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IN THE SUPREME COURT

STATE OF ARIZONA

MICHAEL BEAVER; JACQUELYN

BENDIG; MATT BRASSARD; CRAIG Supreme Court No. CV-20-0190
DENNY; PATRICIA DION; LOUIE
FERNANDEZ; MISTIE GREEN;
DAREL AND TAMIE HARRISON;
BRAD HENRICH; CHARLES
JENKINS; IAN JUUL; COLLEEN
KENDALL; ALAN KOWALSKI;
DOUGLAS LANDRETH; JOSH
MAKRAUER; CHAD NEWBERRY;
BRUCE REID; RUSSEL ROBERTS;
WES AND REBECCA SCHEMER;
PETER SCIACCA; SHERI SHAW;
HEATHER AND JUSTIN WARD; and
CHERI WELLS,

Petitioners,
v.

DOUGLAS A. DUCEY, in his official

capacity as the Governor of the State of
Arizona,

Respondent.
BRIEF OF CARA M. CHRIST, M.D., M.S. IN HER OFFICIAL CAPACITY
AS DIRECTOR OF THE ARIZONA DEPARTMENT OF HEALTH
SERVICES AS AMICUS CURIAE IN SUPPORT OF
RESPONDENT DOUGLAS A. DUCEY
Gregory W. Falls (011206)
Craig A. Morgan (023373)
SHERMAN & HOWARD L.L.C.
201 E. Washington St., Suite 800
Phoenix, Arizona 85004-1043
GFalls@ShermanHoward.com
CMorgan@ShermanHoward.com
Attorneys for Cara M. Christ, M.D., M.S.
 Click on the headings below to go to corresponding page

TABLE OF CONTENTS

Page
AMICUS CURIAE’S STATEMENT OF INTEREST ...............................................1
I. ARIZONANS UNNECESSARILY WILL GET SICK, SUFFER, AND
MAY DIE IF PETITIONERS ARE GRANTED THE RELIEF THEY
SEEK ...............................................................................................................3
A. BARS ARE ESPECIALLY UNSAFE DURING THIS PANDEMIC .......................4
B. COVID-19 IS AN AIRBORNE DISEASE THAT IS SPREAD THROUGH
SOMETHING AS MUNDANE AS TALKING OR BREATHING--ACTIVITIES
THAT ARE PARTICULARLY PREVALENT AND UNAVOIDABLE IN A BAR
SETTING ....................................................................................................6
C. GUIDANCE FROM THE UNITED STATES, STATE AND LOCAL
GOVERNMENT AUTHORITIES, AND RESPECTED EXPERTS AND
PROFESSIONAL ASSOCIATIONS LIKEWISE SUPPORTS (IF NOT COMPELS)
GOVERNOR DUCEY’S DECISION TO TEMPORARILY CLOSE BARS IN
ARIZONA .................................................................................................11
D. ARIZONA IS AT A CROSSROADS WHERE THE DECISIONS MADE WILL
EITHER SAVE LIVES OR EXACERBATE THE SPREAD OF COVID-19
POTENTIALLY TO A POINT OF NO RETURN ............................................16
II. CONCLUSION..............................................................................................19
APPENDIX ..............................................................................................................21
White House Coronavirus Task Force Report .....................................................22

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TABLE OF AUTHORITIES
Page
Statutes
A.R.S. § 36-132..........................................................................................................2
A.R.S. § 36-787..........................................................................................................2

Reports, Studies, and Other Authorities

Asadi, S., Wexler, A.S., Cappa, C.D., et al., Aerosol emission and
superemission during human speech increase with voice loudness, Sci. Rep.
9, 2348 (2019), https://www.nature.com/articles/s41598-019-38808-z (last
visited Jul. 17, 2020) ..............................................................................................7
Colo. Dept. of Public Health Article, https://covid19.colorado.gov/risks-
benefits (last visited Jul. 19, 2020).......................................................................13
Furuse Y, Sando E, Tsuchiya N, Miyahara R, Yasuda I, Ko YK, et al. Clusters
of coronavirus disease in communities, Japan, January–April 2020, Emerg
Infect Dis 2020, https://wwwnc.cdc.gov/eid/article/26/9/20-2272_article (last
visited Jul. 22, 2020) ..........................................................................................8, 9
July 14, 2020 KSDK Article, https://www.ksdk.com/article/news/
health/coronavirus/covid-19-risk-chart/63-723ae01d-4dc6-4a17-a8f0-
1e68013515af (last visited Jul. 19, 2020) ............................................................16
July 16, 2020 Center for Public Integrity Article,
https://publicintegrity.org/health/coronavirus-and-inequality/exclusive-
white-house-document-shows-18-states-in-coronavirus-red-zone-covid-19/
(last visited Jul. 22, 2020) ....................................................................................11
July 17, 2020 CDC Article, Considerations for Restaurants and Bars (updated
Jul. 17, 2020), https://www.cdc.gov/coronavirus/2019-
ncov/community/organizations/
business-employers/bars-restaurants.html (last visited Jul. 22, 2020).............4, 11
July 17, 2020 Time Article, https://time.com/5867751/bars-covid/ (last visited
Jul. 22, 2020) ..........................................................................................................5
July 2, 2020 CBS News Article, https://www.cbsnews.com/news/bars-closing-
stop-coronavirus-covid-19-science-michigan-california/ (last visited Jul. 17,
2020) .....................................................................................................................11

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July 2, 2020 Syracuse.com Article,

