Daily COVID-19 Briefing: Tuesday

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Top news, reports and insights for today:

I wish to thank those who reached out to me in the past few days with encouragement and feedback. I needed to hear that my efforts in this blog are making a difference. My plan is to continue with regular briefings at least 3 times a week (tentatively Tuesday, Friday and Sunday). I will add supplemental posts when timely and important events arise. I plan to add a new feature: reader comments and questions. I will add an option on the blog for visitors to post specific questions of interest. I will try to address those questions as best I can and share the back and forth in this space. Thanks again for continuing to read this blog and I look forward to continuing to bring you fair, balanced and scientifically-oriented news, insights and analysis. Please keep the feedback coming!

1. Daily headline summaries for Tuesday:

• U.S. coronavirus deaths top 150,000 (NBC News)
• It’s not just the U.S. that is experiencing coronavirus fatigue as several European nations are seeing recent spikes in new cases as control measures become more lax (Washington Post)
• At least a dozen states are running out of doctors and nurses as COVID-19 cases surge. Shortages are especially acute in intensive care units. Military units stepping in to assist in California (ARS TECHNICA)
• Opinion from 19 doctors and a nurse: Trump administration issued a new rule this month requiring hospitals to report COVID-19 data directly to the Trump administration instead of the CDC. “This sudden and radical decision to change hospital reporting from the CDC to a private third party within the Department of Health and Human Services will disrupt established lines of communication and has grave potential to hobble our ability to respond to the pandemic….” (USA Today)

2. U.S. daily cases have leveled out; the latest half million cases added in just 7 days
    From Mid-June till Mid-July, we have seen daily cases rapidly and steadily rise in the U.S. as a result of widespread transmission intensity across multiple states and regions. In the last week, that trend has finally shifted and new COVID-19 cases have plateaued. That is welcome news. As was the case in the first apparent peak in late April, it is not clear if the flattening is driven by the epidemic itself or by a new ceiling in testing capacity. There is evidence that both are at play (see main point 3). The U.S. now has over 4.2 million total lab-confirmed COVID-19 cases, which is over 1/4 of the world’s cases (27%). The cumulative total rose from 3.5 to 4 million in just 7 days, the shortest interval thus far that half a million cases were added (See Figure B).
    At the state level, transmission intensity remains high in many states. Two states now exceed the overall rates of infection per 100,000 in New York (now at 2,120 per 100,000): Arizona (2,251) and Louisiana (2,394). New daily cases over the last week per 100,000 is shown in Figure C. Fourteen states added 25 or more new cases per day last week including Arizona (+37), California (+25), Idaho (+27), Nevada (+33), Oklahoma (+26), Alabama (+33), Arkansas (+26), Florida (+48), Georgia (+34), Louisiana (+46), Mississippi (+44), South Carolina (+30), Tennessee (+35), and Texas (+26). Transmission continues to be well controlled in much of the Northeast where Connecticut, Massachussetts, Maryland, Maine, New Hampshire, New York, New Jersey and Vermont remain below the benchmark value of 5 new cases per day per 100,000.
    The bottom line: The overall trend is flattening of new cases. It is possible we have simply maxed out on testing capacity. The virus continues to spread extensively in 14 states. Conditions in Arizona, Nevada, Alabama, Florida Georgia, Louisiana, Mississippi and Texas remain especially alarming.

Figure A

Figure B

Figure C

3. What’s going on with testing in the U.S.?
    Across the nation, testing is under the microscope. Viral twitter posts have planted the idea that the U.S. only thinks it’s in bad shape because we are testing too many people. More tests make more cases, so the logic goes. Some national leaders have suggested a slow down in testing. The Trump administration has sent mixed signals. This week, “Uncle Toni” Fauci, the nation’s top infectious disease doctor told government panels two key things: 1) more testing does not lead to more cases by itself, and 2) he has never been told by the White House to slow down testing. But the question remains in a lot of minds: is the recent surge in cases just about more testing?
    To begin tackling this, let’s consider some basic facts. First, it is true that relative to the true underlying rate of a disease, the more testing that is done, the higher will be the number of cases identified. That’s why we have to look beyond total numbers of positive tests. Second, just as with cases, we can be easily mislead by looking at the raw number of tests. We have to look at rates. There are two that matter. The first is tests per million people. There are now 78 countries with 10,000 or more cases. Among those nations, the U.S. currently ranks 1st in total cases and 9th in testing per 1 million. That’s an improvement since the U.S. ranked 17th 2 months ago. The top graph below is from OurWorldInData.org and shows the current place of the U.S. in testing rate compared to some other key nations. It shows we are in the middle of the pack. It also shows that while testing rates have climbed steadily, there is no big jump that would explain the June surge in cases.
    The other key rate is the test positivity rate (TPR). In many ways, the TPR can be a better measure of viral transmission intensity than the number of positive tests. Ideally, we would like the TPR to be at or below 5%, which tells us we are testing broadly in the population and that 95% of people are testing negative. In the early phase of the epidemic, we are only testing selectively: mostly those we already know to be sick. For that reason, the TPR was over 30% in the initial weeks of the pandemic. Let’s look now at the lower graph I made using data from the COVID Tracking Project, showing total tests per day in the U.S. and TPR since May 1. This graph shows two really important things. The blue bars are how many tests we are doing a day. That number has been steadily climbing since May 1. But, and here is the important point, it appears the growth in testing has flattened in the last week and may be declining. That is important when we put the numbers of daily positive tests in perspective. It is possible that the flattening of new cases is partly due to a flattening in the growth of new tests. To help clarify, we look at the orange line, which shows the TPR. That number fell from 17% on May 1 to around 8% in late June. Total tests continued to rise, but TPR did not fall. That’s important. If it had, we would be able to say that our testing is coming into better alignment with the true magnitude of the outbreak. That didn’t happen. The TPR has been consistent since Mid-June. That’s a sign that the surge in cases is mostly about the epidemic, and not “excess testing” whatever that might mean.
    The bottom line: We still aren’t testing enough. The surge in cases is mostly the spread of disease, not the rise in testing. Our capacity to test may have maxed out, suggesting we should be cautious in celebrating the apparent plateau in cases.

