Friday COVID-19 Briefing

Top news, reports and insights for today:

  1. Daily headline summaries for Friday:
  • Data shows signs the epicenter of the coronavirus epidemic may be shifting to the Midwest on Thursday while Sunbelt states saw new infections begin to decline while cases rise in Ohio, Kentucky, Tennessee, Missouri, Kansas and Nebraska (Reuters)
  • The Trump administration abruptly required hospitals to stop reporting COVID-19 data to CDC and use a new reporting system set up by a contractor. That system remains plagued with delays and inaccuracies. Hearings and investigations now underway (NPR)
  • Scammers are making millions selling bogus dietary supplements to treat and prevent COVID-19. NPR found over 100 supplements listed for sale on Amazon that make unsubstantiated and potentially illegal claims that they fight viruses. These include products sold by a company recently sued by the Department of Justice over fraud allegations related to COVID-19 (NPR)
  • African-Americans are known to suffer disproportionately from COVID-19 in many ways. A recent study in 5 hospitals in Baltimore/Washington from March to May shows that Latinos had test positivity rates 5-times higher than whites and double that of blacks. The Latino community needs greater attention (JAMA)
  1. New daily cases remain flat but “bouncy”, 3 states pass New York for cumulative rates of COVID-19; new case growth pops up in Northeast and Mid-west
     On Tuesday I noted that new daily cases seemed to have flattened. That trend has largely continued this week, although numbers have fluctuated substantially (See Figure A). The U.S. added 442,658 new cases last week, a rise of 11% in total. Over the last 3 days, new record high daily cases were set in Hawaii (124), Missouri (2,084) and Mississippi (1,775). Figure B shows the 1-week growth factors for each state indicating the ratio of new cases this week to the week before. They show something important and unexpected. Our attention has been on the Sunbelt states where the epidemic has been surging. For the first time in weeks, we see bigger hikes in new cases in the Northeast and Mid-west while cases declined in 6 Southern states. Connecticut added a startling 1,438 cases, tripling the previous week’s total. New Jersey also saw new cases more than double, prompting Governor Murphy to update quarantine advisories issued for travelers from 3 new states, Puerto Rico and Washington DC. CBS News in New York is reporting that New Jersey hospitals are bracing for a surge of new cases. New cases also rose by 20% or more in Massachussetts (+22%), Maryland (+23%), New Hampshire (+26%), and Rhode Island (+84). In the Midwest, Missouri (+53%) and Oklahoma (+72%) saw the largest spikes. Michigan (+20%), Minnesota (+14%), Nebraska (+16%) and South Dakota (+21%) all saw new cases rising. In the West, big increases were seen in small states as new cases surged in Alaska (+37%), Hawaii (+280%) and Montana (+33%).
     Figure C updates us on the overall rates of COVID-19 cases at least for that subset captured in our testing. A couple of months ago, it looked like no state could possibly catch up to New York. Now three states have a higher overall rate of cases per 100,000: Louisiana now has the highest (2,463), followed by Arizona (2,347) and Florida (2,148). As a region, the South now nearly matches the Northeast at 1,560 per 100,000 (compared to 1,582). In the South, only Kentucky and West Virginia have kept rates below 1,000 per 100,000, a feat also matched by 7 of 13 Western states and 10 of 13 Midwest states.
     The bottom line: While the flattening of new cases is good news, the whack-a-mole continues as falling new cases are offset by brush fires of transmission intensity breaking out in previous hot spots. Key factors appear to be lax social distancing associated with vacation travel and people staying indoors to avoid the heat.
Figure A
Figure B
Figure C
  1. U.S. COVID-19 deaths pass 140,000; daily totals continue to rise
     On Thursday, 1,231 Americans were reported dead from the SARS-CoV-2 virus. This caps a four-day run of more than 1,000 daily deaths and continues a trend of rising mortality that started around the 4th of July (see Figure D). The U.S. reported over 7,500 deaths last week, a cumulative rise of 6%, which is double the 3% rise seen the week prior to July 26. In all major data tracking sites, the U.S. has now exceeded 140,000 deaths. The U.S. remains the nation with the largest death total with more than twice that of the next two highest countries (Brazil and the UK) combined. Figure E shows the states that rose the most last week compared to the week before. As always, states with fewer than 25 weekly deaths are shown with a patterned bar since the ratios of two small numbers tend to be unstable. As expected, the most consistent region is the South, where despite an apparent peak in cases, deaths continue to surge. Weekly deaths rose by 20% or more in Arkansas (+24%), Florida (+27%), Georgia (+21%), Kentucky (+38%), Mississippi (+37%), North Carolina (+28%), South Carolina (+27%), Texas (+183%) and Virginia (+175%). Deaths spiked particularly in Kansas (+456%) and Delaware (+500%) although the absolute numbers are smaller. Deaths were on the rise significantly in Ohio (+22%) and Oklahoma (+51%) but fell in Illinois, Michigan, Missouri, Minnesota and Wisconsin. In the West, deaths rose in California (+29%), Idaho (+63%), Oregon (+79% and Washington (+49%) while holding steady in Arizona for the first time in several weeks.
