaccine,” New York Times (November 20, 2020, updated November 22, 2020), https://www.nytimes.com/2020/11/20/health/pfizer-covid-vaccine. html?campaign_id=9&emc=edit_nn_20201122&instance_id=24364&nl=the-morning&regi_ id=101208766&segment_id=45168&te=1&user_id=50bd378ba4031891a2ab2da4e4819b5a.

55 Congressional Research Service, CARES Act Education Stabilization Fund: Background and Analysis (updated August 6, 2020), pp. 20-23, https://crsreports.congress.gov/product/pdf/R/R46378.

56 Interviews and information provided by staff of the Texas A&M System Government Relations Office, September 3, 2020 and September 9, 2020; and letter from Ted Mitchell, President of the American Council on Education, to Representative Nancy Pelosi, Speaker of the House, U.S. House of Representatives, and Representative Kevin McCarthy, Minority Leader, U.S. House of Representatives, March 20, 2020, https://www.acenet. edu/Documents/Letter-House-Higher-Ed-Supplemental-Requests-032020B.pdf.

57 Tex. Health & Safety Code §121.021, https://statutes.capitol.texas.gov/Docs/ HS/htm/HS.121.htm#121.021; and Tex. Health & Safety Code Subchapter E, “Control,” https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#E. 58 Tex. Health & Safety Code §§121.007, 121.028, 121.033 and 121.045, beginning at https://statutes.capitol.texas.gov/Docs/HS/htm/HS.121.htm#121.007.

59 Tex. Health & Safety Code §121.023, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.121.htm#121.023.

60 Tex. Health & Safety Code §121.022(b)(2), https://statutes.capitol. texas.gov/Docs/HS/htm/HS.121.htm#121.022.

61 Tex. Gov. Code §418.005, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.005.

62 Tex. Gov. Code §418.013, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.013.

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CHAPTER 4 1 Congressional Research Service, “National Stockpiles: Background and Issues for Congress,” June 15, 2020, p. 1, https://crsreports.congress.gov/product/pdf/IF/IF11574; and Sarah Fitzpatrick, “Why the Strategic National Stockpile Isn’t Meant to Solve a Crisis Like Coronavirus,” NBC News (March 28, 2020), https://www.nbcnews.com/health/health-care/ why-strategic-national-stockpile-isn-t-meant-solve-crisis-coronavirus-n1170376.

2 Interviews with Supply Chain Strike Force members in June and August 2020.

3 Premier Inc., “Premier Inc. Survey Finds 86 Percent of Health Systems Are Concerned About Personal Protective Equipment Shortages Due to Coronavirus,” March 2, 2020, https://www. premierinc.com/newsroom/press-releases/premier-inc-survey-finds-86-percent-of-healthsystems-are-concerned-about-personal-protective-equipment-shortages-due-to-coronavirus.

4 Congressional Research Service, COVID-19: China Medical Supply Chains and Broader Trade Issues (Washington, D.C., updated October 8, 2020), p.

17, https://crsreports.congress.gov/product/pdf/R/R46304.

5 Congressional Research Service, COVID-19: China Medical Supply Chains and Broader Trade Issues, pp. 9, 52.

6 Texas Division of Emergency Management, State of Texas Emergency Management Plan, Public Health and Medical Annex (ESF 8) (Austin, Texas, March 20, 2020), pp. 12, 13, https://tdem.texas. gov/wp-content/uploads/2019/08/Texas-Public-Health-and-Medical-Annex-_May-2020.pdf.

7 Office of the Texas Governor, “Governor Abbott Issues Executive Order Increasing Hospital Capacity, Announces Supply Chain Strike Force for COVID-19 Response,” March 22, 2020, https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-increasinghospital-capacity-announces-supply-chain-strike-force-for-covid-19-response.

8 Details on the operation and recommendations of the Supply Chain Strike Force derived from interviews with strike force members in June and August 2020 and unpublished strike force materials.

9 Texas S.B. 538, 84th Leg., Reg. Sess. (2015), https://capitol.texas.gov/tlodocs/84R/billtext/ html/SB00538E.htm; and Texas Task Force on Infectious Disease Preparedness and Response, Report and Recommendations (Austin, Texas, December 1, 2014), p. 25, https:// static.texastribune.org/media/documents/Task_Force_Recommendations_12-01-2014. pdf?_ga=2.64034662.811266427.1586016884-983913301.1583441583.

10 Texas Division of Emergency Management, Legislative Appropriations Request for Fiscal Years 2022 and 2023 (College Station, Texas, September 18, 2020), p. 3 of the Administrator’s Statement, https://www.lbb.state.tx.us/Agency_Docs.aspx.

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1 Christopher Weaver, Betsy McKay, and Brianna Abbott, “America Needed Coronavirus Tests. The Government Failed,” The Wall Street Journal, March 19, 2020, https://www.wsj.com/articles/howwashington-failed-to-build-a-robust-coronavirus-testing-system-11584552147?mod=article_inline.

2 Testing capacity information provided by the Texas Department of State Health Services, January 22, 2021.

3 Sami Sparber and Raga Justin, “Texas Gets Drive-Thru Coronavirus Testing in San Antonio, But It’s Not Open to the General Public,” The Texas Tribune (March 13, 2020), https://www. texastribune.org/2020/03/13/drive-through-coronavirus-testing-comes-san-antoniotexas/; and Office of the Texas Governor, “Governor Abbott, Texas National Guard Announce COVID-19 Mobile Testing Sites,” April 20, 2020, https://gov.texas.gov/news/post/ governor-abbott-texas-national-guard-announce-covid-19-mobile-testing-sites.

■ ENDNOTES / Chapter 5

CHAPTER 5

4 Federal and state testing timeline provided by the Southwest Texas Regional Advisory Council, October 6, 2020.

5 Office of the Texas Governor, The Governor’s Report to Reopen Texas (April 27, 2020), p. 12, https://open.texas.gov/uploads/files/organization/opentexas/OpenTexas-Report.pdf.

6 State testing site data provided by the Southwest Texas Regional Advisory Council, October 6 and November 18, 2020.

7 Texas Department of State Health Services, “COVID-19 Test and Hospitalization Data,” https://txdshs. maps.arcgis.com/apps/opsdashboard/index.html#/0d8bdf9be927459d9cb11b9eaef6101f.

8 Kaiser Family Foundation, “COVID-19 Testing,” https://www.kff.org/other/state-indicator/covid19-testing/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Total%20Number%20 of%20COVID-19%20Tests%20with%20Results%22,%22sort%22:%22desc%22%7D. 9 Johns Hopkins University and Medicine, Coronavirus Resource Center, “All State Comparison of Testing Efforts,” https://coronavirus.jhu.edu/testing/states-comparison.

10 The Texas Tribune, "Texas Coronavirus Cases Map," https://apps. texastribune.org/features/2020/texas-coronavirus-cases-map/.

11 Office of the Texas Governor, “Governor Abbott Directs TDEM, DSHS, HHSC to Test All Nursing Home Residents, Staff in Texas,” May 11, 2020, https://gov.texas.gov/news/post/ governor-abbott-directs-tdem-dshs-hhsc-to-test-all-nursing-home-residents-staff-in-texas; and Texas Health Care Association, “Quick Facts,” https://txhca.org/quick-facts/.

12 Interviews with staff of the Texas Commission on Fire Protection, September 30, 2020.

13 Testing mission data provided by the Southwest Texas Regional Advisory Council, October 6 and November 18, 2020.

14 Shannon Najmabadi and Emma Platoff, “Outside of Texas’ Big Cities, Some are Still Waiting Nearly a Month for Coronavirus Test Results from State-Run Mobile Units,” The Texas Tribune (June 10, 2020), https://www.texastribune.org/2020/06/10/texas-coronavirus-testing-mobile-sites/; Jay Root et al, “Texans Still Clamoring for Coronavirus Tests as State Promises Availability Will Skyrocket,” The Texas Tribune (March 17, 2020), https://www.texastribune.org/2020/03/17/texans-stillclamoring-coronavirus-tests-state-promises-more-soon/; and Shannon Najmabadi and Jay Root, “Coronavirus Test Results in Texas are Taking up to 10 Days,” The Texas Tribune (March 28, 2020), https://www.texastribune.org/2020/03/28/coronavirus-test-results-texas-are-taking-10-days/.

