Daily COVID-19 Briefing: 4/8/20

Top news, reports and insights for today:

  1. U.S. records deadliest day so far
    Even as reports of cases leveling off in hard-hit areas mount, the grim reality (presaged by Federal officials) is that COVID-19 deaths continue to rise. As the graph below shows, a record high 1,928 deaths were recorded on Tuesday, a rise of 18%. Individual states with notable spikes in deaths include Nevada (+26%), Missouri (+36%), Oklahoma (+31%), South Dakota (+49%), Georgia (+44%), North Carolina (+39%), and New Hampshire (+44%). Three of these states (Missouri, Oklahoma and South Dakota) have refused to issue stay at home orders. Two others (Georgia and North Carolina) did so only recently. Several states bordering New York saw substantial jumps including Connecticut (+34%), New Jersey (+23%), and Pennsylvania (+48%), while New York’s death count rose a more modest 15% to 5,489 (or 43% of the nation’s total).
    What this means? We are now used to the idea that our view of the outbreak is always lagged by days or weeks. Today’s dead were infected 1-2 weeks ago. Even if the epidemic is slowing and the curve is flattening, we can expect to see deaths surging. Until social distancing measures can take root, this trend is likely to continue for the next week or more.
  1. Children are not immune from COVID-19
    One of the most destructive factors in the current pandemic has been the pervasiveness of rumors and false information regarding who is immune. A report about low rates of infection in Africa on March 1 fueled rumors that African American’s were somehow immune to the disease. Now, blacks make up a disproportionate share of hospitalizations and deaths. Another group that has been thought to be immune is children. Early reports from China indicated that children were not getting infected, and when they did, had less severe illness compared with adults. Later, we learned that children were not being tested and that infections were occurring in younger age groups. The CDC publishes a weekly report on illness and death in the U.S. called the MMWR (Morbidity and Mortality Weekly Report). It’s a must-read for epidemiologists. On Monday, the MMWR summarized a new report on the coronavirus outbreak in children in the U.S. covering February 12 to April 2. Based on analysis of 150,000 laboratory-confirmed COVID-19 cases in the U.S. where the age was known, 2,572 (or 2%) were among children <18 years old. Clearly, children are not immune. It looks like children have different symptom profiles. Among those with available information, only 73% of pediatric cases had fever, cough or shortness of breath compared to 93% of adults. While 10% of adult cases require hospitalization, children were hospitalized less (6%). A small number of deaths have been reported in children although the numbers probably are undercounted because of the belief that children are immune.
    The Bottom Line: COVID-19 looks different in kids. They have less severe disease and are less likely to have the classic symptoms. However, children are clearly not immune. We still don’t know what factors increase risk of infection in children, but younger persons who are immune compromised should be assumed to be at high risk, just like adults.
  2. Europe remains the epicenter of the pandemic: tourism may have have played a role.
    A few days ago, I was talking to a colleague, Dr. Usama Bilal, M.D., Ph.D., who is an epidemiologist at Drexel School of Public Health. He grew up in Spain but trained and now works in the U.S.. I was quizzing him on the mystery of why COVID-19 has been so lethal in countries like Spain and Italy. He suggested one possible factor that I had not considered. What do Spain, Italy and France, all have in common, other than each having extremely high crude fatality ratios? They are the biggest destinations for international tourism. We know that the great (albeit poorly named) “Spanish” flu epidemic of 1918-1919 was fueled by unprecedented international travel and trade related to WWI. The current pandemic spread rapidly around the globe in part due to unprecedented international trade and travel. Is it possible that tourism has been a factor in singling out the hardest hit nations? And if so, what does that clue tell us as disease detectives?
    Curious after hearing Dr. Bilal’s idea, I gathered the best available data on international tourist visits from the World Bank, averaging yearly arrivals for each country in Europe for the years 2015-18. I married that to WORLDOMETER data on rates of COVID-19 deaths per 1 million population as of April 6 and created the graph below. The pattern is striking. The three European countries with >40 million annual tourist visits are by far the hardest hit by COVID-19. The two big outliers here are the tiny land-locked principality of Andorra, lying between France and Spain that has a sky-high death rate and very low tourism, and Russia, which despite large numbers of tourists, continues to report exceptionally low rates of disease. These data give us further pause about the accuracy of the statistics from Russia. The correlation between tourist visits and COVID-19 deaths is strong; this single factor explains a third of the variation in the death rate within Europe.
    Why is this important? While these data only tell us about Europe, it gives us a clue as to why Europe (and the U.S.) have become the epicenters of this pandemic. But, there is an important deeper lesson here I believe. What is astonishing about this result is that tourism should have (and in many cased) stopped early in the outbreak. Why does tourism in 2018 so clearly predict which countries would have the worst burden of deaths in 2020? In my opinion, these data support three important ideas.
    1. First, it’s possible that SARS-CoV-2 may have been circulating globally and in Europe well before anyone was aware of it.
    2. Second, it suggests that border closings and travel restrictions have been considerably leakier than is believed;
    3. Third, and more importantly, it suggests that the very first weeks of the outbreak were critical in setting the stage for how the epidemic has played out.
    If correct, the seeding of future hotspots occurred in a short period before anyone was paying attention, before borders were closed and commercial flights grew empty. The New York Times reported on April 4 that 430,000 people have traveled to the U.S. from China since the outbreak in Wuhan began. This includes nearly 40,000 people who arrived on flights from China after the President imposed travel restrictions on February 2. This may partly explain why the U.S. now leads the world in cases, which now approach a half million. Because one-quarter of COVID-19 infections show no symptoms, tourism, and travel caused by the epidemic, may have planted the seeds that grew epidemics of widely different magnitudes. This provides further evidence that America’s delay in acting quickly to curb transmission was so very costly in economic and human terms.

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