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a boy smiles at his ABA therapy counselor

“I can sleep better tonight.” New priority for people with disabilities.

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“I can sleep better tonight.” New priority for people with disabilities. - North Carolina Health News

Families and advocates are cheering the decision to bump up vaccine priority for people with disabilities.

By Rose Hoban

Linda Guzman has been lying awake nights, worried about her son JJ, a young man in his twenties who has autism.

“It could be catastrophic for JJ if he contracted the virus with all his other health issues,” Guzman wrote in an email to John Nash, head of The Arc of North Carolina, an organization that provides services and advocacy for people with intellectual and developmental disabilities.

“I have done my best to protect him, but the stress and anxiety of doing so have been overwhelming at times,” the Chapel Hill mother wrote. She gave Nash permission to share her email with NC Health News.

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Nash received the email around 5 p.m. on Tuesday, after Mandy Cohen, the secretary of the state Department of Health and Human Services, announced that people with intellectual and developmental disabilities would be given higher priority for receiving COVID vaccines. With the addition of the new Johnson & Johnson one-shot vaccine to the arsenal of weapons to fight COVID-19 this week, North Carolina is opening up vaccination opportunities to more people.

Nash and other advocates for people with disabilities have been pressing for this policy change for weeks.

“For me, this is such a relief,” Nash said. “I spent the last several months now, since December, really trying to put this together trying to get enough momentum to be able to be heard.”

Now, after sitting down with DHHS officials and laying out the case, the advocacy has paid off.

“As a historically marginalized population, the I/DD community has long struggled for recognition, understanding, and support, and we greatly appreciate this step to bring us closer to parity with our fellow North Carolinians,” Nash wrote in a statement sent to people on The Arc’s contact list.

‘An important priority group’

At a press conference on Tuesday afternoon, Cohen said that so-called Group 1 vaccine recipients will be expanded from just including health care personnel and residents of nursing homes to include those who have been receiving home and community-based services for more than 30 days. This sweeps in people who have disabilities who receive their care at home.

“This includes home and community-based services for persons with intellectual and developmental disability, private duty nursing, personal care services, home health and hospice,” Cohen said.

But many people with disabilities don’t get formal services, and there are at least 12,000 people with intellectual and developmental disabilities in North Carolina who are languishing on a years-long waiting list for Medicaid-funded services. Instead, those people often receive care from family members, friends and people paid privately to take the burden of care off of aging parents and siblings.

“In addition for group four, we’ve clarified that higher risk medical conditions include intellectual and developmental disabilities such as Down syndrome and neurological conditions such as dementia,” Cohen said on Thursday.

“This is an important priority group,” said Julia Adams, who lobbies on behalf of people with disabilities at the General Assembly.  “Many individuals with disabilities are living at home, are being cared for by either paid or unpaid caregivers.”

While some of those caregivers, in particular older parents of some people with disabilities, have already received vaccines, Adams said, there are still significant gaps that leave people with disabilities at risk.

“You’re only maybe vaccinating one other person in that house, you still may have kids in that house, you may have neighbors in that house who are coming in who have not been in a vaccination priority pool yet,” she said.

More exposure, more risk

It’s hard to know just how many people will benefit from this policy change, just as it’s hard to know how many people with disabilities have died from COVID in the past year.

North Carolina does not include disability status in its data collection about people who are getting vaccinations and there’s little data about people with disabilities who have been among the more than 11,288 North Carolinians who have died from the coronavirus. That’s in contrast to some other states, such as California, which have been collecting information on disability status, along with data such as age, gender, race, ethnicity and some pre-existing conditions.

But Nash said that the science has become clear that people with disabilities, particularly those with intellectual and developmental disabilities, are at increased risk of contracting and dying of COVID-19.

“Every couple of days, somebody comes out with some study that says people with (intellectual and developmental disabilities) are at greater risk,” said Jennifer Mahan, director of public policy with the Autism Society of North Carolina. “Yes, they’re a greater risk because many of them live in some kind of group setting for different kinds of group settings, but some kind of group setting. But they’re also more at risk because they have underlying physical and genetic conditions, some of which we don’t even know about.”

She also said that many of these people are simply exposed to more workers, more family members, more caregivers – more people – because of their conditions.

“It would be the same if you had any other condition that requires somebody to come in your home and take care of you, or provide some kind of support for you to be able to live,” Mahan said.

According to an analysis done last fall by researchers from the Johns Hopkins University School of Medicine and a private consulting firm, people with disabilities were found to be about three times more likely to die from COVID-19 if they were developmentally or intellectually disabled than people without comorbidities. Those were even higher odds for death than for people with Alzheimer’s disease, cancer or kidney disease. Those people with mobility impairments were even more likely to die from COVID than people with heart failure, spinal cord injury or liver disease.

Nash said his agency provides a lot of guardianship services for people with disabilities and those guardians have seen too many deaths from COVID.

“When somebody passes, we do a pretty healthy review of what went on to make sure that everything handled was handled the way it was supposed to and that there weren’t things that shouldn’t have happened,” Nash said. “And just in the last two months, we’ve done probably a dozen COVID deaths.

“Those are so hard because the staff that works with that individual, they get close to the person,” he said. Nash noted that one of his staff members had two guardians die within a two-week period. “It’s just devastating.”

bar graph shows high risk for death from COVID for people disabilities.
COVID-19 patients across all age groups had greater odds of dying if they had any of the 15 comorbidities shown for the patients studied from April – August, 2020. Data were adjusted for age and gender. Data, graph courtesy: Risk Factors for COVID-19 Mortality among Privately Insured Patients, A FAIR Health White Paper in Collaboration with the West Health Institute and Marty Makary, MD, MPH, from Johns Hopkins University School of Medicine, Nov. 2020.

A recent analysis from the Kaiser Family Foundation notes North Carolina is among the states that does not separately list deaths from COVID among people with disabilities. Before Tuesday, the state’s vaccination plan did not specifically prioritize these people, other than noting higher priority for people with “high-risk medical conditions.”

The KFF analysis notes that the high-risk medical conditions group does not always put nonelderly people with disabilities who receive direct care services on an equal footing with people who live in nursing homes or other congregate settings.

“As of early February there had been 111,000 cases and 6,500 deaths from COVID-19 across 31 states that report data in settings such as group homes, personal care homes, adult day care programs, as well as in institutional settings such as intermediate care facilities and psychiatric institutions,” reads a press release from KFF about their data analysis.

