After much thought and consideration, I have decided for personal reasons to stop posting updates to this blog. For those of you who have found my work here to be informative, helpful, comforting or disquieting, please know that I greatly appreciate the kindness of your attention, and your feedback. It was my honor to contribute in what ever small way I could to the events of what was a truly extraordinary year.

Please stay safe and feel free to send me your thoughts and experiences.

With regard,
Thomas A. Glass, Ph.D.
Disease detective

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Top news, reports and insights for today:

1. Curated headline summaries for Saturday/Sunday:

• Top Story: The coronavirus variant first identified in the U.K. has been confirmed in the U.S. with cases reported in Colorado, California and now Florida. Dr. Fauci says he is “not surprised”, and I agree. The new variant (named B.1.1.7.) appears to be more contagious although this has not been confirmed. Whether it causes more severe disease remains unknown (CBS News).
• December was deadliest month of the pandemic, with over 77,000 deaths compared with 58,000 in April as the U.S. passes 20 million total cases (NBC News).
• L.A. County hospitals turn away ambulances, put patients in gift shop: ‘I’ve never seen anything like this’ (Los Angeles Times).
• Concern increases over slow rollout of COVID-19 vaccines. President Trump had promised 100 million Americans would be vaccinated by the end of the year. That number was lowered to 20 million shortly after approval. As of last Thursday, less than 3 million have been vaccinated (Slate).
• At least two California hospitals have diverted COVID-19 vaccines from front-line health workers to family members. This signals that drug diversion is most likely a common and unanticipated part of why vaccine rollout has been slow (Daily Mail).
• Up to half of health care workers are refusing the vaccine. While not true everywhere, 60 percent of nursing home staff in Ohio, between 20-40 percent of health workers in Los Angeles and about half of health workers in Riverside County California are saying no to a vaccine (Daily Mail).
• In just a few weeks, Israel has managed to vaccinate more than 10 percent of its population becoming the world leader. This shows what can be done with the right public health infrastructure and political leadership (Axios, See Figure A).

2. New record high daily totals set for cases yesterday and deaths on Wednesday. The Christmas slow-down is over.
    The Christmas reporting slow-down is over; daily cases spiked to their highest level yet yesterday soaring to over 250,000 (See Figure B). Weekly cases rose by 1.3 million, rising by 8.3 percent compared to the week before. Cases are rising broadly in 34 states (Figure C), led by surges in Connecticut (+74%), Rhode Island (+38%), Texas (+36%) and Washington DC (+32%). Cases also rose substantially in Kansas but the numbers are unreliable because that state is having data problems and consistently fails to report its numbers 3-4 days a week. The South and Northeast are again the regions to watch with rising states outnumbering falling states 10 to 2 in both.
    After 5 consecutive days of fewer than 1,500 daily deaths during the Christmas break, daily fatalities spiked to over 3,250 a day on Tuesday, then leaping again to a new record high of 3,572 on Wednesday (Figure D). This sent the 7-day moving average line back in an upward climb signaling the end of the Christmas reporting slow-down. Overall, deaths rose 19 percent last week compared to the previous week. The state pattern was similar to cases with weekly deaths headed higher in 31 states and in all four regions (Figure E). The largest jumps in weekly deaths were in Wyoming (+195%), Virginia (+169%) and Kansas (+124%). California saw deaths jump 53 percent recording more than 2,300 last week with a record 585 on New Years day. Similar to cases, deaths also increased strongly in Connecticut (+47%), and Texas (+21%).
     Bottom line: I had hoped the data were telling us that the virus may have finally peaked, while suspecting that the numbers were being driven by a slow-down in reporting rather than the virus. That now looks highly probable. Coronavirus keeps coming. Those currently exposed, infected, sick and dying won’t be helped by the vaccine.