15 Office of the Texas Governor, “Governor Abbott, TDEM, DSHS Announce Statewide COVID-19 Test Collection Online Map,” April 24, 2020, https://gov.texas.gov/news/post/ governor-abbott-tdem-dshs-announce-statewide-covid-19-test-collection-online-map.

16 Interviews with staff of the Southwest Texas Regional Advisory Council, September 10, 2020.

17 Interviews with staff of the Texas A&M Veterinary Medical Laboratory, June 19, 2020 and September 15, 2020.

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18 Interviews with staff of the Texas A&M Veterinary Medical Laboratory, September 15, 2020; and letter from John Sharp, Chancellor, the Texas A&M University System, to the Honorable Lamar Alexander, Chairman, U.S. Senate Committee on Health, Education, Labor and Pensions, June 26, 2020.

19 Texas Department of State Health Services, “Public Health Follow Up,” Presentation to the Senate Committee on Health and Human Services, December 7, 2020, https:// www.dshs.texas.gov/legislative/86th/SenateHHS_COVID_Data.pdf.

20 Texas Department of State Health Services, “Texas Public Health Regions,” https://dshs. texas.gov/regions/state.shtm?terms=public%20health%20region%20map.

21 Edgar Walters, “How Years of Underfunding Public Health Left Texas Ill Prepared for the Pandemic,” The Texas Tribune (September 17, 2020), https://www. texastribune.org/2020/09/17/texas-coronavirus-health-funding/.

22 Lindsay Hendrix, “New COVID Investigation Operations Center to Help Texas A&M Safety Resume In-Person Classes this Fall,” Vital Record (July 8, 2020), https://vitalrecord.tamhsc.edu/ new-covid-investigation-operations-center-to-help-texas-am-safely-resume-in-person-classesthis-fall/; and Lauren Caruba, “How an Army of San Antonio Students is Helping Contact Trace for the Coronavirus,” San Antonio Express-News (May 8, 2020), https://www.expressnews.com/ news/local/article/How-an-army-of-San-Antonio-students-is-helping-15257334.php.

23 Department of State Health Services and Texas Public Health Practice Network, “Public Health 101 Course – A Workforce Training Initiative,” summary provided by DSHS, October 29, 2020.

24 History of CDC funding to the USA Center for Rural Public Health Preparedness provided by Texas A&M School of Public Health, October 27, 2020.

25 Texas Health & Safety Code §§121.101, 121.102 and 121.103, https:// statutes.capitol.texas.gov/Docs/HS/htm/HS.121.htm#121.001.

26 Department of State Health Services and Texas Public Health Practice Network, “Public Health 101 Course – A Workforce Training Initiative,” summary provided by DSHS, October 29, 2020.

27 Summary of reportable disease data volume pre- and post-COVID-19 provided by the Texas Department of State Health Services, October 15, 2020 and February 12, 2021.

28 Shawn Mulcahy, “Share of Positive COVID-19 Cases as Texas Reopened was Higher Than Originally Reported, New State Calculations Show,” The Texas Tribune (September 16, 2020), https://www.texastribune.org/2020/09/16/texas-coronavirus-positivity-rate-data-method/.

29 Texas Department of State Health Services, “COVID-19 Public Health Data,” Presentation to the Senate Committee on Health and Human Services, December 7, 2020, https:// www.dshs.texas.gov/legislative/86th/SenateHHS_COVID_Data.pdf; and COVID Tracking Project, “State Grades,” https://covidtracking.com/about-data/state-grades.

30 Texas Department of State Health Services, “Public Health Follow Up.” 31 Shawn Mulcahy, Dan Rosenzweig-Ziff and Abby Livingston, “Eligible Texans can’t get answers about the COVID-19 vaccine. It’s not clear who – if anyone – has them,” The Texas Tribune (December 31, 2020), https://www.texastribune.org/2020/12/31/texas-coronavirus-vaccine-rollout/.

32 Jenni Bergal, “State Watchdogs Plan to Monitor COVID-19 Data Accuracy,” Stateline (September 4, 2020), https://www.pewtrusts.org/en/research-and-analysis/blogs/ stateline/2020/09/04/state-watchdogs-plan-to-monitor-covid-19-data-accuracy?utm_ campaign=09-4-2020+SD&utm_medium=email&utm_source=Pew. 33 State of Delaware Office of Auditor of Accounts, Delaware’s COVID-19 Data Dashboard Opportunities and Successes (Dover, Delaware, December 2020), https://auditor.delaware. gov/wp-content/uploads/sites/40/2020/12/COVID-SPECIAL-REPORT-12-2.pdf.

34 Texas Health and Safety Code §81.041(f), https://statutes.capitol. texas.gov/Docs/HS/htm/HS.81.htm#81.041.

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36 Texas Health and Safety Code §81.046(f), https://statutes.capitol. texas.gov/Docs/HS/htm/HS.81.htm#81.046.

37 Texas Health and Safety Code §181.006, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.181. htm#181.006; and the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191.

Stat. 1936, https://www.govinfo.gov/content/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf.

38 Texas Attorney General Opinion OR2020-16956, July 6, 2020, https://www2.texasattorneygeneral. gov/opinions/openrecords/51paxton/orl/2020/pdf/or202016956.pdf.

39 Interview with staff of the Southwest Texas Regional Advisory Council, September 10, 2020.

■ ENDNOTES / Chapter 5

35 Office of the Texas Governor, “Governor Abbott Issues Executive Order to Strengthen Reporting Capabilities,” March 24, 2020, https://gov.texas.gov/news/post/governorabbott-issues-executive-order-to-strengthen-reporting-capabilities.

40 Interviews with staff of the Texas A&M Veterinary Medical Diagnostic Laboratory, June 19, 2020, and September 15, 2020.

41 Interview with staff of the Texas A&M Veterinary Medical Diagnostic Laboratory, September 15, 2020; and letter from John Sharp, chancellor of the Texas A&M University System, to the Honorable Lamar Alexander, Chairman of the U.S. Senate Committee on Health, Education, Labor and Pensions, June 26, 2020.

42 Letter from John Sharp to Lamar Alexander, June 26, 2020.

43 History of CDC funding provided by Texas A&M School of Public Health, October 27, 2020.

44 Tex. Health & Safety Code §81.041(f), https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.046.

45 Office of the Texas Governor, “Governor Abbott Issues Executive Order to Strengthen Reporting Capabilities,” March 24, 2020, https://gov.texas.gov/news/post/governorabbott-issues-executive-order-to-strengthen-reporting-capabilities.

46 Tex. Health & Safety Code §81.046(f), https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.046.

47 Texas Attorney General Opinion OR2020-16956, July 6, 2020, https://www2.texasattorneygeneral. gov/opinions/openrecords/51paxton/orl/2020/pdf/or202016956.pdf.

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CHAPTER 6 1 Texas Health and Human Services Commission, “Child Care Licensing,” https://hhs. texas.gov/doing-business-hhs/provider-portals/protective-services-providers/childcare-licensing; and “Child Care,” https://hhs.texas.gov/services/safety/child-care.

2 Texas Workforce Commission, “Child Care Program,” https://www.twc.texas.gov/ students/child-care-program; and Texas Rising Star, “Financial Assistance for Child Care,” https://texasrisingstar.org/parents/financial-assistance-for-child-care/.

3 Alicia Sasser Modestino, Jamie Ladge and Alisa Lincoln, “The Importance of Childcare in Reopening the Economy,” Econofact (June 29, 2020), p. 3, https:// econofact.org/the-importance-of-child care-in-reopening-the-economy.