The analysis also notes that few state vaccination plans have specifically mentioned direct care workers who provide long-term services in settings other than nursing homes, such as homes and in group homes, according to a different data set compiled by researchers from Johns Hopkins University. Until now, North Carolina has not explicitly mentioned people with disabilities who live in home- and community-based settings in the vaccination plan.

“Statewide, the number of people who are now eligible has grown exponentially,” Guzman wrote to Nash. “I am thinking there are thousands of families right now, crying tears of joy as I am.”

Guzman’s son is scheduled to receive a vaccine on Thursday, March 4.

We see Ester Amy Fischer hugging her mother while they take a selfie. Her mother Barbara, who wears a purple shirt with spotted patterns, is smiling with laughter.

For some long-term care residents, vaccine comes too late

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For some long-term care residents, vaccine comes too late - North Carolina Health News

What happens when an outbreak strikes a facility while residents inside wait for a vaccine?

By Hannah Critchfield

UPDATE: Barbara Fischer, who was featured in this article, died of her COVID-19 infection on Jan. 23, three days before she was scheduled to get vaccinated. Our thoughts are with her family.

Even as North Carolina enters the second phase of its vaccine plan, some long-term care residents are still waiting for the COVID-19 vaccine.

For Barbara Fischer, an 83-year-old dementia patient at Brookdale Meadowmont, it could be  coming too late.

When the state announced that people in long-term care facilities would be among the first to receive vaccination and that initial doses would arrive by mid-December, Ester Amy Fischer thought her mother’s group home would be offered the vaccine within weeks.

The Chapel Hill facility had been dealing with a COVID-19 outbreak since late November, and though the memory unit where her mother resided remained free of infection, that stability seemed more fragile with each passing day.

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“I was just anxiously waiting for her to get the vaccine,” Fischer’s daughter Ester said.

The first vaccine, made by Pfizer, was released to states on Dec. 14. The second vaccine, manufactured by Moderna, was approved over the weekend of Dec. 22.

“And then on Dec. 31, her facility emailed me.”

Fischer learned Brookdale Meadowmont would not receive the vaccine until Jan. 26, much later than she hoped.

By early January, her mother had tested positive for the novel coronavirus.

“It’s the thing I feared would happen the most, starting way back in November,” Fischer said. “I was livid.”

North Carolina is beginning to offer the vaccine to anyone over 65, having first offered doses to first-responder health care workers.

Vaccination of people who live and work in long-term care facilities, the other first-priority group for inoculation, is different. It’s handled by the federal government in partnership with CVS and Walgreens, two private companies that are administering the doses.

We see Barbara Fischer, 83, eating dessert while holding hands with her daughter Ester Amy across the table at her assisted living facility.
Barbara Fischer dines with her daughter Ester Amy Fischer. Barbara, age 83, tested positive for COVID-19 earlier this month, before the vaccine came to her long-term care facility. Photo credit: Ester Amy Fischer

Some families and staff say the pace of the rollout is too slow for high-risk loved ones living in these congregate settings, where viral outbreaks can spread like wildfire once inside.

“Honestly, when I first heard about the CVS-Walgreens program, I thought it was a good idea,” said Fischer. “But I think the problem is there just was not enough oversight on the state or county level – so when they weren’t getting the vaccine out fast enough, there was no way for states or counties to intervene.”

A federally run/privately run rollout

Residents and staff in long-term care facilities account for about 40 percent of all COVID-19 deaths nationwide.

In mid-December of last year, the federal government seemed optimistic about the vaccine rollout in these homes, with Secretary of Health and Human Services Alex Azar declaring that all nursing home residents could be vaccinated by Christmas.

But approval for the vaccines only came in mid-December. Then, there have been differing speeds for vaccine rollout on the ground, with wide variation by state.

Brookdale Meadowmont, an assisted living facility in Orange County that provides care for Alzheimer’s and dementia patients, is receiving the vaccine through CVS Health, according to Heather Hunter, spokesperson at Brookdale Senior Living, the company that oversees the home.

CVS Health has administered the vaccine to 630 long-term care facilities in North Carolina since beginning the effort in late December, according to Joseph Goode, CVS spokesperson.

Two-hundred and sixty-nine facilities that chose the company as its vaccine partner are still waiting.

The Brookdale Meadowmont facility is one of them — the long-term care facility is slated to receive the vaccine on Jan. 26, Hunter confirmed.

“As part of Phase 1 distribution, vaccinations are already underway at Brookdale Senior Living communities across the state and country,” she said. She also confirmed that the facility is still experiencing a coronavirus outbreak.

Walgreens, the other vaccine partner for long-term care, declined multiple requests for comment on the number of group homes that have already been offered doses under their contract.

For elderly residents like Barbara Fischer, the delay had dire consequences.

She tested positive for COVID-19 on Jan. 4, according to Fischer’s daughter Ester, and is still battling the illness weeks later.

“Her oxygen is normal, but she won’t wake up. I spoke to her doctor over the weekend, and she’s really not doing well,” Fischer said. “I really think the facility did the best they could do [to contain the spread] — but they need the vaccine.”

A staff member within the memory care unit, who requested to speak without being named by North Carolina Health News for fear of losing employment, confirmed that this was the date the outbreak struck the ward.

“People at a memory care unit cannot social distance,” the worker said. “You know, they want to hold hands with each other; it’s things that they do that they don’t know that they’re doing.

“It’s hard to try to keep them apart because six feet to them means absolutely nothing. So they should be at the top of the list, because they’re more susceptible to get it, just like the doctor in the ER.”

The worker also tested positive for COVID-19 two weeks ago, around the same time as resident Barbara Fischer. Infection also comes with high risk for the worker, who lives with elderly family members.

States help set priority

Though the federal government is coordinating these vaccinations to long-term care residents and staff, a CVS spokesperson said the company is still prioritizing which group homes should come first based on each state’s guidance.

“Some states have chosen to activate the program for certain residents of long-term care facilities (e.g., those in skilled nursing facilities) before others,” said Goode in an emailed statement. “We schedule clinics by geography and based on available weekly allocation, facility readiness and staffing to send out to LTCs in that community.”

Skilled nursing facilities are for people who require significant medical care, and are considered medical facilities. Because they’re regulated by federal authorities, who made the decision to  contract with the pharmacy companies to administer the vaccinations.