https://www.syracuse.com/coronavirus/2020/07/why-bars-are-a-big-risk-for-
coronavirus-spread-140-cases-linked-to-one-michigan-brewpub.html (last
visited Jul. 19, 2020) ..............................................................................................6
July 21, 2020 CDC Article, Interactive Serology Dashboard for Commercial
Laboratory Surveys, https://www.cdc.gov/
coronavirus/2019-ncov/cases-updates/commercial-labs-interactive-serology-
dashboard.html (last visited Jul. 21, 2020) ..........................................................16
July 22, 2020 KFF Article, https://www.kff.org/coronavirus-covid-19/issue-
brief/state-data-and-policy-actions-to-address-coronavirus/ (last visited Jul.
22, 2020) ...............................................................................................................13
June 22, 2020 Central District Health News Release,
https://www.cdhd.idaho.gov/pdfs/cd/Coronavirus/Order/06-22-
20%20CDH%20Issues%20Order%20COVID-19.pdf (last visited Jul. 21,
2020) .......................................................................................................................5
June 22, 2020 New York Times Article,
https://www.nytimes.com/2020/06/22/us/new-coronavirus-phase.html (last
visited Jul. 22, 2020) ..............................................................................................5
June 23, 2020 Spectrum News 13 Article, https://www.mynews13.com/fl/
orlando/coronavirus/2020/06/23/ucf-area-bar-gets-liquor-license-pulled-
after-more-than-40-get-covid-19 (last visited Jul. 22, 2020) .................................6
June 25, 2020 ABC 10news Article, https://www.10news.com/news/local-
news/what-activities-pose-the-highest-risk-for-covid-19-experts-weigh-in
(last visited, Jul. 17, 2020) .....................................................................................4
June 25, 2020 Kaiser Health News Article, https://khn.org/news/packed-bars-
serve-up-new-rounds-of-covid-contagion/ (last visited Jul. 17, 2020) ..................5
June 29, 2020 Nebraska Medicine Article,
https://www.nebraskamed.com/COVID/7-steps-to-identify-risky-covid-19-
situations (last visited Jul. 22, 2020) ....................................................................16
Kim N.J., Choe P.G., Park S.J., et al., A cluster of tertiary transmissions of
2019 novel coronavirus (SARS-CoV-2) in the community from infectors with
common cold symptoms, Korean J Intern Med 2020, http://kjim.org/journal/
view.php?doi=10.3904/kjim.2020.122 (last visited Jul. 22, 2020)......................10
Kline SE, Hedemark LL, Davies SF, Outbreak of tuberculosis among regular
patrons of a neighborhood bar, N Engl J Med 1995,
https://pubmed.ncbi.nlm.nih.gov/7791838/ (last visited Jul. 17, 2020) ................8

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Li, Yuguo, et al., Evidence for probable aerosol transmission of SARS-CoV-2

in a poorly ventilated restaurant
https://www.medrxiv.org/content/10.1101/2020.04.
16.20067728v1.full.pdf (last accessed July 17, 2020) ...........................................9
Lu, Jianyun et al., COVID-19 outbreak associated with air conditioning in
restaurant, Guangzhou, China, 2020, Emerg Infect Dis. (2020),
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323555/ (last visited Jul.
17, 2020) .................................................................................................................9
May 12, 2020 Korea Herald Article,
http://www.koreaherald.com/view.php?ud=20200512000586 (last visited
Jul. 19, 2020) ..........................................................................................................6
Texas Medical Association Article,
https://www.texmed.org/uploadedFiles/Current/2016_Public_Health/Infect
ious_Diseases/309193%20Risk%20Assessment%20Chart%20V2_FINAL.p
df (last visited July 22, 2020) ...............................................................................15
Transmission of SARS-CoV-2: implications for infection prevention
precautions, Scientific Brief (Jul. 9, 2020), https://www.who.int/news-
room/commentaries/detail/transmission-of-sars-cov-2-implications-for-
infection-prevention-precautions (last visited Jul. 22, 2020).................................8
Wei, J., Yuguo, L., Airborne spread of infectious agents in the indoor
environment, Am. Journal of Infection Control, Vol. 44, Issue 9, Supp.,
(Sept. 2, 2016),
https://www.sciencedirect.com/science/article/pii/S0196655316305314?via
%3Dihub#f0025 (last visited Jul. 21, 2020) ..........................................................7

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AMICUS CURIAE’S STATEMENT OF INTEREST

We are in the midst of a worldwide pandemic. The novel coronavirus

known by the name SARS-CoV-2, which causes a communicable infectious

disease known as COVID-19, is naturally driven to do one thing, without

prejudice: spread from one person to another, or rather from one person to many

others. People of all ages and socio-economic backgrounds are getting sick. Many

are dying. Many who do not die will be impaired in one way or another for life.

Hospitals are nearing critical capacity.

Most everyone is suffering--physically, mentally, or financially. Now, more

than ever, we must all come together, make sacrifices, and do what we must to

protect the public health and welfare. Many Arizonans, and many Arizona

businesses, have valiantly answered that call. The relief Petitioners seek would

place all Arizonans at greater risk of sickness, suffering, and even death. This

must not happen.

Amicus Curiae Cara M. Christ, M.D., M.S. (the “Director”)1 is Director of

1
The Director started her career with the Department in 2000 as an Infectious
Disease Epidemiologist. She left the Department in 2001 to attend medical school
at the University of Arizona College of Medicine and completed her residency at
Banner Good Samaritan Medical Center in Phoenix. She also has a master’s
degree in microbiology with an emphasis in molecular virology and public health.
She returned to the Department after her residency to serve between 2008 and 2009
as the State Tuberculosis Control Officer and Medical Director for the Bureau of
Epidemiology and Disease Control. From 2009 to 2012, she was the Bureau Chief
for Epidemiology and Disease Control and Public Health Chief Medical Officer.
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the Arizona Department of Health Services (the “Department”). The Department

and its Director are tasked with protecting the health and wellness of all Arizonans.

It is the Director’s duty to “… [p]rotect the health of the people of the state” and

“[e]ncourage and aid in coordinating local programs concerning control of

preventable diseases in accordance with statewide plans that shall be formulated by

the department.” A.R.S. § 36-132(A)(1), (7).2

In a state of emergency--like the COVID-19 pandemic--the Department,

through the Director, must “coordinate all matters pertaining to the public health

emergency response of the state.” A.R.S. § 36-787(A). This includes “[p]lanning

and executing public health emergency assessment, mitigation, preparedness

response and recovery for this state,” “[c]oordinating public health emergency

response among state, local and tribal authorities,” and “[c]oordinating recovery

operations and mitigation initiatives subsequent to public health emergencies.”

A.R.S. § 36-787(A)(1), (2), (4). Accordingly, the Director is tasked with

combating COVID-19 and safeguarding the health and welfare of all Arizonans.

She served as the Assistant Director for the Division of Public Health Licensing
Services from 2012 to 2014. Beginning in 2014, she was the Deputy Director for
the Division of Public Health Services and served as the Department’s Chief
Medical Officer from 2012 to 2015. She was appointed Director of the
Department in May 2015.
2
Unless otherwise indicated, all statutory and administrative rule citations are to
the version currently in effect.

