Sunday COVID-19 Briefing

Top news, reports and insights for today:

  1. Daily headline summaries for Sunday:
  • U.S. tops 5 million confirmed COVID-19 cases as outbreak threatens America’s Midwest (CNBC)
  • Some Mississippi hospitals hit capacity with new COVID-19 patients (NBC News)
  • Testing dropping in half of U.S. states. Harvard Global Health Institute head, and trusted source, Ashish Jha says this shows ‘early cracks’ in a system overwhelmed by demand and not designed for this epidemic (Newsweek)
  • Ex-U.S. chief data scientist says misinformation on social media is killing public trust and is “life or death” (Axios)
  • Study of coronavirus patients isolated in a Korean treatment center shows that asymptomatic patients had levels of virus that were similar to symptomatic patients and for similar durations. This strengthens the evidence that asymptomatic patients can be as contagious as symptomatic patients and makes masks and social distancing even more important (JAMA)
  • Study finds that not all masks/face coverings are equal. In a controlled study, speaking while wearing a fleece neck-wrap was worse than no mask, and a bandana did almost as bad as wearing nothing (Science Advances, see figure below)
Figure A: From ScienceAdvances, August 7. Figure shows measured count of droplets passing through 14 tested masks compared to no mask.
  1. New cases have been steady for 6 days with high intensity in the South. U.S. deaths continue to surge
     U.S. new case totals have been steady this week (See Figure A). In the last 7 days, 365,000 new cases have been reported, a cumulative rise of 8%. That’s about 40,000 fewer weekly cases than were added the August 1. Looking at individual states (Figure B), the picture looks similar to what we saw last week. Eight of 12 Northeast states are under control (<5 new cases per 100K last week). None are over 10. However, the epidemic remains hot in the South where 9 of 13 states are seeing high transmission intensity with 20 or more new daily cases per 100K over the last week. Florida (+31), Georgia (+32) Louisiana (+38) and Mississippi (+33) are seeing especially intense transmission of >30 daily cases. The situation in Louisiana is especially alarming (See main point 3). Midwest states are seeing moderate transmission ranging from Michigan (+6.5) to Kansas (19.4). Western states continue to be inconsistent with heavy transmission intensity in Idaho (+27) and Nevada (+29), while rates are closer to being “in control” in Colorado (+7.5), New Mexico (+9), Oregon (+7.4) and Wyoming (+5).
    Over the last 5 days, the U.S. has seen 1200 or more deaths per day except for Saturday (1,109) (see Figure C). The states where deaths rose more than 20% last week include Illinois (+21%), Minnesota (+20%), Wisconsin (+44%), Arkansas (+30%), Mississippi (+22%), Tennessee (+42%), and Virginia (+86%).
    What it means: New cases appear to have peaked. Slowdowns and delays in testing dampen enthusiasm (see headlines). Deaths are holding steady at well over a thousand a day. The epidemic remains intense in the South and parts of the West.
Figure A
Figure B
  1. COVID-19 rates now highest in the South, Louisiana spiking to unseen highs, 4 states now exceed New York
     Let’s revisit the overall COVID-19 infection rates (or incidence) by state and region (Figure D). As a region, the overall attack rates have been highest in the Northeast until now. The West has an overall rate of 1,802 per 100,000 people, exceeding the northeast by nearly 200. Louisiana, a state that keeps getting hit by big waves of high transmission intensity has surged well past New York and will shortly pass the 3,000 rate barrier. Florida, Arizona, and Mississippi join Louisiana as the 4 states now with greater COVID-19 rates than New York, which in March seemed like the place that would never be matched by the ferocity of the virus’s impact.
    The bottom line: Is anyone else curious why the states in the South appear to have no interest in knowing what New York and New Jersey are doing to keep this virus under control?
Figure D
  1. A neglected consequence of the COVID-19 epidemic: people are not seeking or getting treatment for other serious diseases
     Way back on April 19, the Washington Post ran a story that caught my eye. The headline was “Patients with heart attacks, strokes and even appendicitis vanish from hospitals”. I have been thinking about that story ever since. Many of us have worried that the coronavirus epidemic would draw interest, resources and attention away from other life-threatening medical conditions and that this would lead to trouble down the line. On the other hand, there was a hope that the downturn in health care utilization for the usual things that kill people would be temporary. There was a hope that we would eventually establish a new rhythm and people would resume going to the dentist, seeing their doctor for check-ups, and going to the emergency room with broken bones and chest pain.
     Two important studies have come out recently that suggest things have not gone back to normal, raising further fears that American’s health will suffer later for care not sought now.
     The first study came out June 9 in the Journal of the American College of Cardiology. They looked at how the number of patients coming to 9 high-volume medical centers for treatment of one kind of heart attack changed before and after the pandemic. They found that after the the outbreak, patients coming in for treatment of heart attack fell by 38% (See Figure E). This matches the 40% drop seen in Spain. Given the stress of the epidemic, we might have expected more heart attack patients, not a third less. This raises concerns that people are avoiding seeking appropriate medical care for serious illnesses due to social distancing, fears of getting infected at the hospital, misinformation or a host of other reasons.
     A second study came out August 4 in JAMA Network Open and looked at the number of Americans with newly identified cancer before and after the pandemic. The number of new cancer diagnoses for a given month should be stable over time if patients are seeking care consistently. After COVID-19, the number of weekly patients getting diagnosed with 6 types of cancer fell 46% with big drops in all 6 types. The biggest drop (52%) was seen in breast cancer (See Figure F). Importantly, the drop in new cancer diagnoses leveled off around mid-March and hasn’t gotten worse. But it hasn’t gotten better either.
    Why this matters: We expected a temporary dip in patients seeking and getting care for killer diseases back in the spring when things seemed so crazy and COVID-19 was new. Heart attack is an acute crisis; patients know they are in trouble and need help. It’s possible patients are going to smaller clinics and community hospitals rather than the big medical centers in this study. We also know that when economic activity halts, the number of heart attacks might actually go down. Both could explain the first study. The finding in cancer is more troubling. There is no reason to think fewer people are getting cancer after COVID-19. The fact that we are finding far fewer cases tells us that cancer patients may be diagnosed later in the course of disease, which will lead to higher mortality rates.
    The bottom line: What these studies tell us is that 6 months into the epidemic, American’s are not getting screened, diagnosed and treated for heart disease, and cancer, diseases not directly caused by the virus, but top-killers that when not diagnosed and treated in a timely way, can lead to preventable deaths on a big scale. In the long-run, the possibility exists that SARS-CoV-2 will end up killing as many people because of disruption to our overall health care game than die of the virus itself. That’s a whole different sort of whack-a-mole.
Figure E: From Journal of Am College of Cardiology showing map of 9 high-volume centers and average monthly new activations of heart attack treatment protocols before and after COVID-19
Figure F: From JAMA-open network. Newly Identified Cancers, Baseline Mean and Weekly During the Coronavirus Disease 2019 Pandemic
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