Assisted living facilities like Brookdale Meadowmont, which tend to have fewer on-site medical staff than nursing homes, nevertheless are often home to people at-risk for the worst outcomes of the virus, including those with developmental disabilities and dementia.

“Although older adults who reside in assisted living communities have many of the same risk factors as the older adults who live in nursing homes, in general, they’re less medically impaired,” said Sheryl Zimmerman, co-director of the Program on Aging, Disability and Long-Term Care at the University of North Carolina School of Social Work. “We certainly can’t forget them, and in fact, of all COVID-19 deaths that occur in long-term care settings, those in assisted living account for about 30 percent of the deaths.”

There tend to be more private rooms in assisted living facilities, Zimmerman noted, as well as fewer staff. Both decrease the risk of COVID-19 spread, which may help explain why some states are prioritizing skilled nursing homes first.

North Carolina prioritized skilled nursing facilities for scheduling “when possible,” according to Catie Armstrong, DHHS spokesperson.

“To me, if you wait to vaccinate people in memory care, you really don’t give them a fighting chance,” said the Brookdale Meadowmont staffer. “All elderly people, especially those with underlying issues, should get vaccinated.

“However, if you are capable of simple instructions such as social distance and washing your hands, you should be bumped down that list, and the person that can’t do those things needs to be bumped up.”

shows a young woman snuggling with an older woman
Photo credit: Ester Amy Fischer

‘Too late for my mom’

For now, Fischer tries to keep in touch with her mom virtually.

“I FaceTime her once or twice a day and just talk to her, even though she’s asleep,” Fischer said.

She doesn’t know if her mother will recover.

“I’ve kept fighting [for faster vaccinations], even though it’s too late for my mom,” she said. “I care a great deal about the other residents and the staff who work there — I’ve kept writing to the governor, DHHS and my county health department. I was trying to see if somebody could do anything.

“I understand it’s a federal program,” she added. “But it’s like they’re not even sure what’s going on.”

The staffer who spoke to NC Health News is no longer waiting for the vaccine.

“I’ll be getting my first dose next week,” the worker said. “Orange County is offering it.”

three girls are dressed as a banana split - complete with a large yellow banana made out of carboard that goes around all three of them and tall white hats that look like whipped cream

Should kids trick-or-treat in 2020? How to celebrate the Day of the Dead.

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Should kids trick-or-treat in 2020? How to celebrate the Day of the Dead. - North Carolina Health News

Duke physicians weigh in on celebrating Halloween and Dia de los Muertos as COVID-19 surges.

By Anne Blythe

Halloween is on the horizon and many families are wrestling with the idea of letting their kids deck themselves out in costumes and go trick-or-treating.

Pandemic fatigue has set in at many households, making many nostalgic for the days when the little kids could parade around as little Elsas, fearless Spidermen, witches, ghosts or Avengers on a mission to collect candy at every door.

To top it off, Halloween coincides with a full moon this year — the first time since 2001. It’s a rare blue moon, too, casting another touch of peculiarity to a year like no other.

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Furthermore, Halloween is a holiday that celebrates masks. So should the kids go trick-or-treating?

Not the best idea, public health officials say. COVID-19 continues to haunt the country, spooking physicians and others by the sheer volume of new cases going up on public health department dashboards in North Carolina and elsewhere these past few weeks.

“This year, obviously, is different than past years,” said Emmanuel “Chip” Walter, chief medical officer of the Duke Human Vaccine Institute and a pediatric infectious disease specialist. “I think trick-or-treat will not be as normal this year. I understand everybody is kind of fatigued from COVID. I just have real concerns about trick or treat as usual, going door to door like we usually think about in large crowds of kids. I just think that’s a perfect way to potentially spread the virus.”

That doesn’t mean Halloween has to be ignored, Walter, Cameron Wolfe, an infectious disease specialist at Duke, and Viviana Martinez-Bianchi, associate professor in Family Medicine and Community Health at Duke, said during a briefing with reporters on Wednesday.

It could be a year to go off the beaten path with some alternate ideas. They suggested:

  • Pumpkin carving at home or perhaps with another small group if everyone is wearing masks and social distancing. Don’t forget the hand sanitizer. It’s important, especially with little ones helping.
  • Home scavenger hunts with candy either inside with family or in a yard where social distancing is possible.
  • A home movie night.

The Centers for Disease Control and Prevention issued guidelines for Halloween activities. They do not rule out trick-or-treating but suggest a number of cautions for those who do.

  • Those giving out candy should avoid contact with trick-or-treaters, be outdoors when possible, and consider setting up stations with individually bagged treats for visitors.
  • Cloth face masks should be part of any costume or outing.
  • Stay at least 6 feet away from anybody not in your household.
  • Hand sanitizer should be used after touching objects or other people.

Not just a holiday for kids

“We sort of think of Halloween as a young kid event,” Wolfe said. “I have a young 5- and 7-year-old, they’re excited about this. But I think we should also reflect that for many towns, particularly college towns, for example, Halloween is a big teenager [event] and celebration in your 20s and beyond.”

Chapel Hill, for decades, has seen thousands of college-aged and adult costumed revelers flock to Franklin Street in the downtown area to parade in costumes, some very cleverly crafted.

Bar crawls in other towns and cities often draw large crowds of adults on a hunt for alcohol instead of candy.

Chapel Hill’s police chief and executive director of public safety said earlier this month that public health guidance on crowd size limitations would prevent the town from closing off Franklin Street for the annual Halloween gathering.

Though the event is not sponsored by the town, the street was barricaded and police officers monitored activities throughout the blocked off area to try to keep the festivities as safe as possible.

“We know Halloween on Franklin Street is a beloved annual gathering for so many in our community but crowds greater than 50 people go against the current public health guidance,” Chris Blue, the police chief, said in a statement posted to the town website. “As a Chapel Hill native, I, too, am disappointed that this annual tradition cannot happen. However, given the risks associated with such an event during the current pandemic, supporting a Halloween event in our downtown is not in the best interest of safety for our community.”

Nonetheless, as many college campuses report COVID-19 clusters among students in their late teens and early 20s, there are concerns that young adults might hold Halloween gatherings.

Walter and Wolfe stressed that anyone with COVID-19, even those who are asymptomatic, as well as those exposed to someone who tested positive for the virus within 14 days of Halloween should stay home and not participate in any activities.