3. 2020 is finally over. How did the U.S. do compared to other countries?
    Way back on November 20, I read an article in Mother Jones by the political blogger Kevin Drum. His piece was about how the U.S. stacked up to other countries in terms of COVID-19 mortality rates. He showed a graph plotting cumulative deaths per 1 million people across 15 counties (reproduced below as Figure F). He described the U.S. rates as about the middle of the pack. Sure enough, it looks like the U.S. was in the middle of the lines on the graph. I’ve been pondering this graph and his summary ever since. As 2020 is finally over, I thought I would take this opportunity to look back over the first 10 months of the U.S. response to the coronavirus pandemic and assess where we are and whether Mr. Drum is right that we are about “average” in our handling of the epidemic.
     In the field of epidemiology, we constantly run into what I call the “denominator problem”. The claim that the U.S. is middle of the pack depends on getting two things right: 1) the pack and 2) the middle. Both are quite problematic in this graph, making the overall conclusion shaky at best. I thought I would try to do better. Below is my attempt to address this question (Figure G). The first puzzle is to get the pack right. That means avoiding the tendency to select (or exclude) countries that don’t properly describe the whole pack (aka population of countries we want to compare). The Drum figure includes just 15 countries. To get the pack right, I chose all countries in the WORLDOMETER set of 222 impacted nations meeting 3 criteria: 1) greater than 5 million total population (to exclude smaller countries with non-comparable health sectors), b) countries with more than total 100,000 cases (to rule out some countries that don’t have the capacity to accurately track the epidemic), and c) countries that have done at least 100,000 total tests per million residents (to exclude countries that really have no way of knowing how much coronavirus they even have). Email me if you want details on how I chose these criteria. Figure G shows current cumulative COVID-19 deaths per million people ranked from worst to best for all 45 countries that met these criteria. The range of COVID-19 death rates is nothing short of staggering, from a high of 1,686 per million in Belgium to a low of 15 per million in Malaysia. That represents a 100-fold difference! We don’t see that wide a range for other diseases. The United Arab Emirates (UAE) is a particularly interesting case. With a population of just under 10 million, they have run 2 tests for every citizen for a testing rate of 2.1 million per 1 million people, just about tops in the world. Yet, they have only about 211,000 total cases and only 674 cumulative deaths. Given that level of testing, it is virtually impossible that their success is due to severe undercounting. More likely, aggressive testing has meant they have managed to control secondary transmission to achieve such a low death rate. The U.S. has the 8th worst COVID-19 death rate at 1,080 per million. Of these 45 countries, 37 have lower death rates than the world’s sole remaining “superpower”. That doesn’t sound like middle of that pack. The countries worse than us include less developed nations (Peru, Bulgaria and the Czech Republic) as well as countries hit early and hard when the case-fatality rates were much higher than they are now (Spain and Italy). I’m not sure anyone knows what exactly is going on in Belgium (topic of a future entry). The UK is also a strange case in many ways. The U.S. looks “average” in the Drum graph because most of the countries with low mortality rates aren’t included in the pack. That’s the denominator problem in a nutshell.
   Now let’s tackle the question of the middle. For that we need a number (not just our eyeballs) to describe the central tendency of this distribution. There are two options: the mean and median. Both are averages but any good disease detective knows to be cautious, especially when there is a big outlier value like Belgium in this case. I won’t bore you with more technical issues, but the best number to use here is the median, which for all 45 countries is 473 per 1 million (purple dashed line). The U.S. now looks very far from middle of the pack indeed, with a cumulative mortality that is more than double the “average”. Let’s say you don’t think some of the countries on this list should be compared to us. Maybe we can’t trust the death tally in countries like Jordan, Iraq, Morocco or Belarus. Ok fine, lets make another cut, looking this time at just OECD countries that met the first three criteria (blue bars). The U.S. has the 6th worst OECD mortality rate. That is more than double the death rate of Canada, Germany and Slovakia. Look at Israel, which vaccinated more than 10% of its populace in about 2 weeks and has a COVID-19 death rate that is a third of ours. Among OECD countries, the median jumps to 856 (blue dashed arrow), still considerably less than the U.S. rate.
    Bottom Line: I respectfully disagree with the conclusions reached by Mr. Drum in Mother Jones. It all depends on getting the right middle of the right pack. Now consider this: if the U.S. response to the COVID-19 pandemic had been average, fewer than half the total cumulative deaths (over 350,000 from lab-confirmed infections) would have occurred and nearly 200,000 dead Americans would now be alive.

4. Quirky Qorner: French snails farmers lament sluggish year as COVID crisis dents sales
     Yep, I copied the headline right from the article in yesterday’s Guardian (including the word ‘sluggish’). In France, snail farmers (aka heliciculteurs) depend on Christmas for up to 70 percent of their annual business, thanks to the fondness the French possess for the curly beasts as a holiday hors d’oeuvre. Seems that with COVID-19, business has slowed to, um, a snail’s pace.