Wednesday COVID-19 Briefing


Top news, reports and insights for today:

  1. Curated headline summaries for Wednesday:
  • New study finds since mid-May, U.S. has the highest COVID-19 death rate of any country with a large outbreak. Since June 7, U.S. COVID-19 deaths per 100,000 were more than twice the next highest countries (Israel and Sweden) and 6 times higher than Canada (JAMA, see Figure A below)
  • Sweden’s experiment to avoid shutting down is a “disaster” and should not be a model for the world (Time)
  • For the first time, the U.S. has now hired more than 50,000 contact tracers according to Johns Hopkins data. However, the push to grow a COVID-19 workforce is still less than half way to what experts say we need (NPR)
  • Harvard study finds that patients who survive severe COVID-19 infection retain high antibody levels for up to 4 months. This is as close as we can now come to President Trump’s unsubstantiated claim that he now has lifetime “immunity” to the virus (Daily Mail)
  • A 25-year-old man is now the first in North America to have a documented second infection with SARS-CoV-2. His second infection identified in June was more severe than the first found in April. The true extent of COVID-19 reinfection is not currently known (CBS News)
Figure A: Figure created by me based on https://jamanetwork.com/journals/jama/fullarticle/2771841
  1. U.S. daily cases continue to track upward, surges seen across all regions. Three Midwest states remain white hot and getting hotter
     As we move into a new week, the daily U.S. case data shows a continuing trend toward rising transmission intensity with the 7-day moving average lurching over 45,000 daily cases (Figure B). In the last week 340,470 cases were reported, the first time we have seen more than 300,000 weekly cases since mid-August. At my weekend briefing, cases were rising in all but 8 states. The numbers now look worse (Figure C); all but 5 states are now on the incline. There are numerous states in all regions where cases rose 20% or more week-over-week with the largest number in the Midwest: Iowa (+23%), Illinois (+41%), Indiana (+42%), Kansas (+26%), Michigan (+27%), Minnesota (+21%), North Dakota (+31%), Ohio (+26%), and South Dakota (+33%). The situation in the Dakotas remains especially alarming as things have gone from bad to worse. After weeks of very high transmission, both states saw new cases rise by more than a third. North Dakota added another 3,881 new cases raising its overall incidence rate to 3,706 per 100,000, second only to Louisiana. The largest weekly jumps in new cases actually happened in the West where Colorado (+41%), Montana (+63%), and New Mexico (+55%) are potential new hot spots.
     Switching to the rate of new infections, similar states stand out (Figure D). A week ago, North Dakota had 56 new daily cases per 100,000, now they are at 73. South Dakota, then at 47 is now 62. Montana jumped from 35 to 57 in a week. These are big increases in states that have been hot for some time. All but two Midwest states are now over 20 new daily cases per 100,000 and none are below the 5 benchmark. In the South, only Arkansas, Mississippi and Tennessee remain “hot”. The situation is holding steady in the Northeast although new cases are creeping higher in Rhode Island, now at 22 per day.
     The bottom line: The overall picture is toward rising cases across the board and in all regions. The Dakotas remain the hottest of the hot spots, followed by Wisconsin, and Montana. Thankfully, deaths have not yet started to rise appreciably but it is only a matter of time.
Figure B
Figure C
Figure D