“When we’ve looked on our college campus at the amount of virus that’s shed by different students, I am consistently shocked that some of the most prolific shedders of COVID are completely asymptomatic,” Wolfe said. “If there’s a message there, it’s please don’t fool yourself into believing you’re safe just because your symptoms aren’t there. If you know you’ve had an exposure … please take that seriously even if you’re feeling well. There’s a reasonable chance you can be infected and just not know.”

Walter added that gatherings with beer, wine or other alcoholic drinks could lead to COVID-19 outbreaks or clusters during a time when public health officials would like to tamp down virus spread.

“If you have COVID you really should follow recommendations and not be participating in any Halloween or trick or treat activities,” he said. “The biggest risk is social gatherings with older teens and young adults for Halloween festivities. Those are very, very common. If you potentially mix alcohol in with those kinds of events, you really risk a high-transmission, super-spreader type of event. I really would caution people against larger gatherings.”

a large crowd of people in costume stretches from the foreground to the horizon of franklin st.
As many college campuses report COVID-19 clusters among students in their late teens and early 20s, there are concerns that young adults might hold Halloween gatherings. Photo credit: Selena N. B. H.

How to celebrate Day of the Dead

The day after Halloween is the Day of the Dead, or Dia de los Muertos, celebrated in many Latino households to honor deceased family and friends no longer here.

Traditional festivities include parades in public squares or trips to cemeteries, where graves are decorated with candles, flowers, fruits, nuts and other offerings. There is a lot of food and drink consumed, too.

The holiday, which began in Mexico and is celebrated throughout Latin America, is a time to recognize death as a part of life and share stories and memories of the dead with the living.

Martinez-Bianchi spoke in English and Spanish during the briefing with reporters about how such festivities should occur during a pandemic that has had a disproportionate impact on Latin communities in North Carolina and elsewhere.

“To make it safe, you want to avoid the larger gatherings,” Martinez-Bianchi said. “You want to prepare traditional family recipes. Play music in your home that your deceased loved ones enjoyed.”

In keeping with measures suggested for Halloween this year, Martinez-Bianchi recommended that families try to keep the festivities to family members they live with inside their own homes.

“You can work with your kids to make and decorate masks or make an altar,” Martinez-Bianchi said. “You can set out pillows and blankets in your home intended for your deceased to rest. You can join a virtual get-together.

If families go to cemeteries, they should mask up and distance themselves from others while there.

“The most important thing is to avoid high-risk activities during Day of the Dead,” Martinez-Bianchi said. “You don’t want to attend large, indoor celebrations with singing or chanting. Avoid having a large dinner party.”

shows a sign reading, "Did you remember your MASK?" in the foreground, in the background is the iconic Old Well on the UNC Chapel Hill campus, two young men in masks walk by.

UNC’s one-week experiment with COVID-19 and on-campus life

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UNC’s one-week experiment with COVID-19 and on-campus life - North Carolina Health News

Parties, clusters and too much quick virus spread force UNC-Chapel Hill to reverse course.

By Anne Blythe

The University of North Carolina at Chapel Hill has long touted itself as a place where groundbreaking research occurs.

Six months into this coronavirus pandemic, the university conducted a live research project: Can an academic institution integrate more than 22,000 students in their late teens and early 20s back into a small college town and keep COVID-19 infection to a minimum?

In just one week, the results are in.

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A university that opened its doors wider to in-person learning and on-campus housing than many faculty and staff were comfortable with is reversing course quickly.

Chancellor Kevin Guskiewicz sent a campus-wide email on Monday afternoon announcing that all in-person instruction for undergraduates will shift to remote learning on Wednesday. Because of that, campus leaders are encouraging students in on-campus housing to return to their hometowns and states if possible.

‘We all saw this coming’

An editorial in The Daily Tar Heel, the campus newspaper, summed up the feelings of many as COVID-19 cluster after cluster was reported: “We all saw this coming.”

The chancellor’s decision comes at the heels of a week in which testing for COVID-19 at the Campus Health center soared to a positivity rate of 13.6 percent from just 2.8 percent at the start of classes on Aug. 10. As of Monday morning, the campus had tested 954 students, with 177 in isolation and 349 in quarantine, on and off campus.

By Monday, four COVID-19 clusters, each consisting of five or more related cases, had been reported at Ehringhaus and Hinton James residence halls, private residence hall Granville Towers, and Sigma Nu fraternity house.

“Based on the significant upward trend of positive cases over the last week, we’ve been advised by our public health and infectious disease experts to modify fall plans by further de-densifying campus,” Guskiewicz told faculty at an emergency meeting of the Faculty Council Executive Committee late Monday afternoon.

The modifications were agreed to after the chancellor and his team had conversations with Mandy Cohen, secretary of the state Department of Health and Human Services, Peter Hans, the new UNC system president, Orange County health department leaders and infectious disease experts at UNC Health.

Barbara Rimer, dean of the Gillings School of Global Public Health, published a blog post Monday morning calling for an end to the experiment.

She noted that faculty from her school had been providing advice to university leaders as plans were being made this summer.

“Our chancellor and provost tried to make decisions… with advice from some of the world’s best infectious disease experts. However, they have not had full freedom to act since the [Board of Governors] told system universities they had to reopen and that individual university chancellors could not make those decisions independently,” Rimer wrote.

Where’s the off ramp?

“This is certainly not what we were hoping for this fall semester,” Guskiewicz said at the meeting with faculty. “I’m terribly disappointed for those students who really want to be here and who have followed our community standards over these first two weeks.

“Our first priority has always been our community’s safety and we have always said we would respond to the situation as it evolved,” he added. “The situation has changed and we believe that taking these actions are necessary at this point.”

Students were sent home in the spring to finish their classes through online instruction when COVID-19 was spreading across the state and a stay-at-home order was put in place.

In May, UNC-CH officials began charting a Roadmap for Fall 2020 that called on students, faculty and staff to adhere to Community Standards, which included wearing face masks and other social distancing measures.

Though many students complied with the standards, reports surfaced during the week before classes and over the recent weekends of large parties in off-campus houses and apartment complex swimming pools.

shows a dashboard with numbers and pie charts tracking the number of COVID cases
Screenshot of the Carolina Together dashboard, as of Aug 17 at 3 pm.

“Reports of parties throughout the weekend come as no surprise,” the Daily Tar Heel editorial stated. “Though these students are not faultless, it was the University’s responsibility to disincentivize such gatherings by reconsidering its plans to operate in-person earlier on.”

