Daily COVID-19 Briefing: Saturday


Top news, reports and insights for today:

  1. Daily deadline summaries for Saturday:
  • U.S. posts largest single-day jump in new COVID-19 cases. Downward trend seen in only 2 states (CIDRAP News)
  • Huge daily jump pushes global COVID-19 total past 10.5 million (CIDRAP News)
  • In contrast to recent messages from the White House, CDC Deputy Director says coronavirus is spreading too quickly to contain, calling for an end to wishful thinking (Axios)
  • White house drug policy office analysis shows an 11.4% year-over-year increase in drug-related fatalities in the first 4 months of 2020 as lockdown, anxiety, economic uncertainty and stress combine to amplify the challenges faced by those battling addiction (Politico)
  • Texas Medical Center hospitals go into phase 2 surge plans as patients requiring intensive-care beds now exceeds 100 percent of capacity (Houston Chronicle)
  1. Cases rose last week in all but 3 states; new daily highs set three days in a row
    Another day, another record high reported new cases in the U.S. as a staggering 57,000 infections were added to the total. Friday caps a three day run of new records each day. The bottom graph shows just how widespread the surge has been across the nation. It shows that the growth factors (ratio of last week’s cases to the week before) are >1.0 for 48 of 50 states and the nation’s capital. Only Arkansas, New York and Vermont had steady of falling cases. An astonishing 7 states saw cases rise by 10,000 or more in 7 days: Arizona (+25,400), California (+47,774), Florida (55,634), Georgia (+17,498), North Carolina (+11,423), South Carolina (+11,150), and Texas (+45,908). Ten states saw weekly cases rise 50% or more compared to the week before.
    What it means: The epidemic is raging across the country. We are returning to a period of near exponential growth. This is a critical moment in the pandemic in the U.S. where a clear strategy is needed and hard choices must be made.
  1. Double deja vu: Arizona and Florida are repeating the rate of growth seen in New York during the first peak
     Remember back when it looked like coronavirus was going to be a big deal in New York, but not elsewhere? That was about 100 days ago. Many Americans believed that the epidemic was a coastal thing, having first hit the left edge, then hammering the right. The nation shook its head watching cases skyrocket in New York city and state. Good thing we aren’t there, said many. Must be all the immigrants, the subway, or high population density. Of course it was those things, but it was only the first inning of a long baseball game. We collectively breathed a sigh of relief when the wave of cases in New York finally started to fall, and for a time, it looked like the first was over. The disease detectives weren’t convinced, but the nation wanted to believe that the worst was over. It was time to start getting back to normal. A hurricane had come through, damaging the northeast extensively, but the skies seemed to be clearing.
     Over the last week. I keep having the same conversation with different people. It goes something like this: you know Tom I heard what you were saying, that this is a marathon and not a sprint, that cases would surge again when we stopped social distancing, and that we were in this for the long haul. But, I just didn’t want to believe it. I just hoped that you were wrong. I really wanted the things we did to work and for all this to just go away. I get it. I really do. It’s not been fun to be the bearer of unwanted news and information.
     As I reflect, it seems that America has always been a can-do nation, able with enough resolve and our boundless innovative capacity, to handle any problem. Mother nature, we seem to believe down deep, won’t get the better of Uncle Sam. The forces of nature at play are certainly no match for the indomitable spirit of American resourcefulness! Call it wishful thinking, call it can-do spirit, call it mass denial, the truth is that nature is winning and we are falling further behind by the day.
     On this particular 4th of July, there are reasons for hope. That American spirit is alive and well and capable of great things. Deaths are low right now, partly because we have learned how to keep the sick alive. We are making progress toward a potentially effective vaccine at record pace. States and cities are experimenting, pivoting and reassessing. But on the nation’s birthday, my message is simple. We need to wake up and realize the reality of this situation. The virus is winning in the U.S. and we must face the reality that this will be a long and continuous battle until we get to herd immunity, which remains a long way off. If you still think this is extreme, alarmist thinking, please look at the graph below. This visualization is from 91-DIVOC and shows daily cases per 1 million population by U.S. States on a common time scale. The orange line is New York. The blue and green show that what we are seeing now in Florida and Arizona looks like a repeat of the story seen in New York 100 days ago. Double deja vu. Whack-a-mole strikes again.
Screen grab from 91-DIVOC: http://91-divoc.com/pages/covid-visualization/

Daily COVID-19 Briefing: Monday


Top news, reports and insights for today:

  1. Daily deadline summaries for Monday:
  • Exponential increase in COVID-19 cases continue in Florida as local leaders attempt to crack down on people and businesses. Evidence mounts that recent surges have been mostly among young people (CBSNews)
  • Hospitals are gaining new knowledge about how to combat COVID-19 in patients by sharing information and trying new strategies. One promising approach involves using old treatments to address blood clots (Scientific American)
  • Oxford university researchers have begun testing their vaccine in Brazil and other hard-hit countries to evaluate potential efficacy (BMJ)
  • New poll says 64% of adults believe the CDC mostly gets the facts about the outbreak right; 30% say the same about Trump and his administration. A rising fraction of both Democrats and Republicans now say the epidemic is exaggerated (Pew Research Center)
  1. U.S. now in exponential growth of daily cases, fastest rate of increase since the epidemic began. Does anyone care?
    The U.S. has exceeded the highest previously recorded daily total cases in each of the last 5 days. We are used to seeing significant drops in reported cases on Sunday and Monday for each week since March due to reporting lags (darker blue bars). Astonishingly, the Sunday and Monday reports are still higher than any day that occurred during the first “peak” in late April. Not only are cases rising past that first peak, it is now more evident that it’s rising exponentially. For a clearer view, see the bottom figure showing the total accumulating case totals for the U.S. since March 1. The tell-tale sign of exponential growth is the curvature in the rise in cumulative cases, evident here in the last two weeks. For further context, consider the time it takes to arrive at each 500,000 case plateau. It took 40 days for the first half million cases to be reported. Then, the first peak arose as it took just 19 days to hit 1 million cases. After lockdowns, the pace slowed; it took 21 days to get to 1.5 million and 24 days to reach 2 million. However, the next 500,000 cases have come in just 17 days, the shortest interval yet.
    The bottom line: The U.S. is back to where it was before lockdown, with sustained and widespread community transmission resulting in exponential growth of the epidemic. Cases are now rising in 37 states.
    Are we growing numb to the reality?

Daily COVID-19 Briefing: Friday


Top news, reports and insights for today:

  1. Daily deadline summaries for Friday:
  • Florida just reported nearly 9,000 new daily cases, a record high, bringing the state’s total to 122,960. This is almost 4,000 more cases than the 5,004 reported yesterday (CNN)
  • Both Florida and Texas moved to close bars on Friday after cases exploded in those states. Florida’s Governor left it to the Secretary of Department of Business and Professional Regulation to tweet the announcement. The Texas governor followed suit reinstating some restrictions on dine-in restaurants (NBC News)
  • Top doc “Uncle Tony” Anthony Fauci said today that the White House coronavirus task force is considering the need for a new testing strategy, admitting that the current approach is not working (CNN)
  • It’s more clear than ever that medical workers should be using N95 respirators, not just regular masks. While production has ramped up, shortages remain. N95 masks were designed to be single use. Researchers have now shown an effective method of decontaminating N95 masks using steam and a microwave in just 3 minutes (FastCompany)
  1. Zooming in on weekly growth-factors: key trends in deaths and cases by state
    Every detective has to decide which clues to pay attention to and which to ignore. A good detective will often pay attention to details others miss. This is just as true for disease detectives. While most people are watching case and death totals by day, I watch 1-week growth factors. If you have read my blog you may recall that these are important metrics to gauge recent trends. They tell us how fast the epidemic is moving in a state right now. Below are 7-day growth factors for cases and deaths by state, showing the ratio of cases/deaths in the last seven days and the 7 days before that. For example, 1.5 means there were 50% more cases/deaths last week compared to the week before. In contrast, 0.6 means there were 40% fewer cases/deaths last week. We know that deaths keep falling even as cases are surging. That’s a mystery. What do these growth-factors tell us?
    For cases, outbreaks have slowed in all Northeast states except Delaware (1.22) and Pennsylvania (1.21) where cases are rising. Numbers are too small in Vermont. That, by the way was the only state in the U.S. with fewer than 50 new cases last week. In contrast, growth factors are >1 (cases are rising week-over-week) in all western states, all southern states except Alabama and 9 of 13 mid-west states. While everyone is watching headline states like Arizona, Florida and Texas, the bigger picture is that cases rose by 10% or more in an astonishing 32 states. Idaho spiked the most with 1,122 new cases last week, up from 441 the week before. Arizona (+19,587), California (+34,472), Montana (+148), Nevada (+2,783), Michigan (+1,688), Missouri (+2,518), Florida (+28,092), Georgia (+10,183), Mississippi (+3,875), and Texas (+32,066) all saw weekly cases jump 50% or more.
    Deaths were more volatile despite the overall falling trend. Delaware stands out after reporting 43 deaths last week, more than triple the previous 7 days. Arizona (+219), Kansas (+14), Alabama (+79), and South Carolina (+70) all saw deaths rise by 50% or more last week. Falling deaths in states where cases are surging still begs for an explanation.
    Bottom line: The virus is spreading fast in 32 states, not just the few in the headlines, with trends indicating a return to exponential growth in some. Deaths remain a mystery. It may be the calm before the storm. Few expected the U.S. to be back to the April peak as we head into the heart of summer.
  1. Dark times in the sunshine state: a deep dive in Florida
    Florida is a bellwether state, worthy of close attention for many reasons. It has played a key role in the national epidemic as a hub of early transmission and a touch-off point for national spread after spring break. It is a state that has been under scrutiny for it’s slow actions, confusing messages and challenges in data collection and reporting. Perhaps of biggest concern is that Florida is home to a high concentration of the most vulnerable of our citizens: older people. One fifth of it’s population is over 65 and there are about 700 nursing homes with more than 80,000 beds. It is a treasure trove of America’s grandparents. What happens in Florida will disproportionately contribute to the overall burden of death and suffering in America’s outbreak.
     Florida is our patient, and the patient is sick. As numerous news outlets like CNN are now reporting, Florida is a top candidate for the next hot spot or epicenter as numerous sun-belt states battle the front edge of the U.S. outbreak. New record cases are being set almost daily with no apparent end in sight. In desperation, the governor closed bars this evening. Let’s order a battery of tests and have a look at what’s going on. The gallery below contains 8 figures that represent those test results. What do we learn:
    1. Graph 1: This is the overall epidemic curve for Florida (from STATNews COVID-19 Tracker) showing daily cases. It shows what all the fuss is about. Around June 6, the curve switches from linear growth to exponential growth in cases. There were 60,000 state-wide cases then, that has doubled in 20 days. Today, a record high 8,942 new cases were reported, a rise of 79% over the previous day. The first case was reported 109 days ago.
    2. Graph 2: In states like Minnesota and Arizona, big surges can be blamed on a small number of counties that become white hot for a period. Lets see how wide-spread the problem is. First, we see Miami-Dade County, home of the highest number of cases in the state (28,664 cases and 935 deaths). We see the previous spike there around April 9 that eventually lead the state to shut things down. The shut-down worked and cases fell until Memorial day. Then the old peak was surpassed in just 7 days, and now the county is seeing more than 600 a day, with a 50% rise in the last week.
    3. Graph 3: Maybe the problem is just in the urban south. How about the other end of the state, way up in Nassau county, a suburban area north of Jacksonville. Looks like a carbon copy. First peak is clear in early April, general decline till end of May and then an even more severe spike starting June 10. Here the new peak is twice as large as the April peak. It is the same pattern in a less populous county in the north. While there are only 136 total cases, the weekly new case total jumped 167%.
    4. Graph 4: Ok, what about the Northwest of the state? Leon County is home to the state capital. That part of the state hasn’t been on the radar yet. Now at 642 cases, the picture is fairly similar. First peak occurred later in mid-April at 15 daily cases. Here there was a smaller aftershock in the last two weeks of May, and then around June 15, the firestorm started, surging to the previous peak and then 70% higher in a bit over a week. In the state capital, average new cases have risen 280% week-over-week.
    5. Graph 5: What about the sleepy middle of the state? Perhaps lower density communities in smaller towns and big farms offers some insulation. Polk County covers a large area right in the center of Florida, home to just 603,000, it’s largest city is Lakeland; universities, farming, mining and the headquarters of Publix are key features. The story here is different and the same. Polk county was spared the first peak, never rising above 20 cases a day in April. But even in this low-population, largely agricultural county, a firestorm took off around June 9, with cases surging from 20 a day to over 130. Last week averaged 117 a day, compared to 50 the week before, a rise of 137%. There are some counties in Florida where surge hasn’t happened. The main point is that the surge is occurring all over the state, north to south, urban to suburban, with a similar pattern of exponential growth in June.
    6. Graph 6: Maybe this surge is all about more testing. This graph from rt.live shows positive daily tests and total testing volume for the state. Testing doubled from 20K per day to 40K around May 20. Since then, it’s been up and down but the overall trend has been steady. There is nothing in these numbers that would convince me that the June surge comes from testing increases. The curves for testing and cases are not the same shape. What is evident is that the surge in cases started a month after shelter-in-place orders were lifted.
    7. Graph 7: The effective Reproduction rate (or Rt) is an important test result. We now have pretty compelling models that allow us to see how the R-value changes over time. This graph also comes from rt.live, a model I and others have come to trust. A reminder, the Rt is the time-specific estimate of how many additional people each infected person subsequently sickens. Currently, Florida is estimated to be 1.4, which is the 5th highest in the country. The model shows that Rt was below 1.0 during the SAH phase, then started rising above 1, where it has been flat since Memorial day. A sustained Rt of 1.4 means each infected person passes the illness to 1.4 others. That is sufficient to drive nearly exponential growth. Without any epidemic control measures, Florida experienced an initial Rt of about 3.0. The control measures put in place knocked this down to below 1, where the virus might have then failed to thrive. Reopening the state however has brought the state back to a place where the virus is spreading half as fast as when nothing was being done.
    8. Graph 8: Models like this can be used to predict the near and intermediate term future. My current favorite model uses machine learning and combines many models and various data sources from COVID-19 Projections. This graph tells us where Florida is now, taking account not only of those testing positive, but also for asymptomatic infections that are never tested. This tells us that currently about 3% of Florida’s residents have been infected. That is light years away from the 55-70% attack rate needed for herd immunity to halt the epidemic. It estimates Florida is now actually acquiring around 11,000 true infections every day. Based on these parameters, the model predicts cases will peak again in Florida, but not until July 26, one month from now, at which point there will be an estimated 13,716 infections each day. Given the uncertainty in the model, that could be as high as 24,000 or as low as 4,700. Estimated current infections will rise from 150,000 to over 200,000 before this peak occurs.