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Petitioners here seek to second-guess science, or ignore it altogether, and

undo measures meant to keep Arizona safe and overcome the devastation wrought

by COVID-19. The Director has a genuine and substantial interest in the outcome

of this Special Action. In her medical opinion, science and common-sense compel

the measures Governor Ducey has carefully enacted through Executive Order

(“EO”) 2020-43. Those actions are meant to, and will, save lives. The Director

agreed with Governor Ducey that it is not for Petitioners (or this Court) to second

guess calculated, informed, and constitutionally permitted efforts to protect all

Arizonans and mitigate further disaster. For these reasons, and those that follow,

the Director submits this Brief as Amicus Curiae in support of Governor Ducey.

I. ARIZONANS UNNECESSARILY WILL GET SICK, SUFFER, AND MAY

DIE IF PETITIONERS ARE GRANTED THE RELIEF THEY SEEK

The spread of COVID-19 is greatly exacerbated in certain social settings,

and bars are of particular concern. Governor Ducey’s Response Brief recites

several facts, statistics, and other data related to the spread of COVID-19,

particularly in and around bars. The Director agrees with and adopts those

recitations, and will endeavor not to unnecessarily repeat them again here. Instead,

the Director will provide this Court with additional information and data

(1) supporting Governor Ducey’s decision to focus on bars in his effort to combat

the COVID-19 pandemic, and (2) compelling this Court to show substantial

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deference to Governor Ducey’s decision, as recommended and informed by the

Director, to temporarily close bars for the good of all Arizonans.

A. BARS ARE ESPECIALLY UNSAFE DURING THIS PANDEMIC

COVID-19, which has no known cure or proven vaccine, is transmitted from

person to person mainly through respiratory droplets produced when an infected

person coughs, sneezes, or talks. Those viral droplets can land in the mouths or

noses of people who are nearby or possibly be inhaled into the lungs. They also

may spread to the hands from a contaminated surface and then to the nose or

mouth. Spread is more likely when people are in close contact with one another

(within about 6 feet). See Considerations for Restaurants and Bars (updated Jul.

17, 2020), https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/

business-employers/bars-restaurants.html (last visited Jul. 22, 2020).

Many “experts agree bars pose a particular challenge” to the spread of

COVID-19 because “[n]ot only is there a chance you could encounter a large

crowd indoors, alcohol could discourage social distancing efforts.”

https://www.10news.com/news/local-news/what-activities-pose-the-highest-risk-

for-covid-19-experts-weigh-in (last visited, Jul. 17, 2020). One New Orleans bar

owner aptly summarized these concerns: “On our busiest nights, it’s sweaty, and

it’s loud and it’s impossible to navigate without touching a half-dozen other

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people, he says. That’s why we’re susceptible to shutdowns ….”

https://time.com/5867751/bars-covid/ (last visited Jul. 22, 2020).

Indeed, “bars are emerging as fertile breeding grounds for the coronavirus.

They create a risky cocktail of tight quarters, young adults unbowed by the fear of

illness and, in some instances, proprietors who don’t enforce crowd limits and

social distancing rules.” https://khn.org/news/packed-bars-serve-up-new-rounds-

of-covid-contagion/ (last visited Jul. 17, 2020) (noting “as bars and other public

places reopen, rates of infection in younger adults are rising, and bars are a

particularly dangerous vector.”). Simply put: bars are not safe.3

This concern is not speculative. It is real. For example, at least 100 people

tested positive for COVID-19 after visiting bars in Baton Rouge, Louisiana. See

https://www.nytimes.com/2020/06/22/us/new-coronavirus-phase.html (last visited

Jul. 22, 2020). Ada County, Idaho, had a rapid increase of 303 cases of COVID-

19, many of which were linked with individuals who reported going to bars and

nightclubs. See https://www.cdhd.idaho.gov/pdfs/cd/Coronavirus/Order/06-22-

20%20CDH%20Issues%20Order%20COVID-19.pdf (last visited Jul. 21, 2020).

3
“‘People almost don’t want to social-distance if they go to the bar,’ said Dr.
Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health
Security in Baltimore. ‘They’re going to be drinking alcohol, which is a social
lubricant. People will often be loud, and if they have forceful speech, that’s going
to create more droplets.’” https://khn.org/news/packed-bars-serve-up-new-rounds-
of-covid-contagion/ (last visited Jul. 19, 2020).

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Similarly, in Orlando, Florida, a bar had its liquor license suspended after more

than 40 patrons contracted COVID-19. See https://www.mynews13.com/fl/

orlando/coronavirus/2020/06/23/ucf-area-bar-gets-liquor-license-pulled-after-

more-than-40-get-covid-19 (last visited Jul. 22, 2020). In Michigan, an outbreak

of COVID-19 that spread to nearly 140 people was linked to a large brewpub. See

https://www.syracuse.com/coronavirus/2020/07/why-bars-are-a-big-risk-for-

coronavirus-spread-140-cases-linked-to-one-michigan-brewpub.html (last visited

Jul. 19, 2020). And in Itaewon, South Korea, a 29-year-old who visited multiple

clubs and bars was linked to over 100 people who were infected. See

http://www.koreaherald.com/view.php?ud=20200512000586 (last visited Jul. 19,

2020).

Most everyone enjoys going out with friends, family, and even strangers to

have a drink and celebrate something, or even just to unwind after a long day. In

times of pandemic, what we do during “normal” times must take a back seat to

public health and safety. This is one of those times.

B.COVID-19 IS AN AIRBORNE DISEASE THAT IS SPREAD THROUGH

SOMETHING AS MUNDANE AS TALKING OR BREATHING--ACTIVITIES THAT ARE
PARTICULARLY PREVALENT AND UNAVOIDABLE IN A BAR SETTING
When dealing with an airborne viral disease, we know that the louder

someone talks (perhaps to speak over a loud crowd or loud music or shout at a

friend across the room), the larger the quantity of viral droplets that will emit and

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expose others to infection. See Asadi, S., Wexler, A.S., Cappa, C.D., et al.,

Aerosol emission and superemission during human speech increase with voice

loudness, Sci. Rep. 9, 2348 (2019), https://www.nature.com/articles/s41598-019-

38808-z (last visited Jul. 17, 2020). We also know that airborne viral infection can

spread in short range indoor environments through a “direct spray route by which

large droplets are deposited directly on the mucous membranes of the susceptible

host (large droplet route) or by direct inhalation of fine droplets or droplet nuclei

(airborne route),” with the latter “referred to as the short-range airborne route

because exposure occurs when the 2 individuals are in close contact.” Wei, J.,

Yuguo, L., Airborne spread of infectious agents in the indoor environment, Am.