Conflict in the community

Orange County Health Department Director Quintana Stewart sent a letter to the chancellor and UNC leaders in late July asking them to delay in-person classes for at least five weeks, pushing the start-date into September.

Guskiewicz’s response to Stewart drew fire from the Faculty Council Executive Committee, which questioned why the health director’s information had not been shared immediately with the larger university community.

That committee had more questions for the chancellor, UNC-CH Provost Bob Blouin and housing officials.

The goal is to bring most residence halls down to 20 to 25 percent of their housing capacity, but the student exodus could happen in the coming days, perhaps even the next week.

Students who are in isolation or in quarantine inside dorms will be allowed to stay there until they are cleared to be in public again to try to limit further COVID-19 spread through Chapel Hill and across the state.

Campus officials recognize that other students might have hardships that require them to continue living on campus. Some might be from other countries or live in states that have restrictions about who can cross their borders.

Will students spread COVID back home?

Faculty asked whether the university would do mass testing before sending students out far and wide from campus.

Ken Pittman, executive director of Campus Health, said there were no plans to do so, that testing would only capture a moment and could lead to a false sense of security.

“Whenever you do any kind of a mass testing program and you obtain negative results, you have obtained negative results for that day,” Pittman said. “That really has nothing to do with whether or not they’re in an infectious period. Mass testing without having a period of time in which students did not return home after they were tested would be one of the more advisable things because I would hate for us to give students a sense of false security based on a one-day-in-time result.”

Infectious disease experts suggested that students who leave UNC-CH for their homes spend 14 days after their arrival quarantining in their homes. They encouraged wearing a face mask inside their homes and isolating themselves in a room away from others.

Can classes be paused?

Mimi Chapman, the UNC-CH faculty chair, led the meeting and shared questions she was receiving from others in the Zoom chatroom.

Many faculty suggested a pause on classes to give students time to prepare for trips back home and to give others a chance to move beyond what has been a stressful opening of the semester.

Neither the chancellor nor the provost embraced the idea. Nor did they rule out such a brief break.

“We’ve heard the suggestion and it’s helpful to hear the concern,” Guskiewicz said. “The challenge with a pause would be when do you implement it and for how long would you implement it.”

Throughout the pandemic, many have questioned the timing of key moves, and that was no different Monday, the end of the period designed for UNC-CH students to drop or add classes.

UNC officials have said students and their parents can get refunds for campus housing, but it was not as clear as to whether tuition refunds would be available for dropped classes.

The provost and chancellor said they would explore that.

‘We’re being mocked, the community is upset’

Faculty asked the chancellor and provost whether there were lessons learned from the two-week experiment that could help other universities in the UNC system or across the country as they weigh how to proceed in the pandemic.

Jennifer Larson, teaching associate professor and director of undergraduate studies in the UNC-CH Department of English and Comparative Literature, said the experiment of the past two weeks has put the university in an awkward position with the town and the nation.

“We’re in the news everyday, we’re being mocked, the community is upset,” Larson said. “People are afraid to go to Franklin Street, I think they’re afraid to go out in the community, I just wonder what steps can we take to sort of repair, or start to repair these relationships and maybe even repair our national reputation.”

The chancellor said he planned to work to repair relationships and focus on a future that would bring similar questions about how to proceed with the spring semester later this year.

“I want to look forward,” Guzkiewicz said. “I want to look backward so we can learn from what we’ve gone through over the past several weeks. But we do have to look forward, and forward means we have an awful lot of this semester left. Let’s be honest and my goal is to make sure this is a successful semester for our students, our faculty and our staff.”

shows low level satellite photo of a dam feeding into a river, surrounded by trees, GenX

Attorney general investigating industries that pollute NC’s waterways with PFAS

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Attorney general investigating industries that pollute NC’s waterways with PFAS - North Carolina Health News

The so-called “forever chemicals” are ubiquitous in North Carolina, especially in the Cape Fear River basin. AG Josh Stein says the state must hold polluters accountable.

By Greg Barnes

North Carolina’s attorney general says he has started an investigation into manufacturers that contaminate the state’s waterways with per-or polyfluoroalkyl substances, commonly known as PFAS or “forever chemicals.”

“North Carolinians expect and deserve clean water to drink,” Attorney General Josh Stein said in a news release on Monday announcing his investigation. “The emergence of forever chemicals like PFAS has led to significant and dangerous pollution – and we must hold those responsible accountable.”

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There are an estimated 5,000 different types of PFAS, which are called forever chemicals because they don’t easily break down in the environment. They also build up in blood and organs of people, potentially causing cancer and other human health problems.

The state has known at least since June 2017 that DuPont, and later Chemours, discharged high levels of GenX and other PFAS into the lower Cape Fear River from a plant near Fayetteville.

The state, along with the environmental group Cape Fear River Watch, last year forced Chemours into a consent order that requires the chemical giant to drastically limit its air pollution and to clean up PFAS in the river, soil and sediment. The order assessed Chemours $12 million in civil penalties.

PFAS is a statewide problem

Chemours is far from alone in the production and release of PFAS into North Carolina’s rivers, lakes and streams.

In January, the state Department of Environmental Quality provided figures from a PFAS monitoring program it conducted at 25 municipal wastewater treatment plants in the Cape Fear River basin. Of the 25 plants, total PFAS was detected above 100 parts per trillion at 19 of them.

The federal Environmental Protection Agency does not regulate PFAS, though it is considering doing so. The only health advisory it sets now is for the two oldest types of PFAS — called PFOA and PFOS — at 70 parts per trillion in drinking water, either by themselves or in combination.

Although those legacy compounds are being phased out in the United States in exchange for PFAS with shorter carbon chains, they still show up in North Carolina’s waterways, sometimes in alarming concentrations.

During the DEQ’s monitoring program, PFOS was detected at 1,000 parts per trillion at Sanford’s wastewater treatment plant. That level was more than 14 times greater than the EPA’s standard for drinking water.

Since then, the levels of PFOA and PFOS have been far below the EPA standard, but total PFAS levels at the Sanford plant remain troublingly high — as much as 399 parts per trillion in April, according to figures the DEQ provided Tuesday.

PFAS have also shown up in the food chain along the Yadkin-Pee Dee River, a recent study by N.C. State University revealed.

The DEQ says it remains unknown which industries besides Chemours and DuPont are responsible for the manmade contamination.