4 Elizabeth Bedrick and Sarah Daily, “States Are Using the CARES Act to Improve Child Care Access during COVID-19,” Child Trends Brief (June 8, 2020; updated July 6), pp. 2-4, https:// www.childtrends.org/publications/states-are-using-the-cares-act-to-improve-child-careaccess-during-covid-19; and First Five Years Fund, “Child Care & COVID-19 Economic Relief: Federal Legislation Assisting Children, Families, and Child Care Providers,” May 15, 2020, pp. 1-2, https://www.ffyf.org/relief-for-child-care-providers-included-in-the-cares-act/.

5 Data provided by the Texas Health and Human Services Commission.

6 Child care licensing data provided by Texas Health and Human Services Commission on September 30, 2020.

7 Texas Office of the Governor, “Governor Abbott Issues Executive Order Increasing Hospital Capacity, Announces Supply Chain Strike Force For COVID-19 Response,” March 22, 2020, https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-increasinghospital-capacity-announces-supply-chain-strike-force-for-covid-19-response.

8 Texas Education Agency, “Frontline Child Care,” https://frontlinechild care.texas.gov.

9 Texas Office of the Governor, “Governor Abbott Announces New Processes To Preserve And Extend Child Care Capacity For Front Line Workers,” March 27, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press03272020_child_care.pdf.

10 Texas Office of the Governor, “Governor Abbott Announces Care.com Initiative to Increase In-Home Child Care Access for Frontline Workers,” April 6, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press04062020_child_care.pdf.

11 Texas Office of the Governor, “Governor Abbott Provides Update on COVID-19 in Texas, Announces Frontline Child Care Website for Essential Workers,” April 10, 2020, https://lrl.texas. gov/scanned/govdocs/Greg%20Abbott/2020/press04102020_COVID_presentation.pdf.

12 Texas Office of the Governor, “Governor Abbott, Texas A&M AgriLife Extension Service Announce Free Online Training For Child Care Providers During COVID-19 Response,” April 29, 2020, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press04292020_child_care.pdf.

13 Texas Office of the Governor, “Executive Order No. GA-23,” May 18, 2020, https:// lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-23.pdf.

14 Texas Office of the Governor, “Governor Abbott Announces Phase III To Open Texas,” June 3, 2020, https://gov.texas.gov/news/post/governor-abbott-announces-phase-iii-to-open-texas2.

15 Texas Office of the Governor, “Governor Abbott Expands Local Authority on Outdoor Gatherings, Directs HHSC To Enact Emergency Rules To Increase Safety At Child Care Centers,” June 23, 2020, https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/press06232020_proc_child_care.pdf.

16 Barron’s analysis reported in Erica Pandey, “The Child Care Industry’s Plight,” Axios (September 1, 2020), https://www.axios.com/coronavirus-child-care-business-crisis-035a9fe2-0f8a-4563-bc34-9016f65c6c66. html; and Erica Pandey and Felix Salmon, “The Cost of Closed Schools,” Axios (August 26, 2020), p. 1, https://www.axios.com/economic-cost-closed-schools-e2c7a948-e89f-4431-9f1e-a900a422749c.html.

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18 Calculations based on U.S. Department of Labor, Bureau of Labor Statistics, 2020 timeseries data, Table B-1: Employees on nonfarm payrolls by industry sector and selected industry detail, December 1, 2020, https://beta.bls.gov/dataViewer/view/timeseries/CES6562440001.

19 Steven Jessen-Howard and Simon Workman, “Coronavirus Pandemic Could Lead to Permanent Loss of Nearly 4.5 Million Child Care Slots,” Center for American Progress (April 24, 2020), p.

4, https://www.americanprogress.org/issues/early-childhood/news/2020/04/24/483817/ coronavirus-pandemic-lead-permanent-loss-nearly-4-5-million-child-care-slots/.

20 Texas Small Business Administration data provided by the Texas Association for the Education of Young Children on September 4, 2020.

■ ENDNOTES / Chapter 6

17 Texas Health and Human Services Commission, Child Care Regulation Data Book – Child Day Care Statistics, Fiscal Year 2019 (Austin, Texas, August 6, 2020), p. 4, https://hhs.texas.gov/sites/default/files/ documents/about-hhs/records-statistics/research-statistics/ccl/ccr-data-book-child-day-care-2019.pdf.

21 National Association for the Education of Young Children, “A State-by-State Look: How Child Care Programs are Holding On Until Help Comes,” July 29, 2020, https://www. naeyc.org/sites/default/files/globally-shared/downloads/PDFs/our-work/public-policyadvocacy/naeyc_policy_crisis_coronavirus_survey3statebystatedata.pdf.

22 National Association for the Education of Young Children, “Am I Next? Sacrificing to Stay Open, Child Care Providers Face a Bleak Future Without Relief,” December 2020, p. 14, https://www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/our-work/ public-policy-advocacy/naeyc_policy_crisis_coronavirus_december_survey_data.pdf.

23 Aliyya Swaby, “Texas Scaling Back Child Care Subsidies for Essential Workers, Low-Income Parents,” Texas Tribune reported on kut.org (May 19, 2020), https://www.kut.org/post/ texas-scaling-back-child-care-subsidies-essential-workers-low-income-parents.

24 Aliyya Swaby, “Texas Scaling Back Child Care Subsidies for Essential Workers, Low-Income Parents.”

25 Claire McInerny, “Lack of Child Care Isn't Just A Struggle For Texas Parents. It Could Also Cripple The Texas Economy,” KUT (August 31, 2020), https://www.kut.org/post/lackchild-care-isnt-just-struggle-texas-parents-it-could-also-cripple-texas-economy.

26 City of Austin, “Austin Childcare Provider Relief Grant,” https://www. austintexas.gov/department/austin-childcare-provider-relief-grant.

27 Texas Workforce Commission, “TWC Allocated $106.4 Million for Child Care Programs,” (August 20, 2020 Press Release), https://www.twc.texas.gov/twc-allocated-1064-million-child-care-programs.

28 Interview with staff of the Texas Education Agency, Texas Workforce Commission and Texas Health and Human Services Commission, September 17, 2020.

29 Interview with staff of the Texas Education Agency, Texas Workforce Commission and Texas Health and Human Services Commission, September 17, 2020.

30 Aliyya Swaby and Emma Platoff, “Texas will Start Posting Coronavirus Case Data from Public Schools, Education Commissioner Says,” Texas Tribune (August 20, 2020), https://www.texastribune. org/2020/08/20/texas-schools-coronavirus-cases/; and Aliyya Swaby and Emma Platoff “In Shift, Texas Begins Publishing Some Data on Coronavirus Cases at Childcare Centers,” Texas Tribune (August 20, 2020), https://www.texastribune.org/2020/08/20/texas-child-care-centers-coronavirus/.

31 Bipartisan Policy Center, Creating an Integrated Efficient Early Care and Education System to Support Children and Families: A State-by-State Analysis (December 2018), p. 6, https:// bipartisanpolicy.org/wp-content/uploads/2019/03/Creating-an-Integrated-Efficient-Early-Careand-Education-System-to-Support-Children-and-Families-A-State-by-State-Analysis.pdf.

32 Bipartisan Policy Center, Creating an Integrated Efficient Early Care and Education System to Support Children and Families: A State-by-State Analysis, pp. 20 and 30; and Bipartisan Policy Center, “Texas State Fact Sheet,” December 2018, p. 2, https:// bipartisanpolicy.org/wp-content/uploads/2018/12/Texas-State-Fact-Sheet.pdf.

33 Interview with staff of the Texas Education Agency, Texas Workforce Commission and Texas Health and Human Services Commission, September 17, 2020.

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34 Tex. Gov. Code Chapter 2054, https://statutes.capitol.texas.gov/SOTWDocs/GV/ htm/GV.2054.htm; and Texas Department of Information Resources, “Planning and Policy,” https://dir.texas.gov/View-About-DIR/Pages/Content.aspx?id=42.

35 Information provided by Texas Department of Information Resources staff, August 20, 2020.

36 Tex. Gov. Code Chapter 658, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.658.htm.

37 Texas Legislative Budget Board, “Overview of State Agency and Employee Use of Certain Nonmonetary Benefits,” April 2019, https://www.lbb.state.tx.us/Documents/ Publications/Staff_Report/2019/4732_NonmonetaryBenefits.pdf.