  1. Is the current surge in U.S. cases due to flu? Not yet!
      I want to talk about influenza. There has been a lot of discussion lately about what we should expect given the impending rise of flu cases and what that will mean for the COVID-19 pandemic both in the U.S. and throughout the Northern hemisphere. Some people are suggesting that the kickoff of the flu season may be behind the recent surge in cases.
     I decided to go back and look historically at the time course of influenza in the U.S. in the fall over the last three years. Thankfully, the CDC has a great tool for this called interactive FLUView. It shows trends in influenza-like illness (ILI) across the U.S. by tracking patient visits to doctors with flu-like symptoms each week. Figure E below is my best effort to show you what the U.S. maps look like every two weeks from the middle of October till early January over the last three years. My goal was to answer a very simple question. When does the flu season really start to intensify? If it is late October, it might be true we are already seeing the impact of flu on COVID-19 numbers.
     Have a look at Figure E. There are at least 3 main lessons I take from this picture. First, it is exceptionally unlikely that the surge we are seeing now is the result of early flu activity. Over the last three years, the intensity coming in January through March won’t actually get started until somewhere between late November (last year) and late December (2018-19). The second thing that caught my eye was that flu-like illness intensifies first geographically in the Southeast and works its way north. I don’t know why but it is an interesting epidemiologic puzzle. I will be looking carefully at Louisiana, Texas, Alabama and Georgia as the states most likely to show early flu intensity. Third, last year was a high-intensity flu season months before COVID-19 was on the radar screen.
     The bottom line: It is hoped that with good vaccine uptake, mask wearing and social distancing, this year’s flu season will be less severe. If it is, COVID-19 will be more manageable. If, however, we drop the ball on flu prevention, the co-occurence of influenza and COVID-19 could create a double whammy of tremendous death and suffering.
Figure E
  1. Quirky Qorner: Cyberchondria! Social media and internet browsing are driving COVID-19 fear and anxiety
     I started reading this week about cyberchondria, defined on Wikipedia as the unfounded escalation of concerns about common symptomology based on review of search results and literature online. It’s a very pretty word for a not-so-pretty facet of the COVID-19 pandemic. We all like to believe that having access to more information at our fingertips is a good thing. More and more we are realizing that this is often not true. Researchers find that google search trends can actually predict where outbreaks are heating up. Now, a team from the Netherlands has published a study in the Journal of Anxiety Disorders. The study, based on a survey of 439 adults conducted in March, found that the coronavirus outbreak is causing fear and worry to increase. That’s hardly surprising. The interesting part is that even after controlling for other factors, time spent regularly looking up coronavirus information online, through social media and through regular media increased fear. You would think it is the opposite. Regular intake of social and traditional media heightened people’s fears rather than empowering them. Of course, that can’t apply to my blog. Right? Well in their analysis, looking up information on “professional” websites was not associated with increased fear! Whew!