Laura Brewer, a spokeswoman for Stein, said in an email that she cannot talk about specifics of the attorney general’s investigation

“I can tell you that our office is not looking necessarily at any specific company,” Brewer said. “We are looking at PFAS in our drinking water, determining the source, and determining whether to bring actions to hold accountable the companies that are responsible for damages to our natural resources.

“Our office would potentially take action under the AG’s ability to sue for damages to protect natural resources of the state.”

So far, at least, identifying responsible industries has been elusive.

Water pouring out of a pipe along the Yadkin-Pee Dee River may be a source of PFAS to the river ecosystem. Photo credit: N.C. State University
Municipal and industrial effluents discharged into the Yadkin-Pee Dee River downstream of Rockingham are probable sources of PFAS to the river ecosystem. Credit: N.C State University

Testing shows PFAS widespread

The NC PFAS Testing Network, a consortium of researchers from seven universities in the state, just made public all of its testing of PFAS at 320 municipal water utilities in North Carolina. Of those, nearly half had levels of PFAS above the reporting detection level.

Drinking water at 11 of the utilities measured more than 100 parts per trillion for total PFAS. In Pittsboro, a level of nearly 845 parts per trillion was recorded, much of it coming from industries upstream along the Haw River or its tributaries.

The network, part of the NC Policy Collaboratory, did not investigate the sources of the contamination.

The highest level of total PFAS recorded in the DEQ’s monitoring program at wastewater treatment plants was 4,026 parts per trillion in Sanford. The second highest was nearly 2,296 parts per trillion in Burlington.

Other cities have also been found to have elevated levels of total PFAS in their drinking water, including Cary, Durham, Chapel Hill and Apex in the Triangle. Many of those cities get their water from Jordan Lake, where researchers have also found elevated levels of the contamination.

PFAS have been in use since the 1940s to make products non-stick, waterproof or stain-resistant. They’re used in rain jackets, carpets, upholstery, cookware, fast-food packaging, dental floss and much more.

A large number of studies suggest that PFAS could cause an increased risk of testicular or kidney cancer, increased cholesterol levels, decreased vaccine response in children, changes in liver enzymes, increased risk of high blood pressure or preeclampsia in pregnant women and small decreases in infant birth weights.

Slashed budgets

In the past few years, state lawmakers led by Rep. Pricey Harrison (D-Greensboro), Sen. Harper Peterson (D-Wilmington) and Sen. Kirk deViere (D-Fayetteville) have introduced legislation that would curtail the use of PFAS and hold responsible parties accountable.

At least six bills were introduced in 2019 alone, all of which failed to make it out of committee at the state legislature. Peterson expected the bills to die, including those he co-sponsored, but he said they continue to bring the issue of PFAS to the forefront.

Peterson blames a limited state response to the crisis on the Republican-controlled legislature and deep budget cuts to the DEQ, the Department of Health and Human Services and the Department of Justice over the past decade.

“I compare it to a police force or a fire department,” Peterson said. “How do you do your job if you don’t have the staff and the equipment, and that’s been the case. They’ve done a lot with little.”

Peterson said North Carolina needs to follow the example of other states that have placed tight limits on the release of certain types of PFAS — some as low as 10 parts per trillion for PFOA or PFOS in drinking water.

Peterson also said taxpayers and municipalities should not be forced to pay to clean up the mess left by private industry. He noted that New Hanover County is spending nearly $50 million and Brunswick County about $100 million to filter PFAS out of their drinking water.

“It’s (industries’) responsibility to clean it up,” he said. “We should handle it just like we handled Duke Energy with their coal ash ponds. The bill is on them, not the public.”

In an email, deViere also mentioned the coal ash ponds. The state won a lawsuit last year that forces Duke Energy to spend billions to clean up its remaining ponds by moving them to lined landfills and ensuring that they won’t leak contaminants.

Peterson and deViere, both Democrats, praised Stein for going after the PFAS polluters.

“We have had conversations with Attorney General Stein and presented stakeholder issues directly to him and his staff so I am pleased to see this stance and direction by the NC Department of Justice,” deViere said in an email. “I am hopeful that this action will continue the types of protections and outcomes we have seen for other contaminants like coal ash.”

Stein has detractors

In his news release, Stein said his investigation is about protecting people from PFAS contamination and restoring the state’s natural resources.

“My office will not hesitate to bring legal action against any polluters if that’s what it takes to keep the people of North Carolina safe,” he said.

But not everyone is sold on Stein’s commitment.

Mike Watters, administrator for an advocacy group in Cumberland County, thinks Stein’s actions are purely political.

“In the opinion of many of us this is a political stunt by AG Josh Stein, & Governor Roy Cooper to make the appearance of taking action,” Watters said in an email. “Reality is it is far from looking like they are serious and I really pray that this is wrong.”

Stein and Cooper face Republican opposition in the Nov. 3 general election.

Members of Watters’ Facebook group, Grays Creek Residents united against PFAS in our wells and Rivers, have been fighting to get relief since they discovered that their well water is contaminated with the compounds. Most live next to the Chemours plant near the border of Bladen and Cumberland counties.

Coronavirus Today – July 14: “Plan B” for K-12 schools; district choices; simmering COVID-19 trends and metrics

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Coronavirus Today – July 14: “Plan B” for K-12 schools; district choices; simmering COVID-19 trends and metrics - North Carolina Health News

NC governor recommends in-person combined with remote teaching for the coming K-12 school year. Each district would have discretion over the exact mix.

By Anne Blythe

Once school resumes next month, North Carolina’s 1.5 million public school children will have the opportunity for some in-class instruction across the state while some kids might continue with remote learning only.

Gov. Roy Cooper announced on Tuesday that he had selected his “Plan B,” a hybrid model for instructing children in kindergarten through high school as a new school year begins amid the COVID-19 pandemic that has obliterated traditions and routines since early March.

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“In the spring, when this pandemic first broke out, we made the difficult but necessary decision to close in-person learning at K through 12 schools and move to remote learning,” Cooper said during an afternoon press conference. “March feels like a long time ago given everything that we’ve been through. And that was just the beginning of a series of tough decisions to slow the spread of COVID-19 that have helped our state cope and prevented our hospitals from being overwhelmed.”

Simmering, not boiling

North Carolina has not seen the tsunami of cases that recently have forced some states to reverse reopening plans because hospital beds have filled with COVID-19 patients.