Journal of Infection Control, Vol. 44, Issue 9, Supp., (Sept. 2, 2016),

https://www.sciencedirect.com/science/article/pii/S0196655316305314?via%3Dih

ub#f0025 (last visited Jul. 21, 2020).

Not surprisingly, the enhanced transmission of a viral disease (like COVID-

19) in a bar setting is a very real concern rooted in science. While we know that

COVID-19 is spread through droplet transmission, recently the World Health

Organization (WHO), together with the scientific community, has been evaluating

whether SARS-CoV-2 may also be transmitted via airborne transmission,

particularly in indoor settings with poor ventilation. See Transmission of SARS-

CoV-2: implications for infection prevention precautions, Scientific Brief (Jul. 9,

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2020), https://www.who.int/news-room/commentaries/detail/transmission-of-sars-

cov-2-implications-for-infection-prevention-precautions (last visited Jul. 22, 2020).

One study involving the spread of tuberculosis--an airborne disease--is

particularly alarming and informative. See Kline SE, Hedemark LL, Davies SF,

Outbreak of tuberculosis among regular patrons of a neighborhood bar, N Engl J

Med 1995, https://pubmed.ncbi.nlm.nih.gov/7791838/ (last visited Jul. 17, 2020).

That study followed a homeless patient with highly infectious tuberculosis who

was a regular patron of a neighborhood bar. Id. The result: that one individual, in

a bar setting, transmitted tuberculosis to 41 other bar patrons, 14 of which were

active tuberculosis cases and 27 of which were, at the time, infected but without

disease. Id.

A published study from Japan defined a “cluster” of COVID-19 cases as five

or more cases with primary exposure reported at a common event or venue,

excluding within-household transmissions. The study concluded that 10 of 61 total

clusters of COVID-19 cases were linked to restaurants or bars. See Furuse Y,

Sando E, Tsuchiya N, Miyahara R, Yasuda I, Ko YK, et al. Clusters of

coronavirus disease in communities, Japan, January–April 2020, Emerg Infect Dis

2020, https://wwwnc.cdc.gov/eid/article/26/9/20-2272_article (last visited Jul. 22,

2020). Importantly, the study “noted many COVID-19 clusters were associated

with heavy breathing in close proximity, such as singing at karaoke parties,

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cheering at clubs, [or] having conversations in bars ….” Id. In other words, the

routine activities that occur in a bar setting are the very activities that exacerbate

the spread of COVID-19.

Studies involving restaurants are helpful to understanding why bars pose

such a high risk of exposure and require close attention during this pandemic. Like

bars, restaurants can easily become crowded places where social distancing is

minimal and patrons are engaged in close interaction prone to the spread of viral

droplets. But unlike bars, measures to minimize the spread of viral droplets can

more easily be implemented in restaurants (less tables used, more take-out versus

dining-in, easily enforced masking requirements between courses, etc.). However,

when those protections are not implemented and consistently enforced, science

tells us that COVID-19 spread will undoubtedly increase.

For example, a published study from China concluded that COVID-19 viral

droplet transmission between restaurant patrons was facilitated by close proximity

and air conditioned ventilation. See Lu, Jianyun et al., COVID-19 outbreak

associated with air conditioning in restaurant, Guangzhou, China, 2020, Emerg

Infect Dis. (2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323555/ (last

visited Jul. 17, 2020).4

4
Likewise, a not yet peer reviewed article also concludes that poor ventilation
conditions in a restaurant facilitated transmission of COVID-19. See Li, Yuguo, et
al., Evidence for probable aerosol transmission of SARS-CoV-2 in a poorly

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Similarly, another published study from Korea found that a person showing

only cold-like symptoms transmitted COVID-19 during a 90 minute meal in a

restaurant where people were sitting within one meter (just over 3 feet) of each

other and had no direct contact (not an atypical social distance in a bar setting).

See Kim N.J., Choe P.G., Park S.J., et al., A cluster of tertiary transmissions of

2019 novel coronavirus (SARS-CoV-2) in the community from infectors with

common cold symptoms, Korean J Intern Med 2020, http://kjim.org/journal/

view.php?doi=10.3904/kjim.2020.122 (last visited Jul. 22, 2020). This study is

especially important, because it “suggests that mildly symptomatic patients with

COVID-19 could transmit the virus from the first day of illness through daily

activities in the community”--like socializing in a restaurant or bar. Id.

The foregoing science informed the Director’s recommendation that

Governor Ducey should temporarily close bars to combat the spread of COVID-19.

That science unquestionably demonstrates that bars pose a unique risk for the

spread of COVID-19, warranting not only close scrutiny and regulation in order to

overcome the devastation that is COVID-19, but more than justifying Governor

Ducey’s emergency actions through EO 2020-43.

ventilated restaurant https://www.medrxiv.org/content/10.1101/2020.04.

16.20067728v1.full.pdf (last accessed July 17, 2020) (concluding that “[a]erosol
transmission of SARS-CoV-2 due to poor ventilation may explain the community
spread of COVID-19”).

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C. GUIDANCE FROM THE UNITED STATES, STATE AND LOCAL GOVERNMENT

AUTHORITIES, AND RESPECTED EXPERTS AND PROFESSIONAL ASSOCIATIONS
LIKEWISE SUPPORTS (IF NOT COMPELS) GOVERNOR DUCEY’S DECISION TO
TEMPORARILY CLOSE BARS IN ARIZONA
Dr. Anthony Fauci, director of the National Institute of Allergy and

Infectious Diseases, recently told a United States Senate panel: “Congregation at a

bar, inside, is bad news … [w]e really have got to stop that.”

https://www.cbsnews.com/news/bars-closing-stop-coronavirus-covid-19-science-

michigan-california/ (last visited Jul. 17, 2020). The Centers for Disease Control

and Prevention (the “CDC”), addressing the risks bars pose concerning the

transmission of COVID-19, has stated that the “Highest Risk” is present where

consumption occurs on-site, even with both indoor and outdoor seating, when

seating capacity is not reduced and tables are not spaced at least 6 feet apart.

https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/business-

employers/bars-restaurants.html (last visited Jul. 17, 2020). In fact, the CDC

unequivocally states that bars and restaurants should “[a]void group events,

gatherings, or meetings where social distancing of at least 6 feet between people

cannot be maintained.” Id.