38 Texas Office of the Governor, “Governor Abbott Holds Press Conference on Coronavirus, Declares State of Disaster for All Texas Counties,” March 13, 2020, https://gov.texas.gov/news/post/governorabbott-holds-press-conference-on-coronavirus-declares-state-of-disaster-for-all-texas-counties.

39 Texas Department of Information Resources, “DIR Exemption Announcement,” March 17, 2020, https://pubext.dir.texas.gov/portal/internal/resources/ DocumentLibrary/DIR%20Exemption%20Announcement.pdf.

40 Texas Department of Information Resources, “DIR Town Hall: COVID-19 Series, Technology and Procurement,” April 9, 2020, https://pubext.dir.texas.gov/portal/internal/resources/ DocumentLibrary/DIR%20COVID19%20Series%20-%20Technology%20and%20Procurement.pdf.

41 Information provided by Texas Department of Information Resources staff, August 20, 2020.

42 Interview with Texas Health and Human Services Commission staff, May 1, 2020.

43 Interview with Texas Workforce Commission staff, July 14, 2020.

44 Anna Novak and Mitchell Ferman, “Texans Have Filed Nearly 3.5 Million Unemployment Claims During Coronavirus Pandemic,” The Texas Tribune (November 5, 2020), https://apps.texastribune.org/features/2020/texas-unemployment/.

45 David Lippman, “Texas Workforce Commission Provides Update for People Struggling to Receive Unemployment Benefits,” CBS 19 Local News (June 24, 2020), https://www.cbs19. tv/article/news/local/texas-workforce-commission-provides-update-for-people-strugglingto-receive-unemployment-benefits/501-1f0ff33b-6374-4757-9d13-4c222fd062ce.

46 Dan Rosenzaveig-Ziff and Kelsey Carolan, “Six Months into the Pandemic, Out-of-Work Texans are Still Struggling to Navigate Unemployment System,” The Texas Tribune (September 17, 2020), https:// www.texastribune.org/2020/09/17/texas-unemployment-benefits-workforce-commission/.

47 Texas Workforce Commission, “Information for COVID-19 FAQ, Jobseekers, Self-Employed, ChildCare and Unemployed After Returning to Work Guidance,” https://www.twc.texas.gov/.

48 Dan Rosenzaveig-Ziff and Kelsey Carolan, “Six Months into the Pandemic, Out-ofWork Texans are Still Struggling to Navigate Unemployment System.”

49 Texas Department of Information Resources, “Advancing the Next Generation of Technology in Texas,” 2020 Biennial Performance Report (Austin, Texas, November 1, 2020), p. 4, https://pubext.dir.texas.gov/portal/internal/resources/DocumentLibrary/2020%20 Biennial%20Performance%20Report%20Final%20Accessible.pdf.

50 Texas Department of Information Resources, 2020-2024 State Strategic Plan for Information Resources Management – Advancing the Next Generation of Technology in Texas (Austin, Texas, October 31, 2019), p. 1, https://pubext.dir.texas.gov/portal/internal/resources/DocumentLibrary/2020-2024%20 State%20Strategic%20Plan%20for%20Information%20Resources%20Management.pdf.

51 Connected Nation Texas, Broadband in Texas: A Briefing Prepared for the Governor’s Broadband Development Council (Austin, Texas, April 2020), p. 5, https://gov.texas.gov/ uploads/files/business/Texas_Broadband_Briefing_Book_-_April_2020.pdf.

52 Connected Nation Texas, “The Broadband Landscape in the State of Texas,” July 31, 2020, https://connectednation.org/texas/planning/.

53 Tex. Gov. Code Title 4, Subtitle F, Chapter 490H, https://texreg.sos.state.tx.us/ public/readtac$ext.ViewTAC?tac_view=4&ti=1&pt=10&ch=202.

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55 Texas Medical Association, “Texas Physicians: Expanding Broadband Access Will Help Patients,” November 4, 2020, https://www.texmed.org/TexasMedicineDetail.aspx?Pageid=46106&id=55126.

56 Joey Berlin, “The Tele-Future is Now: Will Telemedicine’s Footprint Be Permanent Post-COVID-19?”

Texas Medicine (July 2020), https://www.texmed.org/TexasMedicineDetail.aspx?id=53946.

57 Texas Office of the Governor, “Governor Abbott Announces Procurement Of Over 1 Million Devices, WiFi Hotspots Through Operation Connectivity,” August 20, 2020, https://gov.texas.gov/news/post/governorabbott-announces-procurement-of-over-1-million-devices-wifi-hotspots-through-operation-connectivity.

58 Aria Jones, “Lawmakers Call on Gov. Greg Abbott to Plan to Expand Broadband Access as Pandemic Worsens Disparities,” Texas Tribune (September 11, 2020), https://www. texastribune.org/2020/09/11/texas-rural-broadband-coronavirus-greg-abbott/.

■ ENDNOTES / Chapter 6

54 Texas Office of the Governor, 2020 Texas Report of the Governor’s Broadband Development Council, November 1, 2020, https://gov.texas.gov/uploads/files/ press/2020_Texas_Report_-_Governors_Broadband_Development_Council.pdf.

59 Nicole Cobler, “Texas State Agencies Uneven on Allowing Working from Home,” AustinAmerican Statesman, March 16, 2020, https://www.statesman.com/news/20200316/ texas-state-agencies-uneven-on-allowing-working-from-home.

60 Nicole Cobler, “Texas State Agencies Uneven on Allowing Working from Home.”

61 Jody Barr and David Barr, “Lawmaker Wants Answers: Why Did TxDOT Provide $8.3 M in Hazard Pay at Start of Pandemic?” KXAN News (July 31, 2020), https://www.kxan.com/investigations/ lawmaker-wants-answers-why-did-txdot-provide-8-3m-in-hazard-pay-at-start-of-pandemic/.

62 Texas Department of Criminal Justice, “COVID-19 TDCJ Update,” December 29, 2020, https://www.tdcj.texas.gov/covid-19/index2.html.

63 Tex. Occupations Code §111.001(3), https://statutes.capitol.texas.gov/Docs/OC/htm/OC.111.htm.

64 U.S. Health Resources and Services Administration, “Telehealth Programs,” https://www. hrsa.gov/rural-health/telehealth; and U.S. Centers for Medicaid and Medicare, “Medicare Telemedicine Health Care Provider Fact Sheet,” March 17, 2020, https://www.cms.gov/ newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

65 U.S. Centers for Disease Control and Prevention, “Using Telehealth to Expand Access to Essential Health Services During the COVID-19 Pandemic,” June 10, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.

66 Kaiser Family Foundation, “Primary Care Health Professional Shortage Areas,” State Health Facts (September 30, 2020), https://www.kff.org/other/state-indicator/ primary-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sor tModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 67 Texas Department of Agriculture, “State of Health Care in Rural Texas,” https://www. texasagriculture.gov/Portals/0/forms/ER/RuralHealth/SORH%20Infographic.pdf.

68 Craig Settles, “Commentary: Rural Public Libraries as Telehealth Providers During Covid-19,” Daily Yonder, October 22, 2020, https://dailyyonder.com/commentary-rural-public-libraries-as-telehealthproviders-during-covid-19/2020/10/22/; and Meredith McCown, “Pottsboro Library teaming with medical school for telemedicine program,” KXII News, December 22, 2021; https://www.kxii. com/2020/12/23/pottsboro-library-teaming-with-unt-medical-school-for-telemedicine-program/.

69 Tex. Ins. Code Chapter 1455, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1455.htm.

70 Texas Medical Board, “Coronavirus Disease (COVID-19) Response,” http://www.tmb.state.tx.us/page/coronavirus.

71 Kenny Wiley, “Texas A&M Health Science Center, Florida Company Unveil Telehealth Station in Cameron,” The Eagle (July 8, 2020), https://theeagle.com/news/local/texas-a-m-healthscience-center-florida-company-unveil-telehealth-station-in-cameron/article_e31b4a46c0cd-11ea-8751-c79d72bbd32c.html; and Rosemound Crown, “Telehealth Booth Brings Healthcare Options to Milam County,” KWTX Channel 10 (November 13, 2020), https://www. kwtx.com/2020/11/14/telehealth-booth-brings-healthcare-options-to-milam-county/.