Nonetheless, there has been a sharp rise in the number of lab-confirmed cases in recent weeks throughout North Carolina that cannot be explained simply by more testing. The percentage of tests coming back positive hovers at 9 to 11 percent, double what health care experts would like to see before opening society up further. These high numbers of positive tests indicate community spread of the virus continues.

Even as North Carolina has seen record hospitalizations there continues to be capacity for more patients as hospitals adjust their routines, adopt plans to add beds and learn better how to care for patients with COVID-19.

But recently, concerns about testing supply shortages have grown. Shortages of equipment and chemicals have created long waits for lab results across the country, putting contact tracers further behind in trying to contain the spread of the virus.

“We continue to simmer,” Mandy Cohen, secretary of the state Department of Health and Human Services, said Tuesday. “We’ve avoided boiling over as many states are doing now.

“If we see indications that we’re changing quickly or there’s new scientific data that emerges, we will not hesitate to act.”

Cohen said planning for the coming school year has been full of difficult decisions.

She and her public health team helped Cooper come to the decision he announced on Tuesday after examining research showing that elementary school-aged children and preschoolers seem to be at lower risk for COVID-19 infection and less likely to transmit it to others.

They weighed that research and medical data against evidence that school is critical to a child’s education, health, emotional and social well-being, as well as advice from pediatricians that missing school is harmful to children.

“With any decision like this it is necessary to weigh the risks and the benefits and there are no easy answers,” Cohen said.

Tailoring plans district by district

Though individual school districts across the state may tailor attendance plans that work best for the areas their students come from, face masks, temperature checks and screenings at the door will be required for any in-person instruction.

For instance, Wake, Durham and Forsyth counties have already developed plans with a priority to bring elementary school children back to in-classroom instruction first. The Chapel Hill-Carrboro district is postponing the return of high school students until mid-September, weeks after the start of the school year.

There’s no one-size-fits-all plan.

The few hard and fast requirements that public health leaders have pushed throughout the pandemic have been the wearing of face masks, social distancing and hand-washing.

Students and teachers will each be issued five cloth face masks, one for each day of the school week, that can be washed and reused. The state also has distributed personal protective equipment and other supplies to school nurses.

Cooper called the state’s baseline plan “a measured, balanced approach,” but acknowledged that some teachers, school staff and families might not be as enthusiastic about being inside school buildings.

“As a part of this plan, we want local districts to provide for remote options for any child that chooses it,” Cooper said.

Eric Davis, chairman of the state Board of Education, said districts are surveying teachers and staff to gauge how many will be willing to teach and work inside school buildings even as COVID-19 continues to spread, and which staffers feel like they need to stay away.

“We certainly anticipate that some teachers and staff members will not be able to return to school for a variety of reasons, where others, as the governor mentioned, are energetically awaiting the day that they can get back with their students and move forward,” Davis said. “We’re confident in the work that our districts have underway to care for the needs of our staff and teachers and we will continue to send them the support and the assistance that they need, including revised policies or other things needed to continue to meet the needs of our teachers.”

Working parents, more home schooling and child care

If a district chooses, Cooper added, it can opt out of any in-classroom instruction and solely provide remote teaching that will require parents or others to help with home schooling children.

That option, as well as plans calling for children to have in-classroom instruction for one week and then two weeks of remote learning, have working parents struggling to figure out what they’ll do about child care in the weeks and months ahead.

Volunteers help children read their books in the Read and Feed van.
In many instances, parents don’t have the ability to suspend their work day to instruct their children. Photo credit: Hyun Namkoong

Not everybody can work from home, and as parents who have that ability will attest, it can be difficult to help with school lessons while also attempting to work.

Not just a place for teaching and learning

Over the decades, schools have become far more than places where children from kindergarten through high school go to learn.

They have become places where children from low-income families have access to food. They provide safety and security for children from abusive homes. They provide a set number of hours of child management for working parents.

Lisa Gennetian, an economist at Duke University, noted these realities in a panel discussion Tuesday morning before Cooper made his announcement.

“When we think about school openings and closings, we should really think hard about the function of schools in these communities,” said Gennetian. “They’re not just environments for learning.”

One in five children, according to Gennetian, are poor in America, a number that is likely to grow during the pandemic.

In many households, one or both parents may have lost jobs or suffered income losses that force them to choose between putting food on the table, paying monthly bills and keeping up economically.

Economists and others are predicting a tsunami of evictions that will make providing shelter even more difficult for some families barely making ends meet.

“The U.S labor market is not designed well to absorb formal care,” Gennetian said, adding that it could be child care for preschool children or for the older ones who still need the supervision of an adult. “This intersects super closely with the question of school closings.

“The U.S. lacks a strong safety net for reaching vulnerable people, and again, schools have played an important role in filling that gap.”

For that reason and others, Gennetian and two pediatricians from Duke agreed that opening schools in a safe way would be beneficial to the children.

Developing COVID-19 research on children

The three offered their thoughts during a panel discussion on Tuesday before Cooper announced his decision.

“There’s a really strong case for trying to reopen schools because there are so many benefits both for children, not only their academic benefits, but also their health and well-being and social, emotional health … and also for families, many of whom are trying to get back to work and reopen the economy,” said Charlene Wong, a Duke pediatrician who specializes in care for adolescents and teens.

“We really need to proceed with caution and care and avoid broad, sweeping mandates about requiring schools to open,” she added. “We are certainly very early in learning about the experience of children and their experiences, particularly in schools and other congregant settings.”

Image by Editor B, flickr creative commons
The classroom experience could be very different this year, with children staying with one cohort and teacher for their entire school day, eating at their desks, wearing masks and social distancing. Image by Editor B, Flickr Creative Commons

Wong suggested that scientists and medical researchers should start including children in broader studies about the impact of COVID-19 that could help guide school decisions and others ahead.

“While we’ve seen an explosion of COVID-19 research and we’re learning something new every day, a relatively small proportion of that research has been on children,” Wong said.

The data show that high school students and elementary school children should be considered in a different light for several reasons.

There is evidence of teens becoming infected and transmitting the virus, as well as acknowledgement that high school students are better suited for remote learning than younger children.

“We are seeing a difference in the way in which the infection presents itself,” said Ibukun Christine Akinboyo, a Duke pediatrician and infectious disease specialist. “It seems to be milder in younger kids.”

Develop a quarantine plan

Nonetheless, that does not mean they are immune, Akinboyo said.