     The bottom line: Consistent with the lag between infections, testing, and mortality, the summer surge in cases is now resulting in a rise of COVID-19 deaths. Importantly, we are still significantly below the peak of 2500+ deaths a day seen in April in May despite vastly more cases. This is because of the doubling of testing. While we were capturing approximately 10% of the total number of actual infections occurring in the population in May, we have now roughly doubled the number of daily tests from 40,000 a day to around 80,000 (see Tuesday’s blog). This expansion of testing as lowered the TPR from 10% to 8% allowing us to capture closer to 20+% of true infections. All this suggests that the overall mortality rate is likely fairly stable. The reality is that we had far more cases of active infection occurring in April and May than we knew – like 10-times more. The best performing model by Youyang Gu and colleagues, suggests that new infections in the U.S. peaked around July 16 and that deaths are projected to peak at just over 1,100 a day around August 13. We will see.
Figure D
Figure E
  1. Two timely and important studies released about the role of schools: reopening this fall carries unavoidable risks
     Here we are in the middle of the strangest summer of our lives. Now is the time people are thinking about the Fall and what it will mean for schools. Should they reopen? Should they stay closed? Is online training even worth it? Why not let the kids go back to school given that they don’t seem to be getting very sick. I want to make you aware of two important and timely studies that have come out that bear on this issue and should be kept in mind as we lurch toward the Fall.
     The first study was published July 29 in JAMA by Katherine Auger and colleagues from Cincinnati. They looked at whether there was a relationship between the timing of state-wide school closures and COVID-19 infection and death rates across all 50 states in the period from March 9 to May 7. The analysis they did was a bit complicated but their approach was very solid. They found that state-wide school closures were associated with a 62% reduction in weekly cases and a 58% lower weekly rate of deaths. This doesn’t prove causation, but it suggests that despite the fact that school-age children are not the ones at highest risk of sickness and death, shutting down schools may have a substantial impact on the overall risk in the community. Children can be conveyors of disease directly by transmitting to more at risk groups. In addition, through the patterns of interaction and mixing that school requires, transmission intensity can increase among all age groups because of the increase in overall interactions in and out of school.
     The second relevant study came out in Eurosurveillance on July 21 and was done by researchers affiliated with the Jerusalem District Health Office in Israel. (Note: I apologize if either of these links are behind a firewall. I can’t tell. Let me know if they are and I can post the article). This study looked at what happened when schools were reopened on May 17 after being closed across the country in Mid-March. Considerable planning went in to the reopening plan; daily health reports, hygiene procedures, facemarks, social distancing and minimal interactions were all required and put into place. Disease detectives were put on stand-bye to monitor the situation. Despite these efforts, ten days later, the first significant outbreak occurred in an Israeli High School. After an official outbreak declaration, mass testing and contact tracing was undertaken. Overall, 153 students and 25 staff members were confirmed to be COVID-19 positive, yielding an attack rate of 13% in students and 17% in staff. This outbreak appears to have started from 2 initial index cases not related to each other that sparked the larger outbreak.
     What do these studies mean? In thinking about what we should do as a nation, these studies suggest two tentative conclusions, recognizing that we are only looking at 2 imperfect studies when we would like to have 200. The first is that open schools can increase the risk for entire communities, not just the students in those schools. We have good evidence that school closures were a vital tool for controlling the spread of influenza in 1918-1919. Cities that reopened schools suffered a worse fate than those that closed schools early and kept them closed. But coronavirus is not influenza and we are tempted by the fact that children seem to be at lower risk. But the JAMA study tells us that what happens in schools, doesn’t stay in schools. Returning to classrooms invites greater chance of community-wide transmission, leading potentially to higher rates of hospitalization and death. The second study warns us that even with the right planning and the best available epidemic control measures in place, outbreaks can happen in school settings and happen fast. Testing, monitoring and social distancing do matter and they do help, but the school environment is to some extent an unavoidable petri dish for infectious disease transmission.

