Iowa Gov. Kim Reynolds Press Conference Transcript September 29

Kim Reynolds: (04:38) Okay. Good morning. I think we'll go ahead and get started. Over the course of the last two to three weeks, the Department of Public Health, and local public health officials have been monitoring elevated positivity rates in rural counties, especially in Northwest Iowa. Sioux County currently has the highest 14 day average positivity rate in the state, at nearly 28%. Neighboring Lyon and Osceola Counties are both above 20%, and some other counties in the surrounding area top 15%. What we're seeing in rural counties is different than what more populous counties have experienced. Rather than positivity cases really being driven by young adults, and those under the age of 40, new COVID cases in Northwest Iowa, and other small counties are more evenly distributed across age groups. Over the last two weeks in Sioux County, more than 1,750 people were tested, resulting in 489 new positive cases. 31% of those cases were among adults 18 to 40, with over a third of those were attributed at 19 to 24 year olds. Kim Reynolds: (05:51) 29% were among middle-aged adults, which is 41 to 60 years old. 21% were among older adults, ages 61 to 80. 12% were children under the age of 18. And most of those were in the 15 to 18 year old bracket. And 7% were above the age of 80. In that same region. We currently have eight long-term care facilities that are in outbreak status, with 103 positive cases among staff and residents. And as we know, these outbreaks can have devastating consequences, and we're taking all necessary steps to work with our facilities to prevent them. The case investigation process tells us that increased cases in these areas aren't... And I mentioned this last week, they aren't really tied to a specific event or activity. Rather as more people get back to life as normal, the virus is simply spreading from person to person during the course of normal daily activities. Kim Reynolds: (06:53) As we know, it's critical that we all do our part to mitigate and manage virus activity, to ensure that our communities remain healthy and strong during this time. Our best defense against the virus continues to be what it has been from the very beginning. Simple, common sense steps that have worked. Kim Reynolds: (07:12) Practice social distancing, wearing a face covering, if you can. Washing our hands, disinfecting surfaces. And of course staying home when you're sick. Not only will the steps help protect you and your families, they will protect those who are most vulnerable, prevent our hospitals and health care resources from becoming overwhelmed, and keep our workforce healthy so that businesses remain open. In many of our rural counties, hospitals and clinics are often the largest employers in the area. And when the healthcare workforce is impacted, it will most definitely affect the entire community. Kim Reynolds: (07:54) Keeping virus activity low will also ensure that our schools remain open. As we know, school is back in session. Sports and extracurricular activities have resumed. And this is a good thing for students in our communities. But as typical, at the start of any school year virus activity increases when students return to the classroom. Evidence shows that the transmission rate for COVID, and the risk of serious illness is lower among our children. Still, schools are taking their responsibility to mitigate the virus very seriously, while also maintaining some sense of normalcy for their students. Kim Reynolds: (08:36) Since schools reopened, I've heard from, and I've spoke with superintendents across the state to get their perspective on what's working well, and what could work better. And a common frustration that was expressed to me was around the guidelines for quarantining students and teachers who have been in contact with positive cases. So despite their commitment to implementing layered mitigation strategies, to protect the health of their students, and teachers, and staff, and to keep everyone in the classroom, in some situations they're having to quarantine a disproportionately high number of students, when just a few positive cases have been identified. Iowa is definitely not alone in this challenge. Kim Reynolds: (09:20) And we have been assessing how other states have handled the situation. Nebraska and Wyoming have recently adjusted their quarantine guidelines for schools, based on whether staff and students are wearing masks. Other States are considering similar changes. And following an assessment that I asked Dr. Pedati to do, and her team, we're prepared to do the same. I've asked Dr. Pedati to talk more about what she's discussed with some of her colleagues, what she looked at, and her recommendations for adjusting quarantine guidelines. Dr. Pedati. Dr. Pedati: (09:58) Thank you, Governor. It has not quite been a year since this virus- Dr. Pedati: (10:03) You know, it has not quite been a year since this virus was first recognized last December, and we know that this has been just an incredibly challenging time for everybody, but we've learned a lot. And as we've learned more and gotten new information, we've made adjustments throughout this response. And that's what we do in medicine, and in public health, and in life, is make adjustments when we have new information. And so we're making an adjustment this week, as you heard, to the way that we make recommendations around quarantine. Dr. Pedati: (10:36) Now, the CDC does currently still recommend that individuals who have been in close contact should quarantine, even if they're wearing face coverings. However, as you've heard, we've