Regarding Arizona specifically, a July 14, 2020 report prepared for the

White House Coronavirus Task Force recommended that Arizona at least

“[c]ontinue bar and gym closures in hot spot counties” like Maricopa and Pima.

See https://publicintegrity.org/health/coronavirus-and-inequality/exclusive-white-

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house-document-shows-18-states-in-coronavirus-red-zone-covid-19/ (last visited

Jul. 22, 2020); see also Appendix at 22 – 30 (Attaching Arizona-related pages of

the document prepared for the White House Coronavirus Task Force updated as of

Jul. 19, 2020). That same report offered Arizona the following policy

recommendations: (1) with regard to “Public Messaging”--convey the message

“[d]o not got to bars, nightclubs, or gyms”; and (2) with regard to “Public

Officials”--act to “[c]lose bars and gyms, ….” Id. at 25.

The decision to close bars in an effort to save lives and prevent the spread of

COVID-19 is not unique to Arizona. Many states have implemented bar-specific

COVID-19 measures. The following map shows that eight states and the District

of Columbia have left in place mandates for the closure of bars, nine others (like

Arizona) have newly closed bars, and two have enacted new service limits:

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See https://www.kff.org/coronavirus-covid-19/issue-brief/state-data-and-policy-

actions-to-address-coronavirus/ (last visited Jul. 22, 2020).

Tellingly, most states in the Southwestern United States have closed bars or

otherwise taken action to closely regulate their activity to help curb the spread of

COVID-19. And of all the states that border Arizona, only one (Utah) has

completely re-opened bars. Arizona’s northeastern neighbor, Colorado--warning

that “[t]he more alcohol or other substances people consume, the less they may be

mindful of masking, distancing, and hand cleaning”--has ranked going to a bar as

among the riskiest social activities during the COVID-19 pandemic:

https://covid19.colorado.gov/risks-benefits (last visited Jul. 19, 2020).

Experts and professional associations agree with Arizona’s (and many other

states’) decision to temporarily close bars during the COVID-19 pandemic. For

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example, the Texas Medical Association ranks going to a bar as among the riskiest

activities for the transmission of COVID-19.

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See https://www.texmed.org/uploadedFiles/Current/2016_Public_Health/Infect

ious_Diseases/309193%20Risk%20Assessment%20Chart%20V2_FINAL.pdf (last

visited July 22, 2020) (Texas Medical Association). Nebraska Medicine ranks

going to a bar as one of the riskiest activities (“9” out of “9”) for the transmission

of COVID-19.

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See https://www.nebraskamed.com/COVID/7-steps-to-identify-risky-covid-19-

situations (last visited Jul. 22, 2020).

Similarly, infectious disease specialist Dr. Andrew Janowski, with

Washington University, ranked activities on a scale of 1-10, with 10 being the

highest risk for contracting COVID-19. https://www.ksdk.com/article/news/

health/coronavirus/covid-19-risk-chart/63-723ae01d-4dc6-4a17-a8f0-

1e68013515af (last visited Jul. 19, 2020). Dr. Janowski ranked going to a bar a

“9” out of “10,” with nobody wearing masks or practicing social distancing, and a

“7” out of “10” when social distancing is observed and masks are worn. Id.

The requirements of EO 2020-43 are far from irrational and comport with

sound accepted scientific opinion.

D. ARIZONA IS AT A CROSSROADS WHERE THE DECISIONS MADE WILL

EITHER SAVE LIVES OR EXACERBATE THE SPREAD OF COVID-19
POTENTIALLY TO A POINT OF NO RETURN
As of July 22, 2020, the Department has reported 150,609 COVID-19

positive cases in Arizona and 2,974 deaths as a result of COVID-19. The CDC has

reported that, throughout the country, the actual number of positive cases is

thought to be many multiples of the number of reported cases. See Interactive

Serology Dashboard for Commercial Laboratory Surveys, https://www.cdc.gov/

coronavirus/2019-ncov/cases-updates/commercial-labs-interactive-serology-

dashboard.html (last visited Jul. 21, 2020).

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After bars were allowed to reopen on May 13, Arizona saw a sharp increase

in the number of new COVID-19 cases reported daily. On May 13, 2020 Arizona

reported 413 new cases. On June 29, 2020 Arizona set a daily record for new

cases: 5,385 (one of several records set in May and June--including repeated daily

records for hospitalizations). Tellingly, during the month of June, there were only

two days where the number of new COVID-19 cases was less than 1,000.

The number of deaths from COVID-19 also has increased since the phased

reopening in May but, fortunately, that increase has not been as sharp as the

number of new cases, hospitalizations, and ventilators in use. That said, in June,

Arizona saw a sharp increase in the number of 20-44-year-old people testing

positive, with that age group representing 47% of all positive tests and 22% of all

hospitalizations. And even with the significant efforts and sacrifices made so far,

there still is “community spread,” which means someone gets COVID-19 without

any known contact with a sick person, and the virus continues to spread. In short:

COVID-19 is widespread and growing fast; it is in all of Arizona’s counties.

Swift and decisive action is necessary to combat the spread of COVID-19.

And given the rapid increase in COVID-19 cases in Arizona since May, the

Director simply cannot ignore the evidence described throughout this brief that

points to bars as especially conducive to the spread of COVID-19. Accordingly, it

is the Director’s professional opinion that:

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1. Bars pose a uniquely dangerous environment for the spread of

COVID-19. Alcohol consumption slows brain activity, reduces inhibition, and

impairs judgment, factors that result in individuals forgetting to exercise

precautions, such as the use of face coverings and social distancing. Moreover,

bars generally attract a younger adult population, which currently represents the

highest demographic carrying COVID-19 in Arizona--a demographic with a higher

likelihood of asymptomatic or mildly symptomatic infection, which makes that

demographic more likely to act is if they are not infected, when in fact they are;

2. Governor Ducey’s declaration of a state of emergency was and is

appropriate given the threat COVID-19 presents to Arizona’s health care system;

3. EO 2020-43, which scales back the reopening of certain businesses,

such as bars, and activities that pose a higher risk of spreading COVID-19, is

necessary to prevent Arizona from facing an even larger increase in COVID-19

related illnesses and death;

4. If Arizona had not acted quickly to mitigate the rapid increase in

COVID-19 cases since the reopening in May, including through the enactment of

EO 2020-43, all the efforts over the past few months to address COVID-19 would

have been for naught, and the spread of COVID-19 would exponentially increase

across Arizona--placing all Arizonans at risk;

