Weekend COVID-19 Briefing

Top news, reports and insights for today:

  1. Curated headline summaries for Saturday/Sunday:
  • U.S. sees highest number of daily coronavirus cases since August raising fears this may be start of a “dreaded second wave”. (CNN)
  • CDC posts warning about added COVID-19 risk for those who are overweight. With Nearly 40% of American adults obese, this greatly expands the list of high-risk individuals. (Bloomberg)
  • Isolated hot spots have popped up in New York causing Governor Cuomo to close schools, nonessential businesses, banning mass gatherings and limiting houses of worship. Some hot spots are in areas where ultra orthodox Jews reside. On Friday, a U.S. district judge rejected a requested restraining order on the Governor’s restrictions made by Jewish groups (New York Times)
  • Results of a randomized clinical trial from Brazil show that COVID-19 with moderate or severe acute respiratory distress syndrome (ARDS) who were given intravenous steroids (dexamethasone) were less likely to die or need mechanical ventilation. This study adds to our confidence that steroids help reduce the chance of deadly hyper-inflammation linked to poor outcomes in ARDS patients (JAMA)
  • A RAND Corporation survey of U.S. adults found that alcohol use increased in terms of the number of days of drinking but not drinks per month during the pandemic. A key finding was that women (but not men) reported more heavy drinking episodes and more alcohol-related problems. This raises concerns that women may be more vulnerable to pandemic stress (JAMA Open Network)
  • President Trump claims he is “immune” to COVID-19. His doctors won’t say if he has yet had a negative test. Now, twitter has flagged the presidential tweet as misleading. It is. (Axios)
  1. U.S. daily COVID-19 cases spike to mid-August levels. Eleven states record new record high infections.
     On Wednesday, it wasn’t clear which way the trend was headed after a see-saw week. But on Thursday, daily cases shot up again to over 53,000, starting a three day run resulting in 162,506 cases reported (See Figure A). Figure B shows the growth factors for cases; compared to the previous week, new cases are rising in 43 of 51 states and DC. Especially rapid growth in new cases was reported in Alaska (+43%), Montana (+54%), New Mexico (+51%), Missouri (+44%), Tennessee (+50%), Washington DC (+72%), Pennsylvania (+64%), and Vermont (+103%). We have not seen such broad, across-the-board growth in cases since August. More striking, eleven states set new daily high case reports either Friday or Saturday including Alaska (249 daily cases), Montana (722), New Mexico (485), Wyoming (195), Indiana (1,918), Minnesota (1,516), Missouri (5,066), North Dakota (656), Ohio (1,734), Oklahoma (1,533), South Dakota (750) and West Virginia (353). That makes this one of the scariest daily case reports of the entire U.S. outbreak. The surge in cases has not yet translated to a rise in deaths (Figure C), however an upturn can be expected in the coming weeks. Last week we did see big jumps in weekly deaths in Colorado (+160%), Missouri (+139%) Alabama (+72%) and Pennsylvania (+51%).
    What does it mean: The last few days have been rough. Former hot spot states like Minnesota, Ohio and Missouri, along with seven other states reported the most cases of the entire outbreak. Cases are rising broadly in all regions and daily numbers break through the 50,000 ceiling again. This tells me we are at a vulnerable inflection point.
Figure A
Figure B
Figure C
  1. Test positivity rate (TPR): a positively good test for transmission intensity
     Over the past few months, I have gone back and forth between different data streams, each tapping into a different aspect of the epidemic. This reminds me of the parable of the blind men examining an elephant. Each has his hands on a different part of the same beast. Thus far, we have emphasized daily cases and deaths, and hospitalizations, graphed by state and region. Let’s zoom in on test positivity rate. TPR is a fairly simple statistic, although getting good data to measure it is anything but easy. Here we are again grateful to the COVID Tracking Project for the best available data. It is the percentage of all tests (with a definitive result) that are positive for COVID-19 infection. Most agree that we want this number to be 5% or lower, indicating that our testing regime is sufficient to identify a healthy fraction of all the cases, while 95% negative results tells us that the barriers to testing are low enough that testing is happening broadly and at sufficient capacity. In the early days, TPR was 40% and higher largely because we were only testing those hospitalized with COVID-19 symptoms and tests were in short supply. We have come a long way and our testing strategies and capacity have evolved.
     I set out to find a data source that would tell me the TPR just for the past two weeks, rather than the entire duration of the outbreak. This is, in my view, a better number for tracking change in transmission intensity. In states where the 2-week TPR is drifting higher, the virus is outstripping capacity, and causing surveillance efforts to fall further behind the eight-ball. I created Figure D below as a new tool to examine state-level variation in TPR in the last two weeks. Not surprisingly, the variation across states is huge. First the good news: out West, six states are keeping up nicely including Alaska, California, Colorado, Hawaii, New Mexico and Washington. To illustrate the value of this data stream, compare the findings in Point 2 above, where Alaska and New Mexico are seeing sharp rises in cases, however their TPRs remain low. Combining the two data streams, we look for states with the deadly combination of rising cases/deaths and high TPR. In the Midwest, Illinois, Michigan, Minnesota and Ohio are in good shape. In the South, that distinction is shared by only Louisiana and West Virginia. All but three Northeast states are in the green zone and none is over 8%.
     Now for the bad news: there are six states, two out West and four in the Midwest where TPRs have shot up past fifteen percent, or three times greater than the quality benchmark. Idaho (23%), South Dakota (23%) and Wisconsin (21%) are extreme with more than 1 in 5 tests coming in positive. All three states are reporting in excess of 30 daily cases per 100,000 population. They also vary in how much testing they are doing. Idaho, for example, is testing only 1.3 per 1,000, among the lowest in the nation and less than half the rate of Colorado (3.0 per 1,000). South Dakota is also at 3 tests per 1,000 residents but their TPR remains high due to explosive epidemic growth (as covered on Wednesday). Wisconsin, also white hot right now, is testing in the middle (2.2 per 1,000) and most likely continuing to fall behind. The maps of these three states show somewhat similar patterns (Figure E, from the Johns Hopkins Coronavirus Resource Center). Each state is a checkerboard of rural counties with very low case totals and a handful of counties in and near cities and towns with extremely high numbers. Tomorrow I will explore how many of these counties have colleges and universities in them.
     The bottom line: While the U.S. overall continues to hover around 5-6% test positivity rate (TPR), this hides tremendous state-level variation. There are now six hot spot states where greater than 15% of tests are positive indicating a mix of inadequate testing and high transmission intensity.
Figure D
  1. Quirky Qorner: 10,000 minks die of COVID-19 in Utah, foreshadowing coming shortage of luxury coats
     The Guardian is reporting on an outbreak of COVID-19 among mink in Utah where almost 10,000 have died prompting quarantines conditions among the state’s mink farms. The first U.S. case of COVID-19 in mink was found in Utah in August. COVID-19 has also been seen in mink populations in Wisconsin and Michigan. How many mink farms are there out there? All this apparently started when it was found that mink in Europe were infected by SARS-CoV-2 by their human handlers back in the Spring. In May, the first examples of animal-to-human transmission of COVID-19 outside of China was found when 2 people in the Netherlands were found to have contracted the disease from mink. Agricultural authorities in Utah are saying that mink-to-human transmission is “unlikely” and are trying to control the outbreak with quarantine measures. Meanwhile, a million mink have been euthanized in Netherlands and Spain. That’s what countries do who place public health above short-term economic gain.
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