gotten some information from here in Iowa, as well as from some of our neighboring states, that help us to adjust our current recommendation while continuing to look at available information and data, and move forward to make sure we're doing everything we can to keep people as healthy as possible. Dr. Pedati: (11:04) So, as you've heard, public health has had a lot of conversations with school administrators and families about their experiences in quarantine, and the fact that we don't frequently see additional infection in situations where people have been wearing face coverings. In addition to that, we were able to take a look at some of our own data from Sioux County, an area that's unfortunately experiencing increased community spread right now, and we were able to compare a district that was using face coverings to three districts that were not. And the three districts that did not make use of those face coverings actually saw 30 to 130% higher rates of new COVID cases. Now, in addition to that, as you've heard our neighbors in Nebraska, as well as our colleagues in Wyoming, have made changes similarly in their school settings. And in addition to that, in July, the CDC's morbidity and mortality weekly report published a study out of our neighbors in Missouri, looking at 139 adults who are exposed to two symptomatic confirmed COVID positive hairdressers with zero associated secondary cases. And the authors of that study concluded that broader use of face coverings can help mitigate the spread of this virus. Dr. Pedati: (12:25) So taking all of this information together, we're able to update our recommendation, which is going to say that for non-healthcare, non-residential settings, individuals who, in the case and close contact, have been wearing a face covering consistently and correctly for the entire time, will not need to self quarantine at home. However, we'll still want them to self monitor, which means wearing your face covering and keeping a close eye on your symptoms. Now, this is exactly the kind of adjustment that we want to make as we move along based on best available evidence. And we're going to continue to work with our partners here in Iowa, with our neighboring States, and with our federal colleagues to gain more information and a better understanding. And if we find that there's new information where we need to make another adjustment, we'll do that as well, just as we always have all along. Public health and I remain committed to keeping Iowans informed and healthy. Thank you. Kim Reynolds: (13:26) Thank you, Doctor Pedati. I think your recommendation is a reasonable change that will make a positive difference as schools continue to adapt to this challenging and very fluid situation. Iowa's robust testing strategy is key to keeping schools and businesses open. And thanks to the additional support from the federal government, it's about to expand even further. Yesterday, President Trump announced a new rapid point of care test for our nations testing system. 150 Binax Now, a test from Abbott Laboratories, will be distributed nationwide to expand strategic testing. The FDA authorized test is simple to use, it's cost effective, and it doesn't require any equipment to process results other than the card that comes as part of the kit. The federal government has already begun distributing tests and is prioritizing nursing homes, assisted living facilities, home health and hospice agencies, and other organizations that serve our vulnerable population. Kim Reynolds: (14:32) The President also informed the nation's governors yesterday that a hundred million tests will be allocated to the states to assist our efforts with reopening our schools and reigniting our economies, and that we have the flexibility to use the test as we deem necessary. We are aware that some long-term care facilities and assisted living facilities in Iowa have already begun receiving the test. We expect the first shipment of our state allocation to arrive anytime at the State Hygienic Lab. We anticipate receiving between 40 and 50,000 tests a week between now and December, for a total allocation of approximately 900,000 tests. While the Department of Public Health and the State Hygienic Lab are working on a detailed distribution plan, these tests will be prioritized for rural areas with less access to testing and for school staff and students. However, unlike some tests, we're not going to ship tests directly, like some states, we're not going to ship tests directly to schools. Kim Reynolds: (15:43) Instead, what we will do is we're going to be working with our local healthcare providers who can not only provide the test, but also check the general health of children. During the pandemic, many families have understandably fallen behind with well-child visits and other preventative care since the start of the pandemic, and it's important that families maintain a connection with their provider, especially if their child has been exposed to a COVID-19 case. So as soon as we know more about when and where the Binax Now test will be available, we'll be sure and share that information as it becomes available. Kim Reynolds: (16:25) Finally, I want to provide a quick update regarding other testing happening across the state. As you know, Test Iowa clinic sites are partnerships with regional healthcare providers to expand access in rural areas where there are fewer testing options. The state provides the testing supplies and equipment through the Test Iowa program, and the tests are processed through the State Hygienic Lab. Local healthcare providers staff and operate the sites in their communities. Kim