5. EO 2020-43, along with the other emergency measures taken Arizona,

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is critical in slowing the rate of COVID-19 cases;

6. EO 2020-43 is critical to allow Arizona to ensure adequate PPE

supplies and hospital space availability, which in turn will help ensure that health

care providers are not forced to make triage decisions as to which patient should be

saved and are otherwise able to protect our most vulnerable citizens;

7. Although Arizona has significantly increased its capacity and

resources since the beginning of this pandemic, the recent surge of COVID-19

cases, coupled with the limited remaining availability of hospital beds and

ventilators, threatens to compound the problem of addressing a pandemic without

adequate resources; and

8. Governor Ducey’s reasonable and narrow directives through EO

2020-43 encourage physical distancing measures which the Director believes are

critical to continue to slow the spread and impact of COVID-19, lessen the strain

on health care providers, and ensure the on-going capabilities of Arizona’s health

care system.

In the end, the Director fully, and without reservation, believes that

Governor Ducey’s decision to temporarily close bars is necessary in order to help

curb the spread of COVID-19 and protect the health and wellness of all Arizonans.

II. CONCLUSION

EO 2020-43 has helped, and will continue to help, curb the spread of

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COVID-19 and save lives. If EO 2020-43 is prematurely lifted, or if Governor

Ducey is prohibited from exercising reasonable judgement in an effort to protect

the public, it is the Director’s professional opinion that COVID-19 cases will rise,

placing renewed pressures on the health care system, and increasing the threat to

all Arizonans. In that event, many more Arizonans will get sick, many will suffer,

and some will die. From the Director’s perspective, the temporary burden EO

2020-43 places on bars is far outweighed by the lives that will be saved.

Accordingly, for the foregoing reasons, the Court should deny jurisdiction

or, alternatively, deny Petitioners the relief they seek.

Respectfully submitted: July 23, 2020.

SHERMAN & HOWARD L.L.C.

By /s/ Gregory W. Falls

Gregory W. Falls
Craig A. Morgan
2800 North Central Avenue, Suite 1100
Phoenix, Arizona 85004-1043
Attorneys for Cara M. Christ, M.D., M.S.

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APPENDIX

Document Page

White House Coronavirus Task Force Report .........................................................22

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ARIZONA
STATE REPORT | 07.19.2020

SUMMARY
• Arizona is in the red zone for cases, indicating more than 100 new cases per 100,000 population last week, and the
red zone for test positivity, indicating a rate above 10%.
• Arizona has seen a decrease in new cases and a decrease in testing positivity over the past week.
• The following three counties had the highest number of new cases over the past 3 weeks: 1. Maricopa County, 2.
Pima County, and 3. Yuma County. These counties represent 86.3 percent of new cases in Arizona.
• Arizona had 297 new cases per 100,000 population in the past week, compared to a national average of 140 per
100,000.
• The federal government has deployed the following staff as assets to support the state response: 10 to support
operations activities from FEMA; 150 to support medical activities from ASPR; 2 to support operations activities
from ASPR; 6 from CDC; 1 to support operations activities from USCG; 63 to support medical activities from VA;
and 3 to support operations activities from VA.
• The federal government has supported a surge testing site in Phoenix.
• During Jul 15 - Jul 17, on average, 149 patients with confirmed COVID-19 and 259 patients with suspected COVID-
19 were reported as newly admitted each day to hospitals in Arizona. An average of 61 percent of hospitals
reported each day during this period; therefore, this may be an underestimate of the actual total number of
COVID-related hospitalizations. Underreporting may lead to a lower allocation of critical supplies. *

RECOMMENDATIONS
• Continue weekly testing of all workers in assisted living and long-term care facilities and require masks and social distancing for all visitors.
• Mandate public use of masks in all current and evolving hot spots.
• Continue bar and gym closures in hot spot counties.
• Move to outdoor dining and limit indoor dining to less than 25% of normal capacity.
• Ask citizens to limit social gatherings to 10 or fewer people.
• Encourage individuals that have participated in large social gatherings to get tested.
• Increase messaging regarding the risk of serious disease in all age groups with preexisting obesity, hypertension, and diabetes mellitus.
• Continue the scale-up of testing, moving to community-led neighborhood testing and pooled household testing in Maricopa, Pima, and Yuma
counties.
• Work with local communities to implement and provide clear guidance for households that test positive, including on individual isolation
procedures.
• Continue to enhance contact tracing and ensure the ability of cases and contacts to quarantine or isolate safely.
• Monitor testing data to identify additional sites of increased transmission and focus public health resources on them.
• Test households in one tube with rapid turnaround testing. For households that test positive, isolate and conduct follow-up individual tests.
• Expand testing capacity in public health labs, adding shifts and weekend shifts to decrease turnaround times; institute 2:1 pooling of test
specimens.
• Tribal Nations: Continued enforcement of social distancing and masking measures in areas of increased transmission. Continue enhanced testing
activities. Support 100% pooled testing in households with isolation for positive households to ensure all outbreaks are immediately curtailed.
Increase supplies of Abbott ID Now to test individuals in positive households.
• Specific, detailed guidance on community mitigation measures can be found on the CDC website.

The purpose of this report is to develop a shared understanding of the current status of the pandemic at the national, regional, state and local levels. We recognize
that data at the state level may differ from that available at the federal level. Our objective is to use consistent data sources and methods that allow for comparisons
to be made across localities. We appreciate your continued support in identifying data discrepancies and improving data completeness and sharing across systems.
We look forward to your feedback.