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72 Texas Medical Board, Texas Medical Board Sunset Self-Evaluation Report (Austin, Texas, August 2015), p. 3, https://www.sunset.texas.gov/public/uploads/files/reports/Medical%20 Board%20SER%20Sept%201%202015.pdf%20-%20Adobe%20Acrobat%20Pro_0.pdf.

73 Texas Administrative Code Title 22, Chapter 174, https://texreg.sos.state. tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=P&p_rloc=186659&p_ tloc=&p_ploc=1&pg=10&p_tac=&ti=22&pt=9&ch=174&rl=6.

74 Texas Health and Human Services Commission, “Telemedicine, Telehealth, and Home Telemonitoring Services in Texas Medicaid,” December 2018, https://hhs.texas.gov/sites/default/files/documents/lawsregulations/reports-presentations/2018/sb-789-telemedicine-telehealth-hts-medicaid-dec-2018.pdf.

75 Tex. Ins. Code Title 8, Chapter 1455, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1455.htm.

76 Joey Berlin, “The Tele-Future is Now: Will Telemedicine’s Footprint Be Permanent Post-COVID-19?”

77 U.S. Department of Health and Human Services, “Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency,” https://www.hhs.gov/hipaa/for-professionals/special-topics/emergencypreparedness/notification-enforcement-discretion-telehealth/index.html.

78 U.S. Centers for Medicare and Medicaid Services, “Medicare Telemedicine Health Care Provider Fact Sheet,” March 17, 2020, https://www.cms.gov/newsroom/ fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

79 U.S. Centers for Medicare and Medicaid Services, “Trump Administration Drives Telehealth Services in Medicaid and Medicare,” October 14, 2020, https://www.cms.gov/newsroom/ press-releases/trump-administration-drives-telehealth-services-medicaid-and-medicare.

80 Texas Office of the Governor, “Governor Abbott Waives Certain Regulations For Telemedicine Care in Texas,” March 17, 2020, https://gov.texas.gov/news/post/ governor-abbott-waives-certain-regulations-for-telemedicine-care-in-texas.

81 Texas Department of Insurance, “Telemedicine Emergency Rule,” July 8, 2020, https:// www.tdi.texas.gov/news/2020/telemedicine-emergency-rule.html.

82 Texas Department of Insurance, “TDI Extends Telemedicine Emergency Rule into September,” June 24, 2020, https://www.tdi.texas.gov/news/2020/tdi06242020.html.

83 Texas Office of the Governor, “Governor Abbott Announces Agreement With Health Insurers To Continue Payment Parity For Telehealth,” September 25, 2020, https://gov.texas.gov/news/post/governorabbott-announces-agreement-with-health-insurers-to-continue-payment-parity-for-telehealth.

84 Texas Office of the Governor, “Governor Abbott, TDI Ask Health Insurance Providers to Waive Costs Associated with Coronavirus,” March 10, 2020, https://gov.texas.gov/news/post/governorabbott-tdi-ask-health-insurance-providers-to-waive-costs-associated-with-coronavirus; and “Governor Abbott Announces Agreement With Health Insurers To Continue Payment Parity For Telehealth,” September 25, 2020, https://gov.texas.gov/news/post/governor-abbottannounces-agreement-with-health-insurers-to-continue-payment-parity-for-telehealth.

85 Texas Health and Human Services Commission, “Medicaid and CHIP Services Information for Providers,” https://hhs.texas.gov/services/health/coronavirus-covid-19/medicaid-chip-services-information-providers.

86 U.S. Department of Health and Human Services, “Section 1135 Waiver Flexibilities-Texas Coronavirus Disease 2019 (Second and Third Request)," May 22, 2020, https://www.medicaid. gov/state-resource-center/disaster-response-toolkit/federal-disaster-resources/98631.

87 Texas Department of Insurance, “Health Coverage Guide,” November 6, 2020, https://www.tdi.texas.gov/pubs/consumer/cb005.html.

88 Texas Office of the Governor, “Governor Abbott, TDI Ask Health Insurance Providers to Waive Costs Associated with Coronavirus,” March 10, 2020, https://gov.texas.gov/news/post/governorabbott-tdi-ask-health-insurance-providers-to-waive-costs-associated-with-coronavirus.

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90 U.S. Department of Health and Human Services, “ASPE Issue Brief: Medicare Beneficiary Use of Telehealth Visits: Early Data From the Start of the COVID-19 Pandemic,” https://aspe.hhs.gov/pdf-report/medicare-beneficiary-use-telehealth.

91 Phil Galewitz, “Telemedicine Surges, Fueled By Coronavirus Fears And Shift In Payment Rules,” KHN (March 27, 2020), https://khn.org/news/telemedicinesurges-fueled-by-coronavirus-fears-and-shift-in-payment-rules/.

92 Joey Berlin, “The Tele-Future is Now: Will Telemedicine’s Footprint Be Permanent Post-COVID-19?”

93 Joey Berlin, “The Tele-Future is Now: Will Telemedicine’s Footprint Be Permanent Post-COVID-19?”

■ ENDNOTES / Chapter 6

89 Texas Department of Insurance, “Texas Health Insurers Waiving Cost-Sharing for Testing,” May 19, 2020, https://www.tdi.texas.gov/news/2020/covid-19-health-plan-actions.html.

94 Alycia Hardy and Katherine Gallagher Robbins, “Child Care Relief Funding in the YearEnd Stimulus Deal: A State-by-State Estimate,” CLASP (December 2020), https:// www.clasp.org/sites/default/files/publications/2020/12/2020%20COVID%20 Deal%20CC%20state%20by%20state%20Fact%20Sheet%20final.pdf.

95 Interview with staff of the Texas Education Agency, Texas Workforce Commission and Texas Health and Human Services Commission, September 17, 2020.

96 Texas Office of the Governor, 2020 Texas Report of the Governor’s Broadband Development Council (Austin, Texas, November 1, 2020), https://gov.texas.gov/uploads/files/ press/2020_Texas_Report_-_Governors_Broadband_Development_Council.pdf.

97 The PEW Charitable Trusts, “How States Are Expanding Broadband Access,” February 2020, https://www. pewtrusts.org/en/research-and-analysis/reports/2020/02/how-states-are-expanding-broadband-access.

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CHAPTER 7 1 Betsy McKay and Phred Dvorak, “A Deadly Coronavirus Was Inevitable. Why Was No One Ready?”

The Wall Street Journal (August 13, 2020), https://www.wsj.com/articles/a-deadly-coronavirus-wasinevitable-why-was-no-one-ready-for-covid-11597325213; and Texas Task Force on Infectious Disease Preparedness and Response, Report and Recommendations (December 1, 2014), p. 1, https:// static.texastribune.org/media/documents/Task_Force_Recommendations_12-01-2014.pdf.

2 Jay Root and Shannon Najmabadi, “In 2015, Texas Lawmakers Rejected Effort to Upgrade State’s Disease Response,” The Texas Tribune (March 13, 2020), https://www.texastribune. org/2020/03/13/2015-texas-lawmakers-nixed-bill-fight-diseases-coronavirus/.

3 Jon Hilsenrath, “Global Viral Outbreaks Like Coronavirus, Once Rare, Will Become More Common” Wall Street Journal (March 6, 2020), https://www.wsj.com/articles/ viral-outbreaks-once-rare-become-part-of-the-global-landscape-11583455309.

4 Judge Glock, “Why Two Decades of Pandemic Planning Failed,” Cicero News (April 9, 2020), https:// medium.com/cicero-news/why-two-decades-of-pandemic-planning-failed-a20608d05800#_ftnref4.

5 Betsy McKay and Phred Dvorak, “A Deadly Coronavirus Was Inevitable. Why Was No One Ready?”; and CNN Health, “Avian Flu Fast Facts," updated May 21, 2020, https://www.cnn.com/2013/08/23/health/avian-flu-fast-facts/index.html.