“Particularly in our area, we have had child care settings that have been open … until recently we have not seen rapid clusters around spread in those settings,” she said. “As the community prevalence has gone up, we have seen some clusters of spread among staffers, among children. And that is not unexpected.

“I’m in full support of making decisions based on local data,” Akinboyo added. “That may be on the state level, that may be on the county level. We have to ensure resources are available across the board, so counties that historically have not had adequate access to resources have them.”

Whether a district chooses in-person instruction or remote learning, Wong suggested that families develop quarantine plans that anticipate lab-confirmed cases in a school and the disruption that would come at home and work.

“In many ways these unpredictable two-week quarantines for individual children or classrooms … can sometimes cause more chaos for families than what we saw with the blanket closures in the spring when all of us who were working parents were mostly in the same boat as we tried to juggle our personal and professional obligations,” Wong said.

She said people need to prepare for the inevitable disruptions.

“Preparation now will help ensure that families will be able to follow these quarantine guidelines so that we can slow the spread of the virus and so schools can remain open for learning,” Wong said.

What happens if students, teachers or staff test positive?

If a student or teacher contracts a lab-confirmed case of COVID-19, Cohen said contact tracers will work to find close contacts and encourage those people to get testing and isolate themselves while awaiting results.

Schools or classrooms wouldn’t necessarily be closed down, even if a student were to test positive for the virus.

“We would do what we would do now related to somebody being positive,” Cohen aid. “If it was in elementary school it is likely that they would have been cohorted and with the same number of students and one teacher throughout the day and would only have come into contact with the students.”

In such a case, contact tracers would alert people who were within six feet of that person for longer than 10 minutes, telling them to get tested. Public health officials also would work with schools on cleaning protocols outlined in their guidelines and recommendations.

“It doesn’t mean immediately that a school needs to close,” Cohen added. “They may want to go beyond our protocols and do that. Again, it depends on the situation, what was the age of the kid, how those contacts were arrived at.”

“We don’t want to have a one-size-fits-all,” Cohen added. “We really do need to tailor to what the situation is, what kind of student, how long were they in school, what were their contacts. That’s why we really need local health departments involved in each one of those situations.”

First five days of school year

The protocols for the coming school year are included in an updated StrongSchoolsNC public toolkit created by DHHS.

“In-person education is important for children, and it happens in the context of a community,” said Theresa Flynn, a Wake County pediatrician who serves on the board of directors of the North Carolina Pediatric Society. “This plan strikes the right balance between health and safety, and the benefits of having children learn in the classroom. We must all continue with proven measures to reduce COVID-19 transmission like wearing a face covering, keeping distance between people, and frequent hand and surface cleanings so we can move closer to safely re-opening public schools.”

Cooper, an advocate for higher salaries for teachers who has pushed for more state spending for public schools by the Republican-led General Assembly, said he would be asking for more to be allocated from both the state and federal government to address increased school needs.

Phil Berger, the Republican from Eden at the head of the state Senate, and Cooper were in a budget stand-off for much of last year in large part over the school budget.

During the session that just ended, Berger added an additional twist to how schools would open next month when he failed to put forward a requested lifting of a law that requires North Carolina school children to spend the first five days of a school year in classrooms.

During the Duke panel discussion, the pediatricians and economist said such a mandate could cause health and safety problems.

“Certainly that could cause a spike in spread,” said Wong, whose practice focuses on  adolescents and young adults. “It’s my opinion there shouldn’t be such a broad sweeping mandate to say that every child must attend in person at any point during the semester and certainly not during the first week when everyone’s going to be trying to work out the kinks of the new systems that have been put together over the summer time. … There should always be a remote learning option.”

Cooper said Tuesday that Josh Stein, a fellow Democrat and the state attorney general, had provided the Cooper administration with a letter saying that his office thought it was OK to proceed with a hybrid model.

“We’re in a state where we’re rethinking everything. We’re rethinking how we eat, how we buy groceries, how we go to the restaurants, gyms, how we take public transit,” said Akinboyo.

“Now more than ever, we need to rethink how we go to school and how kids go to school. So I’m not sure that mandating in-person appearance for every kid allows each administrator, each group, each parent and staff — they’re trying to figure out the best thing for a child —  to be flexible in those options.”

Coronavirus by the numbers

According to NCDHHS data, as of Tuesday afternoon:

  • 1,552 people total in North Carolina have died of coronavirus.
  • 89,484 have been diagnosed with the disease. Of those, 1,109 are in the hospital. The hospitalization figure is a snapshot of people hospitalized with COVID-19 infections on a given day and does not represent all of the North Carolinians who may have been in the hospital throughout the course of the epidemic.
  • 67,124 people who had COVID-19 are presumed to have recovered. This weekly estimate does not denote how many of the diagnosed cases in the state are still infectious.
  • To date, 1,254,846 tests have been completed. As of July 7, all labs in the state are required to report both their positive and negative test results to the lab, so that figure includes all of the COVID-19 tests performed in the state.
  • Most of the cases (45 percent) were in people ages 25-49. While 12 percent of the positive diagnoses were in people ages 65 and older, seniors make up 79 percent of coronavirus deaths in the state.
  • 264 outbreaks are ongoing in group facilities across the state, including nursing homes, correctional and residential care facilities.
  • There are 3,374 ventilators in hospitals across the state and 921 ventilators in use, not just for coronavirus cases but also for patients with other reasons for being in the hospital.

Fayetteville hospital system gets COVID-19 diagnostic equipment

Cape Fear Valley Health, the state’s eighth largest health system, is now using lab equipment that can diagnose inpatients for the coronavirus in an hour.

The health system, which is based in Fayetteville, bought the $140,000 equipment through a donation from its foundation. The equipment allows Cape Fear Valley to test inpatients suspected of having COVID-19 by performing a Respiratory Pathogen Panel test. The tests can simultaneously check for dozens of potential targets, including bacteria, parasites, yeast, antimicrobial resistance genes and viruses such as COVID-19.

Cape Fear Valley no longer will have to send inpatients’ test kits out of state for testing.    Patients admitted during weekends who are suspected of having COVID-19 previously waited up to three days for results, hospital officials said in a news release.

“We get the results in real time now,” said Chris Tart, Cape Fear Valley’ vice president of professional services. “That helps us place COVID-19 patients on the appropriate unit.”

BioFire Diagnostics, the equipment manufacturer, says its system can run up to 264 samples a day. Faster diagnosis means faster treatment for the correct condition, according to the news release. — Greg Barnes

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