* This figure may differ from state data due to differences in hospital lists between federal and state systems or inclusion of hospitals that
are not admitting COVID-19 patients. We are working to incorporate feedback on an ongoing basis to update these figures. These data
exclude psychiatric, rehabilitation, and religious non-medical hospitals. COVID-19
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COVID-19

ARIZONA
STATE REPORT | 07.19.2020
STATE, % CHANGE FEMA/HHS
STATE, FROM PREVIOUS REGION, UNITED STATES,
LAST WEEK WEEK LAST WEEK LAST WEEK

NEW CASES 21,637 90,868 460,366

-13.6%
(RATE PER 100,000) (297) (177) (140)

DIAGNOSTIC TEST
17.7% -3.8%* 10.3% 9.1%
POSITIVITY RATE

TOTAL DIAGNOSTIC TESTS 126,154 790,849 4,940,998

+13.2%
(TESTS PER 100,000) (1,733) (1,542) (1,505)

COVID DEATHS 501 1,160 5,122

+70.4%
(RATE PER 100,000) (7) (2) (2)

SNFs WITH AT LEAST ONE

28.6% -0.2% 17.3% 10.0%
COVID-19 CASE
MOBILITY

* Indicates absolute change in percentage points

DATA SOURCES
Cases and Deaths: State values are calculated by aggregating county-level data from USAFacts; therefore, the values may not match
those reported directly by the state. Data is through 7/17/2020; last week is 7/11 - 7/17, previous week is 7/4 - 7/10.
Testing: State-level values calculated by using 7-day rolling averages of reported tests. Regional- and national-level values calculated
by using a combination of CELR (COVID-19 Electronic Lab Reporting) state health department-reported data and HHS Protect laboratory
data (provided directly to Federal Government from public health labs, hospital labs, and commercial labs) through 7/15/2020. Last
week is 7/9 - 7/15, previous week is 7/2 - 7/8. Testing data are inclusive of everything received and processed by the CELR system as of
14:00 EDT on 07/19/2020. Some dates may be incomplete due to delays in reporting. Testing data may be backfilled over time, resulting
in changes week-to-week in testing data. It is critical that states provide as up-to-date testing data as possible.
Mobility: Descartes Labs. This data depicts the median distance moved across a collection of mobile devices to estimate the level of
human mobility within a county; 100% represents the baseline mobility level. Data is anonymized and provided at the county level. Data
through 7/16/2020.
SNFs: Skilled nursing facilities. National Healthcare Safety Network. Last week is 7/6-7/12, previous week is 6/29-7/5.
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COVID-19

ARIZONA
STATE REPORT | 07.19.2020

LOCALITIES IN LOCALITIES IN
RED ZONE YELLOW ZONE
Phoenix-Mesa-Chandler
Tucson
Yuma
METRO Show Low
AREA
11 0
Lake Havasu City-Kingman
Flagstaff N/A
(CBSA) Prescott Valley-Prescott
Sierra Vista-Douglas
LAST WEEK Nogales
Payson
Safford
Maricopa
Pima
Yuma

13
Pinal

2
Navajo
COUNTY Mohave Apache
Coconino Greenlee
LAST WEEK Top 12 shown Yavapai
(full list Cochise
below) Santa Cruz
Gila
Graham

All Red Counties: Maricopa, Pima, Yuma, Pinal, Navajo, Mohave, Coconino, Yavapai, Cochise, Santa Cruz, Gila,
Graham, La Paz

Red Zone: Those core-based statistical areas (CBSAs) and counties that during the last week reported both new cases above 100 per
100,000 population, and a diagnostic test positivity result above 10%.
Yellow Zone: Those core-based statistical areas (CBSAs) and counties that during the last week reported both new cases between 10-
100 per 100,000 population, and a diagnostic test positivity result between 5-10%, or one of those two conditions and one condition
qualifying as being in the “Red Zone.”
Note: Top 12 locations are selected based on the highest number of new cases in the last three weeks.
DATA SOURCES
Cases and Deaths: State values are calculated by aggregating county-level data from USAFacts; therefore, the values may not match
those reported directly by the state. Data is through 7/17/2020; last week is 7/11 - 7/17, three weeks is 6/27 - 7/17.
Testing: CELR (COVID-19 Electronic Lab Reporting) state health department-reported data through 7/15/2020. Last week is 7/9 - 7/15.
Testing data may be backfilled over time, resulting in changes week-to-week in testing data. It is critical that states provide as up-to-
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POLICY RECOMMENDATIONS FOR COUNTIES IN THE RED ZONE

Public Messaging
• Wear a mask at all times outside the home and maintain physical distance
• Limit social gatherings to 10 people or fewer
• Do not go to bars, nightclubs, or gyms
• Use take out or eat outdoors socially distanced
• Protect anyone with serious medical conditions at home by social distancing at home and using high levels of personal hygiene, including
handwashing and cleaning surfaces
• Reduce your public interactions and activities to 25% of your normal activity

Public Officials
• Close bars and gyms, and create outdoor dining opportunities with pedestrian areas
• Limit social gatherings to 10 people or fewer
• Institute routine weekly testing of all workers in assisted living and long-term care facilities. Require masks for all staff and prohibit
visitors
• Ensure that all business retailers and personal services require masks and can safely social distance
• Increase messaging on the risk of serious disease for individuals in all age groups with preexisting obesity, hypertension, and diabetes
mellitus, and recommend to shelter in place
• Work with local community groups to provide targeted, tailored messaging to communities with high case rates, and increase community
level testing
• Recruit more contact tracers as community outreach workers to ensure all cases are contacted and all positive households are
individually tested within 24 hours
• Provide isolation facilities outside of households if COVID-positive individuals can’t quarantine successfully

Testing
• Move to community-led neighborhood testing and work with local community groups to increase access to testing
• Surge testing and contact tracing resources to neighborhoods and zip codes with highest case rates
• Diagnostic pooling: Laboratories should use pooling of samples to increase testing access and reduce turnaround times to under 12
hours. Consider pools of 2-3 individuals in high incidence settings and 5:1 pools in setting where test positivity is under 10%
• Surveillance pooling: For family and cohabitating households, screen entire households in a single test by pooling specimens of all
members into single collection device

POLICY RECOMMENDATIONS FOR COUNTIES IN THE YELLOW ZONE IN ORDER

TO PREEMPT EXPONENTIAL COMMUNITY SPREAD
Public Messaging
• Wear a mask at all times outside the home and maintain physical distance
• Limit social gatherings to 25 people or fewer
• Do not go to bars or nightclubs
• Use take out, outdoor dining or indoor dining when strict social distancing can be maintained
• Protect anyone with serious medical conditions at home by social distancing at home and using high levels of personal hygiene
• Reduce your public interactions and activities to 50% of your normal activity