6 U.S. Homeland Security Council, National Strategy for Pandemic Influenza (Washington, D.C., November 2005), https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-strategy-2005. pdf; and National Strategy for Pandemic Influenza: Implementation Plan (Washington, D.C., May 2006), https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-implementation. pdf?fbclid=IwAR0L2Mdh6-pwWYpDQ_pcvSRWRM6T772WNTqGfIp2pk9G2nm6ahP2d-2VsOc. 7 U.S. Department of Homeland Security, Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans (Washington, D.C., January 2017), https://www.fema.gov/medialibrary-data/1511178017324-92a7a7f808b3f03e5fa2f8495bdfe335/BIA_Annex_Final_1-23-17_(508_ Compliant_6-28-17).pdf; and Federal Emergency Management Agency, “National Preparedness System,” https://www.fema.gov/emergency-managers/national-preparedness/system.

8 CNBC, “The Most Dangerous Places to Live in America That Are Prone to Natural Disasters,” updated July 15, 2019, https://www.cnbc.com/2019/07/10/billiondollar-natural-disasters-rising-these-states-better-prepare.html.

9 U.S. Centers for Disease Control and Prevention, “Pandemic Influenza Funding Announcement for Competitive Proposals (Activities)” (undated, probably 2007), https://www.cdc.gov/cpr/ documents/coopagreement-archive/fy2007/panflu-funding-opportunity-tp08-802.pdf; and “Public Health Emergency Response (PHER) Grant (2009-2010) for H1N1 Influenza Pandemic,” https://www.cdc.gov/cpr/readiness/funding-h1n1.htm#:~:text=CDC%20administered%20 %241.4%20billion%20through,influenza%20preparedness%20and%20response%20capacity.

10 Interviews with staff of the Texas Department of State Health Services, October 5, 2020, November 4, 2020, and December 29, 2020.

11 Texas Department of State Health Services, Respiratory Viruses Having Pandemic Potential (Austin, Texas, March 2015), https://dshs.texas.gov/IDCU/disease/influenza/Respiratory_Virus_ Plan_FINAL_V-1-2_03-20-15-fixed.doc; and interviews with staff of the Texas Department of State Health Services, October 5, 2020, November 4, 2020, and December 29, 2020.

12 Interviews with staff of the Texas Department of State Health Services, October 5, 2020, November 4, 2020, and December 29, 2020.

13 Texas Division of Emergency Management, State of Texas Emergency Management Plan: Basic Plan (Austin, Texas, February 2020), cover letter, https://tdem.texas.gov/wp-content/ uploads/2019/08/2020-State-of-Texas-Basic-Plan_WEBSITE_05_07_gs.pdf.

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15 Texas Department of State Health Services, Respiratory Viruses Having Pandemic Potential; and interviews with DSHS staff, October 5, 2020 and November 4, 2020.

16 Collin County, Texas, Pandemic Influenza Response Plan — Appendix 4 to Annex H, Health & Medical Services (January 10, 2020), https://www.collincountytx.gov/public_health/Documents/Annex%20H%20 -%20Appendix%204%20-%20Pandemic%20Influenza%20(1-10-2020%20Draft).pdf, and interviews with staff of the Texas Department of State Health Services, October 5, 2020 and November 4, 2020.

17 Texas Division of Emergency Management, “State of Texas Emergency Management Basic Plan — Hazard Annexes,” https://tdem.texas.gov/state-of-texas-emergency-management-plan/.

■ ENDNOTES / Chapter 7

14 Texas Division of Emergency Management, State of Texas Emergency Management Plan (Austin, Texas, February 2020), p. 4, https://tdem.texas.gov/wp-content/ uploads/2019/08/2020-State-of-Texas-Basic-Plan_WEBSITE_05_07_gs.pdf.

18 Texas Division of Emergency Management, State of Texas Emergency Management Plan, p. 5.

19 Office of the Texas Governor, “Governor Abbott Issues Executive Order Increasing Hospital Capacity, Announces Supply Chain Strike Force for COVID-19 Response,” March 22, 2020, https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-increasinghospital-capacity-announces-supply-chain-strike-force-for-covid-19-response; and details on the operation and recommendations of the Supply Chain Strike Force derived from interviews with strike force members and unpublished strike force materials.

20 Office of the Texas Governor, Texans Helping Texans: The Governor’s Report to Open Texas (Austin, Texas, April 27, 2020), https://open.texas.gov/uploads/files/organization/opentexas/OpenTexas-Report.pdf.

21 Texas Department of State Health Services, “COVID-19 Vaccination Plan,” October 16, 2020, https:// www.dshs.state.tx.us/news/updates/Texas-Vaccine-Plan-10-16-2020-DRAFT-CDC-Submission.pdf; “COVID-19 Vaccine Distribution Plan,” October 19, 2020, https://www.dshs.state.tx.us/uploadedFiles/ Content/Consumer_and_External_Affairs/TaskForceID/docs/6_COVID-19_Vaccination_Plan%2010-192020.pdf; and “COVID-19 Vaccine Distribution Plan Update,” December 7, 2020, https://www.dshs. state.tx.us/TaskForceID/docs/Agenda-Item-5-COVID19VaccineDistributionPlan-Update-12072020.pdf.

22 Office of the Texas Governor, “Governor Abbott, DSHS Announce COVID-19 Distribution Plan,” November 23, 2020, https://gov.texas.gov/news/post/governor-abbott-dshs-announce-covid-19vaccine-distribution-plan%22; and Texas Department of State Health Services, “COVID-19 Expert Vaccine Allocation Panel,” https://www.dshs.texas.gov/coronavirus/immunize/evap.aspx.

23 Office of the Texas Governor, “Executive Order RP 79 Relating to the Creation of the Texas Task Force on Infectious Disease Preparedness and Response,” October 6, 2014, https://lrl.texas.gov/scanned/govdocs/Rick%20Perry/2014/RP-79.pdf.

24 Office of the Texas Governor, Texas Task Force on Infectious Disease Preparedness and Response: Report & Recommendations (Austin, Texas, December 1, 2014), listing of task force members and p. 1 (Preface), https://static.texastribune.org/media/documents/Task_Force_Recommendations_12-01-2014.pdf.

25 Office of the Texas Governor, Texas Task Force on Infectious Disease Preparedness and Response: Report & Recommendations, pp. 61-62.

26 Tex. Health & Safety Code, Chapter 81, Subchapter J, https://statutes. capitol.texas.gov/Docs/HS/htm/HS.81.htm#J. 27 Tex. Health & Safety Code §81.403, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.403.

28 Tex. Health & Safety Code §773.003(10), https://statutes.capitol.texas.gov/Docs/HS/htm/ HS.773.htm#773.003; Tex. Health and Safety Code, Chapter 81, Subchapter J, https:// statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#J; and Texas Department of State Health Services, “Task Force on Infectious Disease Preparedness and Response,” updated December 18, 2020, https://www.dshs.state.tx.us/TaskForceID/.

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29 Texas Department of State Health Services, “Task Force on Infectious Disease Preparedness and Response,” updated December 18, 2020, https://www.dshs.state.tx.us/TaskForceID/; and interviews with staff of the Texas Department of State Health Services, December 14, 2020.

30 Texas Department of State Health Services, “Task Force on

Infectious Disease Preparedness and Response.”

31 State Health Access Data Assistance Center, “State Health Compare — Per Person State Public Health Funding: Rank,” http://statehealthcompare.shadac. org/map/117/per-person-state-public-health-funding#a/27/154.

32 U.S Centers for Disease Control and Prevention, “Public Health Emergency Preparedness Cooperative Agreement (PHEP) Program,” https://www.cdc.gov/cpr/pubs-links/2019/ documents/National2019.pdf; and U.S. Department of Health and Human Services, Assistant Secretary for Preparedness and Response, “Hospital Preparedness Program,” https:// www.phe.gov/Preparedness/planning/hpp/Documents/HPP-15-anniversary.pdf.