Reynolds: (16:55) This week, three new test Iowa clinic sites are opening in Dubuque. The Grand River Medical Group Respiratory Clinic began testing yesterday, and that is the second clinic site in Dubuque County. And two sites are opening this week in Sioux County, one with Orange City Area Health System and the other was Sioux Center Health. Both providers are participating in the Test Iowa's higher education program, testing their students and staff at Northwestern College and Dordt University, so this really is an expansion of their operations, and this will allow them to serve the entire community and the surrounding area. Kim Reynolds: (17:36) And it's in addition to other Test Iowa clinics and drive through sites that are already serving the Northwest Iowa region in Dickinson, Kossuth, Buena Vista, and Plymouth County. So we've got a pretty good access process up in Northwest Iowa. So my team is working with a number of other counties that are interested in opening clinic sites, and we expect the number of Test Iowa clinics to continue to increase over the coming weeks, and we'll make those announcements as they come on. Kim Reynolds: (18:04) We're also working on relocating large drive-through sites in advance of changing weather, and we'll keep Iowans informed as those moves occur, excuse me. I'd like to thank the Department of Transportation, the Iowa National Guard, Homeland Security, and county emergency managers for all that they are doing to coordinate this effort and ensure that testing will remain convenient and accessible for Iowans regardless of the season. Kim Reynolds: (18:34) So now we'll go ahead and open it up for questions. Speaker 2: (18:38) Yes, Governor, thank you for the time. With the new guidelines for schools and quarantining, how do you trust there is consistent mask wearing between the parties, and talking about the efficacy of masks, is there going to be a mandate for public schools to require them? Kim Reynolds: (18:53) No, it's not a mandate and this new guidance is not a mandate, it's guidance. So schools will have the ability to decide whether they're going to practice this or not. As I indicated, many of the schools are really taking this very serious, they've put in layered mitigation steps to help assure the students and the staff that they are doing everything they can to make sure that the kids, and the educators, and the staff are coming back to school in a safe environment. So they know what the qualifications are. They're doing a great job. We have a lot of kids that are back in school. We've been at it almost a month and we're seeing great success in those schools that are doing it. Kim Reynolds: (19:34) What I heard over and over what was happening, so we're wearing the mask, we're telling people that the mask are effective, and as you heard, Dr. Pedati lay out some of the different studies that they are referring to, that they're relying on. So we know that they're effective and if they're using them, then we ought to be able to, if they're doing it properly and everybody was wearing a mask, then they shouldn't have to quarantine for 14 days. And it just makes that whole process, I think, it provides some flexibility to them. Kim Reynolds: (20:03) ... and it just makes that whole process... I think it provides some flexibility to them ,and it really helps keep the kids in school, but it helps keep the kids in school in a safe and responsible manner. In addition to that, a lot of them are trying to apply to social distance guidelines. They're cleaning the surfaces frequently. They're washing hands. They're making sure that they're reiterating if you're sick, stay home. And so they're doing layered mitigation efforts, and all of that really speaks to protecting the students. Audience: (20:30) How do you quantify consistent mask wearing? Kim Reynolds: (20:33) Well, I have to put some trust in the superintendents that are running these schools and the school board. And so they know that it's in their best interest to do it right, and so I assume that they're working with their team and their staff. They want this to work. They want their kids to be safe. So we just got to believe that they're doing the right thing. I do believe they're doing the right thing, and honestly, I think the numbers are proving that out. We've been in school over a month in a lot of these school districts, and they're doing it safely and responsibly. They're taking appropriate actions when they need to, and we can continue to monitor that. As Dr. Pedati said, it is fluid. We learn more all the time. And if we find that maybe something is not working the way that we thought it would, we'll reevaluate like we have with everything. And if we have to back up and do something different, we'll do it. Audience: (21:17) Governor, the evidence that Dr. Pedati Just laid out, the study in Missouri where there was no secondary infections from the hairdressers who were wearing masks, even mentioning the districts that didn't use the masks seeing upwards of, I think if I didn't mishear you, 30 to 130% increase in cases... I mean, doesn't this just lay bare the need for requiring people to wear masks, because the evidence proves it? Kim Reynolds: (21:43) I think, Caroline, it's a great incentive to move forward. And you know what? If you just looked at the recent survey, over 75% of Iowans are wearing masks if they can't social distance. So we're going to continue to run the campaign about step up, mask up. This is an incentive to get them to do it. This is what the superintendents are asking for. I think it's a great effort that we can put in place to provide them the flexibility