Daily COVID-19 Briefing: Thursday

Top news, reports and insights for today:

  1. Daily deadline summaries for Thursday:
  • U.S. daily coronavirus case count crosses 50,000 setting a single day record as some states reverse course on reopening and hospitals were hit by a surge of patients (Wall Street Journal)
  • Experts suggest a plastic face shield, if properly fitted and warn, has advantages over cloth masks for use by the public and should be used more widely (JAMA)
  • The American Academy of Pediatrics issues guidance in favor of reopening schools in the fall. Guidance stresses that children do not appear to be driving the epidemic, are less likely to be infected than other respiratory illnesses and that in-person education is better than online teaching (American Academy of Pediatrics)
  • Italian researchers studied nearly all residents of one town before and after lock-down. Main results were that 40% of those infected never developed symptoms. None of the children in the study became infected. Those with and without symptoms did not differ on viral load. Half of those infected had cleared the virus 2 weeks later. The lockdown was very effective at halting transmission (Ars Technica)
  1. U.S. enters new dangerous phase, smashing previous daily high record new cases, decline in deaths stops
     I have said for months that a return of widespread community transmission with Rt>1 was inevitable by July 1 given that states reopened recklessly. However, the ferocity of the resurgence in cases has caught me and many experts off guard. I apologize for showing you 4 different graphs for today’s briefing, but the story they tell is chilling. The first graph is our usual epidemic curve of new reported lab-confirmed COVID-19 cases by day. A record high 52,554 new cases were reported yesterday, the first day with more than 45,000 cases and 16,000 more than the peak set in late April. For the first time since the epidemic, the U.S. reported more than 300,000 new cases in one week. In just 7 days, the U.S. reported more infections than were accumulated from the start of the epidemic until April 4. The U.S. now has more than 2.6 million reported cases, 26% of all cases on the planet and twice as many as Brazil, still ranked second.
    Deaths flatten: The second graph shows daily deaths. This remains a mystery. The 7-day moving average has been falling since Memorial day. In the last few days, that decline looks to have stopped. Yesterday, Arizona, a state on the front edge of the case surge, reported a spike in deaths with 88, a rise of 100% from the previous day. Arizona, Iowa, Oklahoma, South Dakota, Kentucky, Texas, Virginia, and Rhode Island, all have seen deaths rise by 20% or more in the last week. I believe we will see deaths rising sharply in the states where cases first started surging.
    Cases increased last week in all but 3 U.S. states: The next graph shows the weekly growth factors by state. Nationally, the U.S. had it’s first week with 300,000 new cases. Astonishingly, the growth factors for last week compared to the week before are >1 in all U.S. states except Rhode Island, New Jersey and the nation’s capital. Weekly cases rose by 50% or more in Alaska, Idaho, Montana, Kansas, Florida, Georgia, Louisiana, Mississippi, and Tennessee.
    13 States reported more than 15 new daily cases per 100,000 population last week. The last graph shows the rate of new daily cases last week. Arizona continues to be the most extreme, now reporting more than 47 new cases per 100,000 every day. That is the highest rate we have seen anywhere at any point. In the South, 9 of 13 states are above this mark, which is 3-times higher than the 5 cases per day per 100,000 benchmark for low transmission. Florida, Georgia, Louisiana, Mississippi, South Carolina and Texas are all over 20. Only 1 Northeastern state is over 5.
    The bottom line: The U.S. epidemic is out of control with no end in sight.
  1. U.S. capturing about 2/3 of the true number of COVID-19 deaths
    We already know that deaths from COVID-19 are undercounted for a variety of reasons. We also know that an accurate tally of the death toll is very important. As I have emphasized here before, our best tool for understanding the true mortality picture is to examine deaths from all causes using the best available data and comparing the numbers from 2020 to previous yearly averages. This allows us to capture excess deaths above what is expected in a “normal” month taking seasonal variation into account. It’s not perfect, but it is closer to the truth than our current count. Previous studies using similar methods have found that the ascertainment rate (% of true COVID-19 deaths that are counted) is about 50%. Over time, we hope that will improve. Yesterday, a new study was published by my former colleague and friend demographer Steven Woolf and in JAMA that adds important new information. They used a state-of-the art model to estimate total excess deaths that are probably COVID-19 related. This includes cases where COVID-19 is mentioned on the death certificate, but also more indirect causes. They specifically examine rises in deaths above temporal trends in past years that may reflect those who died because they didn’t seek care for existing problems, had exacerbations of chronic diseases, or may have succumbed to secondary distress (e.g., drug overdoses). Their main finding is that in the 8-week period from March 1 through April 25, about 65% of the excess deaths likely related to COVID-19 were actually counted as such. That means, the remaining 35% of deaths were not counted. The 5 states with the most COVID-19 deaths experienced large proportional increases in deaths from non-respiratory underlying causes including diabetes (96% increase), heart disease (89%), Alzheimer disease (64%) and cerebrovascular disease (35%). New York City, which reported the highest number of COVID-19 deaths, saw a 398% rise in the number of heart disease deaths. The graph below, taken from the paper, shows that in the 5 hardest hit states, a significant jump in deaths can be seen in March and April of this year for heart disease, diabetes. Smaller but still substantial increases happened for stroke and Alzheimer disease as well. Diabetes deaths rose from 40% to more than doubling depending on the state.
    The bottom line: The true number of COVID-19 deaths is probably about 1/3 higher than our current numbers suggest. If true, the U.S. now has an estimated 177,000 deaths rather than the official count of 131,000. Significant numbers of people are dying of non-respiratory manifestations of SARS-CoV-2 and are not being counted. States vary widely in the accuracy of their counts.
From Woolf et al, JAMA Published online July 1, 2020. doi:10.1001/jama.2020.11787

Top pick of the day: Friday

How the virus won

Graphically intensive moving-picture presentation of the U.S. COVID-19 epidemic seen from above by Derek Watkins, Josh Holder, James Glanz, Way Can, Benedict Carey and Jeremy White, posted online at the New York Times, June 25, 2020.

If you ever think about the big-picture of how we got to this moment in the U.S., what we did wrong as a nation and how things went so badly, take 10 minutes to walk through this fascinating timeline of events for a 50,000-foot view that provides some deep and troubling lessons.

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.