Public Officials
• Limit gyms to 25% occupancy and close bars until percent positive rates are under 3%; create outdoor dining opportunities with
pedestrian areas
• Limit social gatherings to 25 people or fewer
• Institute routine weekly testing of all workers in assisted living and long-term care facilities. Require masks for all staff and prohibit
visitors
• Ensure that all business retailers and personal services require masks and can safely social distance
• Increase messaging on the risk of serious disease for individuals in all age groups with preexisting obesity, hypertension, and diabetes
mellitus, and recommend to shelter in place
• Work with local community groups to provide targeted, tailored messaging to communities with high case rates, and increase community
level testing
• Recruit more contact tracers as community outreach workers to ensure all cases are contacted and all positive households are
individually tested within 24 hours
• Provide isolation facilities outside of households if COVID-positive individuals can’t quarantine successfully

Testing
• Move to community-led neighborhood testing and work with local community groups to increase access to testing
• Surge testing and contact tracing resources to neighborhoods and zip codes with highest case rates
• Diagnostic pooling: Laboratories should use pooling of samples to increase testing access and reduce turnaround times to under 12
hours. Consider pools of 3-5 individuals
• Surveillance pooling: For family and cohabitating households, screen entire households in a single test by pooling specimens of all
members into single collection device
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COVID-19

ARIZONA
STATE REPORT | 07.19.2020
NEW CASES
TESTING

Top counties based on greatest number of new cases in

last three weeks (6/27 - 7/17)
TOP COUNTIES

DATA SOURCES
Cases: County-level data from USAFacts. State values are calculated by aggregating county-level data from USAFacts;
therefore, the values may not match those reported directly by the state. Data is through 7/17/2020.
Testing: CELR (COVID-19 Electronic Lab Reporting) state health department-reported data through 7/15/2020.
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COVID-19

Top 12 counties based on number of new cases in the

last 3 weeks
TOTAL DAILY CASES

DATA SOURCES
Cases: County-level data from USAFacts through 7/17/2020. Last 3 weeks is 6/27 - 7/17.
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COVID-19

ARIZONA
STATE REPORT | 07.19.2020

CASE RATES AND DIAGNOSTIC TEST POSITIVITY DURING THE

LAST WEEK
NEW CASES PER 100,000 DURING TEST POSITIVITY DURING LAST
LAST WEEK WEEK

WEEKLY % CHANGE IN NEW WEEKLY CHANGE IN TEST

CASES PER 100K POSITIVITY

DATA SOURCES
Cases: County-level data from USAFacts through 7/17/2020. Last week is 7/11 - 7/17, previous week is 7/4 - 7/10
Testing: CELR (COVID-19 Electronic Lab Reporting) state health department-reported data through 7/15/2020. Last week is 7/9 -
7/15, previous week is 7/2 - 7/8. Testing data may be backfilled over time, resulting in changes week-to-week in testing data. It is
critical that states provide as up-to-date testing data as possible.
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COVID-19

National Picture
NEW CASES PER 100,000 LAST WEEK

TEST POSITIVITY LAST WEEK

DATA SOURCES
Cases: County-level data from USAFacts through 7/17/2020. Last week is 7/11 - 7/17
Testing: Combination of CELR (COVID-19 Electronic Lab Reporting) state health department-reported data and HHS
Protect laboratory data (provided directly to Federal Government from public health labs, hospital labs, and commercial
labs) through 7/15/2020. Last week is 7/9 - 7/15. Testing data may be backfilled over time, resulting in changes week-to-
week in testing data. It is critical that states provide as up-to-date testing data as possible.
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COVID-19

Methods
STATE REPORT | 07.19.2020

COLOR THRESHOLDS: Results for each indicator should be taken in context of the findings
for related indicators (e.g., changes in case incidence and testing volume)
Metric Green Yellow Red
New cases per 100,000 population per week <10 10-100 >100
Percent change in new cases per 100,000 population <-10% -10% - 10% >10%
Diagnostic test result positivity rate <5% 5%-10% >10%
Change in test positivity <-0.5% -0.5%-0.5% >0.5%
Total diagnostic tests resulted per 100,000 population >1000 500-1000 <500
per week
Percent change in tests per 100,000 population >10% -10% - 10% <-10%
COVID-19 deaths per 100,000 population per week <0.5 0.5-2 >2
Percent change in deaths per 100,000 population <-10% -10% - 10% >10%
Skilled Nursing Facilities with at least one COVID-19 case 0% 0.1%-5% >5%
Change in SNFs with at least one COVID-19 case <-0.5% -0.5%-0.5% >0.5%
DATA NOTES
• Cases and deaths: County-level data from USAFacts as of 13:00 EDT on 07/18/2020. State values are calculated by
aggregating county-level data from USAFacts; therefore, values may not match those reported directly by the
state. Data are reviewed on a daily basis against internal and verified external sources and, if needed, adjusted.
Last week data are from 7/11 to 7/17; previous week data are from 7/4 to 7/10.
• Testing: CELR (COVID-19 Electronic Lab Reporting) state health department-reported data are used to describe
state-level totals when able to be disaggregated from serology test results and to describe county-level totals
when information is available on patients’ county of residence or healthcare providers’ practice location. HHS
Protect laboratory data (provided directly to Federal Government from public health labs, hospital labs, and
commercial labs) are used otherwise. Some states did not report on certain days, which may affect the total
number of tests resulted and positivity rate values. Total diagnostic tests are the number of tests performed, not
the number of individuals tested. Diagnostic test positivity rate is the number of positive tests divided by the
number of tests performed and resulted. Last week data are from 7/9 to 7/15; previous week data are from 7/2 to
7/8. HHS Protect data is recent as of 16:30 EDT on 07/19/2020. Testing data are inclusive of everything received
and processed by the CELR system as of 14:00 EDT on 07/19/2020. Testing data may be backfilled over time,
resulting in changes week-to-week in testing data. It is critical that states provide as up-to-date testing data as
possible.
• Mobility: Descartes Labs. These data depict the median distance moved across a collection of mobile devices to
estimate the level of human mobility within a locality; 100% represents the baseline mobility level. Data is recent
as of 13:00 EDT on 07/18/2020 and through 7/16/2020.
• Hospitalizations: Unified hospitalization dataset in HHS Protect. This figure may differ from state data due to
differences in hospital lists and reporting between federal and state systems. These data exclude psychiatric,
rehabilitation, and religious non-medical hospitals.
• Skilled Nursing Facilities: National Healthcare Safety Network (NHSN). Quality checks are performed on data
submitted to the NHSN. Data that fail these quality checks or appear inconsistent with surveillance protocols may
be excluded from analysis. Also note that data presented by NHSN is more recent than the data publicly posted by
CMS. Therefore, data presented may differ slightly from those publicly posted by CMS.

30