to move in that directions. I think you're probably seeing the majority of the schools that are already doing it, so we're doing the right thing. Even the surgeon general, I think he acknowledged that by educating Iowans about the importance, we're sometimes more likely to get them to comply. I believe in Iowans. I believe they do the right thing. Over 75% are doing the right thing. Some Iowans cannot wear a mask because of health issues. We don't know what percentage that is, but we're doing pretty good. And so I'm confident with the direction that we're going, and I'm confident with the results that we're going to see. Audience: (22:41) In talking about Northwest Iowa and the very high positivity rates there, you're saying you can't tie it to a single outbreak of any kind, and it's just people out and about going about their daily lives, but nothing has been closed in Northwest Iowa for several months. I mean, the way you're talking about it would make it seem as if the reopening just happened recently. Kim Reynolds: (23:04) No. Audience: (23:05) So, I mean, doesn't more have to be done to make sure the virus stops spreading so quickly there? Kim Reynolds: (23:10) I think what we're seeing is the same thing that we've seen that's typical with this virus. And then Dr. Pedati, I might have you... But it moves. I mean, at the beginning of this virus, remember how there was almost a line down the middle of the state, and all of the outbreaks and the higher numbers were on the eastern side of the state? We saw it in New York, and then we saw it moved down to Florida, then we saw it move across the southern part of the United States. Now we're seeing it move into the Midwest. We're seeing an uptick in cases in Missouri and in Nebraska, South Dakota, North Dakota, Wisconsin. So we're seeing that move into the area, and a lot of the counties in Northwest Iowa really had very, very low positivity rates. We've seen the virus move in. We've opened things up. We're seeing community spread, and that's a reflection in the numbers that we're seeing. But also, I mean, we are seeing an uptick in hospitalization rates as well. Kim Reynolds: (24:02) We're monitoring that very closely with daily conversations. Our hospitals have done such a great job of coordinating and collaborating. They have surge plans in place. Not only are they meeting with the RMCC regions and talking about coordination and collaboration across the state, but up in the Northwest corner, the tri-states region, they're also doing calls with South Dakota and Nebraska because they utilize all of the health care systems up there based on that region. We're bringing in additional tests so that we can identify, so I think we're going to see kind of, hopefully what we saw in other areas, where we'll see that spike. And then hopefully, we'll see that come back down and continue to not only provide more contact, continue to educate. We're reaching out to community leaders to help get the message out. And when I talked to superintendents, they had met with all the schools, higher education, all the hospital systems. So they are really, I think as a community, trying to address this and get in front of it. Dr. Pedati, is there anything that you need to add to that? Dr. Pedati: (25:07) Yeah. I would just add, again, we're talking about the patterns of a disease, the epidemiology. So the people, the place, and the time. And sometimes, you can tie that to a single event or a single setting. Now, that's not what we're seeing, unfortunately, in Northwest Iowa. What we're seeing are people of different ages in different settings participating in different activities. And when we go back to what we know biologically about a virus like this, it moves from one person to the other, between us when we're in close proximity. And so everything that we can do to encourage each other to practice all of the good public health measures of staying home when you're sick with anything, staying home if you've had a high-risk exposure to somebody, practicing social distancing, using face coverings and washing your hands, all of those things together are things that we want people to continue to practice. Particularly in areas that are seeing increased community spread, because those are the public health tools that we have available right now to help limit that opportunity for the virus to move from one of us to the other. Dr. Pedati: (26:17) And then I think the other thing I would say to just keep in mind is that those interventions, those control measures are helpful not just for COVID, but for other respiratory illnesses, which as we move into the fall and winter, we do start to see increases in other kinds of respiratory viruses, including flu. And now is the time for everybody six months and older to take advantage of the flu shot to keep themselves healthy this winter. Audience: (26:42) Governor, you've expressed frustration with DMPS over not getting back or getting to a hybrid plan. Not back to a hybrid plan, but not getting to a hybrid plan yet at all. This may be a bit of an extrapolation, but Friday, the state removed the Davenport superintendent for non-COVID reasons, the non-Return to Learn reasons. Is that something that could be in play at DMPS if they don't follow... Is that something they should worry about, or- Kim Reynolds: (27:11) Now, these are two completely separate issues. Audience: (27:11) Right, I acknowledge that. Kim Reynolds: (27:12) Completely separate issues. I agree with the board of education's decision on the steps that they are taking with Davenport. This is something that they have been working with them for three years, I