33 U.S. Centers for Disease Control and Prevention, “Public Health Emergency Preparedness (PHEP) Cooperative Agreement,” https://www.cdc.gov/cpr/pubs-links/2019/documents/National2019.pdf.

34 Texas Legislative Budget Board, Top 100 Federal Funding Sources (Austin, Texas, April 2019), p. 129, https:// www.lbb.state.tx.us/Documents/Publications/Primer/5075_Top_100_Federal_Funding_Sources_2018.pdf.

35 U.S. Department of Health and Human Services, “About the Hospital Preparedness Program,” https://www.phe.gov/Preparedness/planning/hpp/Pages/about-hpp.aspx.

36 Texas Department of State Health Services, “Texas Emergency Medical Task Force (EMTF), Infectious Disease Response Unit (IDRU),” by Eric Epley, August 9, 2016 (informational presentation), https:// www.dshs.state.tx.us/TaskForceID/docs/GovTFID-TDMS-EMTFepley.pdf; Texas Department of State Health Services, Emergency Medical Task Force, “About,” http://txemtf.org/about/; and information provided by the Texas Department of State Health Services, February 1, 2021 and February 7, 2021.

37 Texas Department of State Health Services, Emergency Medical Task Force, “About.”

38 Information provided by the Texas Department of State Health Services, February 1, 2021.

39 “More Than 100,000 U.S. Coronavirus Deaths Are Linked to Nursing Homes,” The New York Times (Updated December 4, 2020), https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html.

40 Texas Health and Human Services Commission, “Texas COVID-19 Case Data: Nursing Facilities,” https://apps.hhs.texas.gov/providers/directories/Texas_Nursing_Facilities_COVID_Status.xls; “Texas COVID-19 Case Data: Assisted Living Facilities,” https://apps.hhs.texas.gov/providers/directories/ Texas_Assisted_Living_Facilities_COVID_Status.xls; and Coronavirus Dashboard, “Additional Data” tab, “Accessible Dashboard Data” link, data reported as of December 20, 2020, https://txdshs. maps.arcgis.com/apps/opsdashboard/index.html#/0d8bdf9be927459d9cb11b9eaef6101f.

41 The University of Texas at Austin, Lyndon B. Johnson School of Public Affairs, COVID and Corrections: A Profile of Covid Deaths in Custody in Texas (Austin, Texas, November 2020), pp. 6-12, https://repositories.lib.utexas.edu/bitstream/handle/2152/83635/Profile%20 of%20COVID%20deaths%20in%20custody.pdf?sequence=6&isAllowed=y.

42 Texas Department of Criminal Justice, “COVID-19 Updates,” https://txdps.maps.arcgis.com/apps/ opsdashboard/index.html#/dce4d7da662945178ad5fbf3981fa35c; and Texas Department of Criminal Justice, “COVID-19 TDCJ Update,” December 29, 2020, https://www.tdcj.texas.gov/covid-19/index2.html.

43 Interviews with staff of the Texas Division of Emergency Management and Texas A&M University, June 8, 2020 and July 28, 2020.

44 Texas Department of State Health Services, “Coronavirus Disease 2019 (COVID-19): Prevention of COVID-19,” updated December 18, 2020, https://dshs.texas.gov/coronavirus/default. aspx#ifsick; and Texas Department of State Health Services, “Checklist for All Individuals,” (revised July 3, 2020), https://dshs.texas.gov/coronavirus/docs/opentx/Individuals.pdf.

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46 Interview with staff of Texas A&M AgriLife Extension, September 30, 2020.

47 Texas A&M AgriLife Extension, “Growing a Healthy Texas: Economic Impacts of Extension Education,” https://cdn-ext.agnet.tamu.edu/wp-content/uploads/2019/05/ Healthy-Texas-2019.pdf; and Texas A&M Foundation, “Healthy Texas,” September 24, 2018, https://www.txamfoundation.com/News/Healthy-Texas.aspx.

48 Texas A&M AgriLife Extension, “Growing a Healthy Texas: Economic Impacts of Extension Education.”

49 Texas A&M Foundation, “Healthy Texas.”

50 Texas Department of State Health Services, “Community Health Workers,” video describing the role of community health workers, August 26, 2019, https://www.youtube.com/ watch?reload=9&v=hfpGKmA1aNE; and Texas Department of State Health Services, “Community Health Worker or Promotor(a) Training and Certification Program," last updated September 5, 2019,” https://www.dshs.texas.gov/chw.aspx.

■ ENDNOTES / Chapter 7

45 Texas A&M AgriLife Extension, “Family & Community Health,” https:// agrilifeextension.tamu.edu/programs/family-community-health/.

51 Tex. Gov. Code §418.005, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.005.

52 Tex. Gov. Code §418.005; and Tex. Gov. Code §418.054, https://statutes. capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.054.

53 CNBC, “The Most Dangerous Places to Live in America That Are Prone to Natural Disasters,” updated July 15, 2019, https://www.cnbc.com/2019/07/10/billiondollar-natural-disasters-rising-these-states-better-prepare.html.

54 The Governor’s Commission to Rebuild Texas, Eye of the Storm (November 2018), pp. 134-135, 145, https:// www.rebuildtexas.today/wp-content/uploads/sites/52/2018/12/12-11-18-EYE-OF-THE-STORM-digital.pdf; and Tex. Gov. Code §418.057, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.418.htm#418.057.

55 Texas Division of Emergency Management, Emergency Management Professional Development Working Group, “Recommendations to the Texas Legislature,” June 2020, https://tdem. texas.gov/wp-content/uploads/2019/08/EMPDWG_PMP_MS_gs_FINAL_2.pdf.

56 Homeland Security Council, National Strategy for Pandemic Influenza (Washington, D.C., November 2005), https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-strategy-2005.pdf.

57 Homeland Security Council, National Strategy for Pandemic Influenza: Implementation Plan (Washington, D.C., May 2006), https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-implementation. pdf?fbclid=IwAR0L2Mdh6-pwWYpDQ_pcvSRWRM6T772WNTqGfIp2pk9G2nm6ahP2d-2VsOc. 58 Tex. Health & Safety Code §81.403, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.403.

59 Tex. Health & Safety Code §81.404, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.404.

60 Texas Department of State Health Services, “Task Force on Infectious Disease Preparedness and Response,” last updated December 21, 2020, https://www.dshs.state.tx.us/ TaskForceID/?terms=task%20force%20infectious%20disease%20and%20response.

61 Tex. Health & Safety Code §81.408, https://statutes.capitol.texas.gov/Docs/HS/htm/HS.81.htm#81.408.

62 U.S. Centers for Disease Control and Prevention, “Public Health Emergency Preparedness Cooperative Agreement (PHEP) Program,” 2019, https://www.cdc.gov/cpr/pubs-links/2019/documents/ National2019.pdf; and U.S. Department of Health and Human Services, “Hospital Preparedness Program,” https://www.phe.gov/Preparedness/planning/hpp/Documents/HPP-15-anniversary.pdf.

63 Data provided by Texas Department of State Health Services and adjusted for inflation according to the Consumer Price Index.

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Members of the Texas Emergency Medical Task force transport a COVID-19 patient from Joint Base San Antonio, February 24th, 2020. (Southwest Texas Regional Advisory Council)

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CONTRIBUTORS We interviewed and received information from many individuals and organizations to inform this report. Many are listed below, although the list is not comprehensive due to the sheer volume of persons involved in one way or another. We thank all who provided information and assistance.

While the listed individuals and organizations informed this report, we want to make it clear that their inclusion here does not mean they agree with or endorse the report’s recommendations.