Daily COVID-19 Briefing: Sunday

Top news, reports and insights for today:

  1. Daily headline summaries for Sunday:
  • New study from the South Korean CDC finds no evidence that “re-infection” cases resulted in a new secondary case. Crucially, they also did viral cell culturing in 108 such cases finding that all were negative. Taken together, this is the strongest evidence yet that getting infected a second time is not happening and that those who re-test positive are not passing the disease to others. The vast majority of these cases are test errors or a period of prolonged recycling of viral waste that cause a positive test result, not a true second infection in the same person (KCDC)
  • Social distancing measures aimed at COVID-19 have stopped influenza in its tracks 6 weeks early (Nature)
  • New study from China (not yet peer reviewed) examined 319 outbreaks in detail finding most occurred at home and on transportation. Importantly, they find evidence of only 1 outbreak that occurred outdoors. Study may provide important evidence of substantially lower risk of transmission outside (medRxiv)
  • CBS News and others have reported that CDC guidance has been updated to say that COVID-19 is “…not caught easily” from touching surfaces and that “…40% of transmission occurs before people feel sick”. I can’t find either of those statements on the CDC website (CBS News)
  1. Map check, 4 weeks later: the epidemic has shifted to places nobody notices or wants to talk about
    I am a map fanatic. I enjoy staring at them. It actually is a pretty useful fetish if you are a disease detective because the spatial patterning of disease is often among our most vital clues. I last showed you a U.S. map of incidence (confirmed COVID-19 cases per 100,000 residents) back on April 30, just under 4 weeks ago. I grabbed a picture from a similar map today from my colleagues at coronashutdown. Comparing the 2 maps tells us where we have been in recent weeks. Here are my take-home messages from this comparison:
    1. The epidemic has shifted from the east coast to the midwest, south and southwest.
    2. Epidemic radiation from last month’s hotspots can be seen from southwest Georgia all the way to Eastern Texas and Northern Florida, Southern New Jersey into Delaware and eastern Maryland, southern Utah and western New Mexico, the Texas panhandle, and Ford county in southern Kansas.
    3. New hotspot counties include (marked on map) Franklin Parish in Louisiana (1433), Liberty County Florida (2442), Duplin County North Carolina (927), Buckingham Co. Virginia (2560).
    4. Continuous corridors of higher infection can be seen along major transportation routes. Compare for example the area from New Orleans all the way to Chicago. Or note the increasing connection of high incidence counties going west from Chicago into parts Illinois, Wisconsin, Iowa, Minnesota and South Dakota.
    5. Ford County Kansas was a hotspot on April 30 at 2,088 per 100,000. That county has now more than doubled to 4,634, which is twice the rate of infection in the county containing part of New York City. The rates have gone to more than 1,000 in 5 surrounding counties.
    6. The bottom line: while many congratulate themselves on winning the battle against COVID-19, these maps tell us that what has really happened is that the epidemic has shifted to places nobody notices or wants to talk about.
  1. Severe illness similar to Kawasaki disease impacting children
    Recent articles in Science, the Lancet, and Nature have drawn attention to a rare and severe post-infection syndrome associated with coronavirus that is occurring in children. While children are at lower risk of severe illness during the pandemic, it now appears that a small number are becoming very sick with a condition that looks similar to Kawasaki disease – a rare condition affecting about 1 in 10,000 children in Western countries, characterized by a hyperactive immune response to viral infection leading to rash, fever, and dangerous inflammation in blood vessels (also called vasculitis). The disease named after a Japanese physician who was the first to describe it is associated with dangerous heart complications, most notably aneurisms. Hot spots for this newly recognized Kawasaki-like illness have been noted in Bergamo Italy and New York city. A study in the Lancet found a 30-fold increase in the incidence of Kawasaki-like illness in one region of Italy. New York state is investigating about 157 cases. Outbreaks have also been noted in the UK (where it was first noticed) and Los Angeles. Kawasaki disease is not new. It is generally assumed to be a post-viral syndrome involving an immune system “overshoot”. Currently, experts are not certain whether the outbreak of cases is Kawasaki disease or something similar. In Europe they are using the term paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS), or multisystem inflammatory syndrome (MIS-C) at the CDC. So far, children treated for MIS-C have had good survival, but when it occurs, it requires urgent and comprehensive medical intervention. The condition has been seen mostly in children under age 18 but is increasingly appearing in somewhat older ages. There is no certain diagnostic test for Kawasaki or MIS-C and more will be learned in the coming weeks.
    What this means? While it’s scary to think that we have to add very sick kids to the list of things to worry about, the disease detective in me believes at this point that the emergence of super-rare autoimmune reactions to a novel virus is an inevitable development in a disease impacting almost 5.5 million people. At this time, I do not believe this is cause for concern. Having said that, it is urgent that experts determine whether children and young adults with a previous history of Kawasaki disease should be considered at elevated risk for MIS-C.

Daily COVID-19 Briefing: 4/25/20

Top news, reports and insights for today:

  1. NEW FEATURE: Top headlines for today:
  • Older persons have different, atypical COVID-19 symptoms (Kaiser Health News)
  • FDA warns against anti-malaria drugs for COVID-19 promoted by President Trump (Business Times)
  • San Francisco thought they had 1918-19 “Spanish” Flu under control. Then it exploded after restrictions were lifted (NBC News)
  • Substance use disorders may be another high risk group for COVID-19 (Scientific American)
  • World Health Organizations warns that re-infection cannot be ruled out (Bloomberg)
  • New study shows promising anti-viral drug remdesivir is not effective against COVID-19 (Stat)
  • New study shows that as the case definition for COVID-19 changed in China, more cases were detected, highlighting importance of broadening the clinical indicators that should be considered (Lancet)
  • Experts emphasize that COVID-19 will be with us for months (Axios)
  1. Low agreement on U.S. Death totals
    Where do you look for information on the number of COVID-19 deaths in the U.S. and elsewhere? It should be straight forward to count deaths, even as we find increasingly that determining the fraction of Americans who are infected is a genuine hornet’s nest. According to WORLDOMETER, the U.S. has now experienced more than 52,843 deaths from COVID-19 as of noon today. Are we done? Not so fast. As the numbers grow, we increasingly see variation in the total death toll depending on where you look. The table below summarizes that variability as of noon on Saturday.
    What does this mean? This far into the epidemic, one might think that these discrepancies would be shrinking as we gain more experience, but that is not what we see. The average for these estimates is 47,500, but the standard error is a whopping 8,200 deaths! The high and low estimates disagree by 24,000. This means a couple of things: a) different reporting systems are not all using the same sources, b) CDC sites that use death certificates are so severely lagged that we shouldn’t be paying attention to them; c) whether or not a given reporting platform includes ‘probable’ deaths explains a big part of this discrepancy. It’s often difficult to tell what each site is doing with probable deaths. This is not a small issue. The New York Times data excludes over 5,000 probable deaths, and would be much more in alignment with the Johns Hopkins and Worldometer estimates if they were added. I believe that probable deaths should be included, because most probable deaths are people who died in hospitals (or outside hospitals) that had COVID-19 but weren’t tested or the test results were not available at time of death. Given the inadequacy of testing, particularly in hard-hit areas, it’s likely that the vast majority of “probable” deaths were COVID-19 infections. Add to this a false-negative testing rate of up to 30%, and the case for inclusion gets stronger. From a surveillance point of view, I am much more worried about undercounting deaths than over counting them.
Source:U.S. DeathsComments:
Worldometer52,843Highest estimate
World Health Organization44,053Only “confirmed” cases; source not clear
Wikipedia46,102State reporting, “probable” deaths not included
Johns Hopkins CSSE Dashboard52,782Confirmed & probable, CDC guidelines
CDC/National Vital Statistics System24,555Based on death certificates, severely lagged
CDC/Case updates48,816Includes some probable deaths + 4 US territories
Our world in data51,017ECDPC data
New York Times46,254Excludes 5,100 “probable” deaths in New York
European Centre for Disease Prevention and Control51,017Definitions not clear
COVID Tracking Project45,786Data from State public health authorities
Comparison of death totals across data sources as of 4/25/20
  1. Is COVID-19 worse than the seasonal flu? And other mass casualty events?
    Many people are still wrestling with the question of whether this disease is worth the hit our economy is taking. Isn’t this just like the flu? As states move toward re-opening, big questions emerge about whether we are over-reacting. All of this is understandable. But as Michael Osterholm recently said, we are in the 2nd inning of a baseball game. Take a good look at this new graph I spent the day making. I think it’s pretty impressive. This puts the COVID-19 death toll into a broader perspective. It says that by March 2, we had passed total U.S. deaths for Ebola. We passed SARS deaths around March 7. By March 28, we had exceeded the average deaths from influenza in March and April over the last 5 years. By April 6, we had more deaths than for all flu deaths in March and April for 5 years. By April 7, more people had died of COVID-19 in 5 weeks than all who died of 2009 Swine flu. And by April 21, COVID-19 had killed more Americans than died of influenza over the last 5 years combined. For further context, more us us died by April 10 than died in Ebola, SARS, Los Vegas shootings, the Gulf War, Hurricanes Andrew and Katrina, Swine flu, and the September 11 attacks. Combined.
    Bottom line: This is not like the flu