believe, quite some time to help them mitigate some of the concerns, and they made the decision last week to take a different step. Ann, do you have anything you want to add to that? Ann Lebo: (27:40) So I think potentially what the connection there is that this initiated with a noncompliance issue of federal state level, and Des Moines is currently just at the very beginning of that process. And there's a whole phase. There's a phase one, phase two that has to go to the state board. So it's a much longer, detailed process that would be in play. We have had communication from Des Moines on the citation currently, but it's for different reasons. But it is a similar process, but again, this takes quite a bit of time. Districts need the opportunity to respond, implement their remediation plans, get feedback from the board, support from the department. If that doesn't continue, there would be a phase two, and then that would have to go to the state board. Audience: (28:22) Follow up. What are you hearing from DMPS? Obviously, they're going to be having this meeting soon where they're formulating their own metrics potentially that may differ from the state's. I mean, what's your take on where the district is at right now in terms of getting closer to compliance? Ann Lebo: (28:41) We have not had much communication with Des Moines. We did receive a plan in our system based on the citation that they received that, if implemented, would be a compliant plan. Beyond that, there hasn't been any outreach or communication from the district. Audience: (29:00) Governor, it's going to be game day in Ames on Saturday. Will you wait until Friday, late afternoon to tell bars and restaurants in Ames, and by extension Iowa City, whether there'll be open on Saturday? Kim Reynolds: (29:17) No, the proclamation runs through next week, so that decision has already been made. We're monitoring it carefully every day, and we the direction that the positivity rates are heading is really good. They're stabilizing. So I've seen a little bit of... We're monitoring Story County a little bit. We've seen a little bit of a bump, but nothing to be concerned about. And so hopefully though, [Kay 00:09:37], we'll continue to monitor that, and by next week we'll be able to open things back up. Audience: (29:43) Governor, you mentioned you're talking with the hospitals. The hospitalization rates are higher than they've been since May, and the new admissions are actually higher than they've ever been. What are the hospitals telling you about their capacity and any level of concern for what the next couple of weeks might bring? Kim Reynolds: (30:00) Yeah. So I would really want to, at this point, give a shout out for an incredible- Kim Reynolds: (30:03) Yeah. So I really want to, at this point, give a shout out for an incredible team that I have, not only on my staff, but at the Department of Public Health, the RMCC regions, and the unprecedented collaboration that's taking place with our healthcare systems across the state. And they talk at least once a day, if not multiple times a day, we're monitoring where the upticks are at, we're reaching out individually to those hospitals to make sure that they still have bed capacity and if we're meeting the staffing ratios. A lot of it is workforce, too. That really is a key element to them being able to staff the number of hospitalizations that we're seeing, so we're monitoring that. A lot of this has to do with delayed care, the increase in some of the numbers that we're seeing, as well as they're testing everyone who comes in. They weren't doing that before, so that's had an impact. Kim Reynolds: (30:51) And then just the areas where we're seeing increased virus activity, that equates. We know there's about a week to two week lag, and that equates to increases in hospitalization. We're not seeing the number of individuals go beyond vent, so that number remains pretty stable and actually coming down. So I think the way that they're addressing the patients has changed and we're having better outcomes for that. What I'm not sure about, Dr. Pedati, the length of stay is maybe shorter, or is that accurate to say that? Dr. Pedati: (31:23) Maybe a bit. Kim Reynolds: (31:25) Maybe a little bit. So we're monitoring all of that as well. But honestly, the coordination and... What they're doing is they're actually implementing or doing what they need to do within the hospitals to address the ebbs and flows of the hospitalization. So, again, our hospitals are doing a great job of managing it, but we've made it very clear that if you need something or we need to implement the surge plans or talk about workforce or other issues that you may be having, we stand ready to help facilitate that. Speaker 3: (31:59) [inaudible 00:31:59] for that yet, or do they feel like they can handle what's happening? Kim Reynolds: (31:59) Not yet. No, no. They have indicated that they still are able to handle what they're seeing. Speaker 4: (32:08) [crosstalk 00:32:08] Governor, will people who are exposed by a person with COVID-19 who reports they were wearing a mask be notified by IDPH if they were exposed? And why break with CDC quarantine recommendations? Are there other recommendations possibly that we might not be following in the future from the CDC? Kim Reynolds: (32:26) Oh, well, we take a look at what's going on in state... What was your first question? I'm sorry. Speaker 4: (32:30) Will people will be notified by IDPH if they're exposed to a person with COVID-19- Kim Reynolds: (32:35) Are you talking about the schools? Speaker 4: (32:36) Yeah. Kim Reynolds: (32:37) I assume the schools will continue to notify