Today’s bite-sized, handpicked selection of important news, information or science for all who want to know where this epidemic is going and what we should do.
- COVID-19 cases spike in Maryland, African Americans bear disproportionate burden
Today, I want to focus attention on my home-state of Maryland. Not only is it my backyard, but the story here provides useful clues about what is happening elsewhere. The number of new cases leapt by 1,158 on Wednesday, more than doubling the previous daily high. That was followed by a 12% rise today (656 new cases). Cases have risen by 53% in the past 3 days for a total of 6,185 or 1.5% of total U.S. cases. The distribution of cases across Maryland is extremely uneven, suggesting both that population density and in-state travel and commerce matter. As the insert graphic shows, two of Maryland’s counties, both bordering the DC area have more than 1,000 cases, while counties in Western and coastal MD have single-digit numbers. Combined, Baltimore City and county have a state-wide high of 1,617 cases, showing that the epidemic spreads extensively in and around cities. In hard-hit Montgomery county, the epidemic has wreaked havoc in nursing homes. As reported in the Washington Post, 10 of the county’s nursing homes have reported cases. Supplies of PPE have been inadequate in area nursing homes as masks, gloves and tests have been redirected to hospitals. A key challenge has been inadequate testing kits. Even as reported cases spike, it is likely that insufficient testing means the magnitude of the outbreak in nursing homes remains under-estimated. Importantly, Maryland today begins reporting race/ethnic breakdown in cases and deaths. African Americans, who make up 30% of the state’s population, are a disproportionate 49% of cases among the 75% of confirmed cases for which race/ethnicity information is available. The Baltimore Sun today reported (erroneously) that blacks were “nearly 40%” of deaths. I checked these numbers and blacks represent 54% of the deaths for whom race is known. Maryland has acknowledged the number of cases in it’s prisons has tripled in the last few days with 57 new cases.
What this all means? Maryland is a candidate to be among the next hotspots with large case rises in recent days. Within the state, big cities and their surrounding communities make up intra-state hotspots. Blacks suffer disproportionately in infections and deaths. Women outnumber men in infections but more men have died. Prisons and nursing homes remain critical areas of vulnerability where lack of staffing and resources threaten to add fuel to the fire.
- Tourist destinations in the U.S. were sitting ducks for the pandemic
Yesterday, I suggested that Europe become the epicenter of this pandemic in part because, as a top tourist destination, travelers imported the disease in the weeks before we were aware of its potential to turn pandemic. A story in the New York Times by Carl Zimmer supports this line of thinking. The article reports on new research indicating that, based on genetic studies, the majority of cases in New York came from Europe and were probably circulating by mid-February, weeks before the first confirmed case. While U.S. officials barred visitors from China on Jan. 31, it wasn’t till mid-March that travel restrictions were imposed on flights from Europe. By that time, the seeds were already planted for explosive growth in New York by travelers from Europe who were oblivious to the fact that they were bringing the virus with them.
What this means? Just as it appears that heavy tourist traffic created a vulnerability that made Europe the epicenter of the pandemic, in the U.S., the virus exploited similar mixing dynamics that insured the most visited places here would be the hardest hit. High-intensity outbreaks in California, Seattle, New Orleans, Washington DC, and New York were seeded by early travel before the threat was known.
- Not just China: Evidence shows that COVID-19 deaths are severely under-counted in several hard-hit countries
A story in New York magazine by James Walsh on April 4 digs into the problem of undercounting COVID-19 deaths. It’s a sobering account of why in countries like Italy and Spain, determining peak cases and deaths will be very challenging. We know that there is under-counting for many reasons. Increasingly, researchers are using creative ways to estimate the extent of the problem. A powerful tool comes from examining non-coronavirus deaths compared to expected deaths based on previous years. In Spain and Italy, reports show excess deaths have been rising dramatically and that COVID-19 accounts for as little as a quarter of this rise. Examining “excess deaths” from all-causes offers a potentially more accurate accounting. The graph below is from a publicly available report of death surveillance in Spain. The graph shows that starting around March 10, daily deaths rose dramatically, peaking on March 23 at over 2,100. About 1,100 daily deaths were expected, meaning there were about 1,000 excess deaths in Spain on that day. The official COVID-19 death count on March 23 was only 539. That suggests that the actual death toll could have been double what was officially reported. Many factors contribute to undercounting. What we know is that deaths occurring in prisons and nursing homes are often not included. The official tally of COVID-19 deaths rose 40% when France added nursing home deaths. Deaths in those suspected of COVID-19 without a positive test aren’t counted either (this remains CDC policy in the U.S.). False positive tests exacerbate the problem. Routine deaths from heart or lung diseases that would not happen without the additional burden of COVID-19 are another source. It makes sense that systems that are overwhelmed with caring for very sick patients don’t make testing everyone a top priority.
What this means? Both deaths and cases are doubtlessly being undercounted, potentially by large numbers. Surveillance of all-cause mortality offers a valuable tool to address under-counting. Existing surveillance systems, however are also suffering from resource shortages, leading to significant lag in our ability to track the pandemic. All this means we must be cautious about declaring a peak in places that are hardest hit by the epidemic.