THE TEXAS A&M UNIVERSITY SYSTEM Billy Hamilton, deputy chancellor and chief financial officer, Chancellor’s office Josie Wytaske, assistant to the deputy chancellor, Chancellor’s office Kelli Linza, project manager, Chancellor’s office Brooks Moore, deputy general counsel, General Counsel office Julie Masek, assistant general counsel, General Counsel office Dr. Jon Mogford, vice chancellor, Research office

TEXAS A&M UNIVERSITY AGENCIES Texas Division of Emergency Management Nim Kidd, chief Mike Miller, deputy chief

Greg Hartman, vice chancellor, Strategic Initiatives office; and chief operating officer and senior vice president, Texas A&M Health Jenny Jones, vice chancellor, and staff, Government Relations office Laylan Copelin, vice chancellor, Marketing and Communications office Dr. Jay Treat, chief manufacturing officer and principal investigator, Center for Innovation in Advanced Development and Manufacturing

Dr. Stephen Green, assistant agency director, Family and Community Health, Texas A&M AgriLife Extension

Suzannah Jones, deputy chief

Dr. Bruce Akey, director, Texas Veterinary Medical Diagnostic Laboratory

Chuck Phinney, chief operating officer

Tom Boggus and staff, Texas A&M Forest Service

Gabriela Stermolle, division chief Josh Davies, division chief

Texas A&M Engineering Agencies

Dr. Susan Ballabina, deputy vice chancellor

David Coatney, agency director; Hank Lawson, director, National Emergency Response and Recovery Training Center; and Warren (“Country”) Weidler, program manager, Texas A&M Engineering Extension Service

Dr. Angela Burkham, executive associate director, Texas A&M AgriLife Extension

Dr. Katharine Banks and staff, Texas A&M Engineering Experiment Station

Dr. Monty Dozier, program director, Disaster Assessment & Recovery, Texas A&M AgriLife Extension

Greg Winfree, director, Texas Transportation Institute

Joshua Bryant, section chief

Texas A&M AgriLife

CO

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TEXAS A&M UNIVERSITY Dr. Gerald Parker, associate dean, College of Veterinary Medicine & Biomedical Sciences; and Bush School of Government and Public Service (College Station) Dr. Christine Blackburn, deputy director, Pandemic & Biosecurity Policy Program, Bush School of Government and Public Service (College Station)

Dr. Shawn Gibbs, dean, School of Public Health (College Station) Dr. Rebecca Fischer, assistant professor, School of Public Health (College Station) Dr. Benjamin Neuman, professor and chair, Biological Sciences, Texas A&M University (Texarkana)

THE UNIVERSITY OF TEXAS SYSTEM Dr. David L. Lakey, vice chancellor for health affairs and chief medical officer Nagla Elerian, director, Population Health Strategic Initiatives

THE UNIVERSITY OF TEXAS Dr. Eric Boerwinkle, dean; Dr. Susan Tortolero Emery, senior associate dean for academic and research affairs; and other staff; School of Public Health, The University of Texas Health Science Center at Houston

Dr. Jay M. Bernhardt, dean, Moody College of Communication, The University of Texas at Austin Dr. James LeDuc and staff, Galveston National Laboratory, The University of Texas Medical Branch

Dr. Lauren Ancel Meyers, executive director, UT COVID-19 Modeling Consortium, The University of Texas at Austin

BAYLOR COLLEGE OF MEDICINE Dr. Peter Hotez, dean, National School of Tropical Medicine, Baylor College of Medicine

STATE AGENCIES AND RELATED ENTITIES Texas Department of State Health Services

Texas Health and Human Services Commission

Dr. John Hellerstedt, commissioner

Cecile Young, executive commissioner

Kirk Cole, senior advisor

Phil Wilson, general manager, Lower Colorado River Authority (on loan to the Texas Health and Human Services Commission)

Jennifer Sims, deputy commissioner Ricky Garcia, chief of staff Barbara Klein, general counsel David Gruber, associate commissioner, Regional & Local Health Operations Imelda Garcia, associate commissioner, Laboratory & Infectious Disease Services Jeff Hoogheem, director, Center for Health Emergency Preparedness & Response Dr. Jennifer Shuford, chief state epidemiologist Many other staff who gave generously of their time

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Karen Ray, chief counsel Hailey Kemp, chief public affairs officer Victoria Ford, chief policy & regulatory officer David Kostroun, deputy executive commissioner, Regulatory Services Kay Molina, deputy executive commissioner, Procurement & Contracting Services Julie Richards, deputy associate commissioner for program operations, Child Care Regulation

Keith Miears, senior vice president of worldwide procurement, Dell Technologies Elaine Mendoza, chair of the A&M Board of Regents, assisting with statewide child care infrastructure for critical workers Dr. John Zerwas, executive vice chancellor for health affairs, The University of Texas System

Julie Kopycinski, director of strategic initiatives, Texas Education Agency Lauren Zbyszinski, inter-agency deputy director of early childhood, Division of Early Childhood Education, Texas Education Agency Marcy Weldin, director of government affairs; and Shelia Taylor, director of state administration, Texas Military Department

Nelda Hunter, assisting Dr. John Zerwas

Mike Wisko, executive director, Texas Commission on Fire Protection

Clint Harp, vice president of transmission strategic services, Lower Colorado River Authority

Randy Townsend, deputy executive director, Texas Workforce Commission

Other State Agencies

Reagan Miller, director, Child Care & Early Learning Division, Texas Workforce Commission

Brandon Wood, executive director, Texas Commission on Jail Standards Brian Francis and staff, Texas Department of Licensing and Regulation Bryan Collier, executive director, Texas Department of Criminal Justice Dr. Harrison Keller, commissioner; and Ray Martinez, assistant commissioner for academic quality and workforce, Texas Higher Education Coordinating Board

■ Contributors / Contributors

Governor’s Supply Chain Strike Force

Allison Wilson, manager, Child Care Program Policy & Early Learning Initiatives, Texas Workforce Commission Robert Wood, associate deputy comptroller for operations and support; and Phillip Ashley, associate deputy comptroller for fiscal matters, Texas Comptroller’s office Steve Pier, chief of staff, Texas Department of Information Resources

Jennifer K. Harris, council member, Texas Governor’s Broadband Development Council

LOCAL AND REGIONAL ENTITIES AND WORKGROUPS Eric Epley and staff, Southwest Texas Regional Advisory Council Rick Antonisse and staff, North Central Texas Trauma Regional Advisory Council Steven Williams and staff, Houston Health Department

Six feedback workgroups of various city and county officials and staff involved in the COVID-19 response. The Texas Division of Emergency Management and the Texas Engineering Extension Service organized these groups in each of the six emergency management regions of Texas.

Sean Strawbridge, chief executive officer; and Danielle Hale, emergency manager, Port of Corpus Christi

ASSOCIATIONS AND ORGANIZATIONS Stacy E. Wilson and staff, Children’s Hospital Association of Texas Kim Kofron, executive director, Texas Association for the Education of Young Children Jamie Dudensing, chief executive officer, Texas Association of Health Plans

John Hawkins, senior vice president of government relations; and staff, Texas Hospital Association Troy Alexander, associate director; and other staff, Texas Medical Association Jon R. Comola, chief executive officer; and Anita D’Souza, Wye River Group

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CONSULTANTS Karl Spock Katharine Teleki Joey Longley Dianne Longley Esha Clearfield Tim Graves Cecile Young* Reed Clay *Left before completion of the project to become the executive commissioner of the Texas Health and Human Services Commission

SPECIAL THANKS Dr. Gerald Parker and Dr. Christine Blackburn, who, among their various titles, hold positions as director and deputy director of the Pandemic & Biosecurity Policy Program at the Scowcroft Institute of International Affairs at the Bush School of Government and Public Service at Texas A&M University. They found time in their busy schedules to write detailed initial drafts of what became Chapter 1, Viruses and Pandemics and to provide other advice through the course of this work.

Bruce Wright, who edited this report with his customary quick turnaround, amazing capacity to reduce content to well-organized and directly-stated essentials and unrelenting refusal to use the Oxford comma (as demonstrated in this sentence).

Kelli Linza, Texas A&M University System, for being willing to chase down hard-to-locate information and people we needed to interview quickly and always with good humor.

Kim Topp and Texas A&M AgriLife Marketing & Communications for doing the hard, time-consuming work of laying out this report and very patiently dealing with a multitude of changes along the way.

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■ Contributors / Contributors

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FEBRUARY 2021

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