the parents as they've been doing. So they have a system in place where they're actually the ones that are making the notifications, and that won't change- Speaker 4: (32:48) IDPH, will they be doing the contact tracing still? Kim Reynolds: (32:48) You don't do it, do you? Yeah. I don't know. I don't know that, Caitlin. Dr. Pedati: (32:55) So just like we have been, we're going to continue to do investigations on these cases. And as part of that, we're going to follow up and assess contacts, and so that's going to involve assessing mask usage, right? And so those conversations are still going to be happening. And, again, I understand that this is different from what CDC currently recommends. It's something that I've been talking with CDC about, other states have been talking with CDC about, and they're very eager to work with all of us to gather more information because this is how you do it in a response like this is you take a look at what's going on, you use the information, you work together to assess how we can kind of make recommendations that are in the best interest of everybody's health and wellbeing. And that's absolutely something we're going to continue to do. This is often how our states work together and how we work with our federal partners. Dr. Pedati: (33:51) And so, again, if we move along and if we see information that suggests we need to do something different, we'll do that. I don't want to insinuate that there is zero risk associated with this, right? There's always some risk associated with most things in life, but we want people to understand what that risk is and what they can do to protect themselves. And so, again, this is a place where we're absolutely committed to learning more and working with our partners on this. [crosstalk 00:34:18] Speaker 5: (34:21) For Dr. Pedati, you spoke a little bit and said that the new guidelines were based off of local information and you spoke a little bit about the school districts, some neighboring states that you spoke with. I mean, can you speak a little bit more specifically? Which school districts did you look at? Which professionals or which state officials have you talked with to base this new guideline off of? Dr. Pedati: (34:45) Yeah. So as I mentioned, we looked at four districts in Sioux County, in particular, with regard to mask use. Now Sioux County was helpful because, again, unfortunately they're a place where we're seeing increased activity. So we took a look at one district that's using masks and three that have not implemented that recommendation, or hadn't at the time. And I'd be happy to follow up. I think we can get additional information afterwards. But by comparing those rates of new cases, again, what we saw were that in the districts where masks weren't being used, there were 30% to 130% higher rates of new COVID cases reported associated with those districts. Dr. Pedati: (35:25) Now that's not a randomized controlled trial, right, which is what we think of when we think of sort of the scientific gold standard for how to evaluate these kinds of things, and sometimes those options are not always available in a response like this. And, again, this is exactly why this is a place where we want to work very closely with other states and with our federal partners to follow this information, and with everybody here in Iowa to continue to gather this information and understand the trends of illness and what we can do to protect people and encourage the use of things like face coverings. [crosstalk 00:36:01] Speaker 6: (36:00) Go ahead. Speaker 7: (36:01) There are 50 nursing homes that have reported outbreaks. What's the cause for that, and what level of concern is there with those number of outbreaks and the hospitalization rate that we're seeing? Kim Reynolds: (36:14) Yeah. So a lot of that I think is attributed to the really implemented significantly new surveillance testing, and this is a relatively recent change that CMS and HHS has implemented. So we're testing depending on the positivity rate. That depends on how many times a week you have to test the staff, and then for a facility to move into outbreak status, there has to be three residents that test positive. So because, I think, of the increased testing, we're seeing kind of facilities move into outbreak status. Kim Reynolds: (36:50) But what we're also seeing that we didn't see at the beginning is they're doing a better job of controlling it once it's in the facility. So we're seeing higher numbers with staff, but even with the facilities that move into outbreak because of the three residents that have tested positive. We're not seeing that really take over the facility like we experienced at the beginning. And a lot of that has to do with just the outreach between DIA and the Department of Public Health, education training. PPE is a big piece of that, making sure that they're adequately using the PPE and just the infection control measures that we continue to put in place. Kim Reynolds: (37:28) And again, not only the Department of Public Health, but my team has been reaching out to these long-term care facilities, especially in counties where we're seeing increased activity to really be proactive about what they need to be doing, how they need to be testing, how can we facilitate that, and hopefully, again, it's about workforce, and that's another key issue there too, to make sure that we're meeting their needs so that they can meet the needs of the residents that are housed there. But we're working with them in a collaborative manner again, and I think we're seeing better outcomes from what we've learned throughout this pandemic. So thank you.