From: https://ourworldindata.org/coronavirus

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Daily COVID-19 Briefing: Monday

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Top news, reports and insights for today:

1. Daily headline summaries for Monday:

• Florida breaks state, and U.S. all-time record for highest daily cases with 15,300. The state-wide total including non-residents is 269,811 (Orlando Sentinel, see graph below)
• At least 26 members of Mississippi’s legislature have tested positive for the COVID-19 after weeks of working at the Capital, often absent face masks and social distancing (NPR)
• MIT has developed a robot that uses UV light to kill coronavirus in stores and warehouses (Yahoo/Finance)
• White House seeks to discredit Dr. Fauci as cases surge (The Guardian)

2. U.S. COVID-19 daily cases doubling previous peak daily cases. 13 States adding 20 or more new daily cases per 100,000
   The U.S. crossed the 3 million case threshold this weekend, adding more than 60,000 new cases in three of the last 4 days. We continue to set new daily records at an alarming pace. The most recent daily record of 66,660 came on July 10. That number is almost double the number of daily high cases set during the first peak on April 24. The middle graph below shows the number of days it took to reach each 500,000 new cumulative cases. We went from 2.5 to 3 million cases in a record 10 days, a week faster than the previous fastest interval and half the time it took to add 500,000 cases any previous period. The bottom graph shows what is happening in states. It shows new daily cases per 100,000 population. In the West, Midwest and South, the only 2 state with its epidemic under control (<5 new daily cases per 100K) were Wyoming and Hawaii. Thirteen states added more than 20 (4-times the benchmark) daily cases per 100,000; four in the West (Arizona, California, Idaho and Nevada) and 9 in the South (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Tennessee, South Carolina and Texas). The Northeast, which was the sole focus of national attention for most of this spring, remained quiet with low growth in cases in all states except Delaware. Arizona (+50), Florida (+43), and Louisiana (+42) remain “off the charts”.
   The Bottom Line: Uncontrolled community transmission is widespread throughout the South despite very hot and humid conditions. The South and West are losing ground as the epidemic surges across many states. More than a dozen states slow or reverse reopening as we enter a period of uncertainty and stagnation. There is no national leadership visible on the horizon.

3. We were waiting to see if deaths would start rising. They just did
   The post-reopening surge in cases took longer to arrive than we thought. But it came. As cases surged beyond the previous peak, we waited to see what would happen with hospitalizations. It took a bit longer than we thought, but the surge in sick patients came. Then we waited to see the numbers rise for deaths. For a moment, it seemed that something had changed, that the gap between cases and deaths was peculiarly large. This week, as the graphs below show, that has now shifted. Eric Topol called it on Twitter on July 13. In the last week, the 7-day moving average for daily reported COVID-19 deaths inflected upward (top graph). According to CNN, counties in Texas are running out of morgue space and asking FEMA for refrigerated trucks to hold the dead. The lower graph shows the story at the state level. Compared to 2 weeks ago, deaths last week rose in all Western states, all Midwest states except Minnesota and all Southern states except Virginia. While numbers were two small for stable estimates in several states (patterned bars), the trend in the south especially is clear where weekly deaths rose from a low of 19% in Alabama to more than doubling (208%) in Texas. Weekly deaths rose by 50% or more in Arizona, Nevada, Washington, Iowa, Florida, Georgia, Mississippi and Tennessee.
   What it means: The much-anticipated rise in daily deaths has begun and its not limited to a few high-profile states. Deaths are rising fast in 8 states. This trend should continue and accelerate. If hospital capacity is dramatically exceeded, deaths may spiral.

Daily COVID-19 Briefing: Saturday

Top news, reports and insights for today:

1. Daily headline summaries for Saturday:

• Alabama sees new cases, hospitalizations and test positivity rates on the rise amid reopening (PBS Newshour)
• Good news on the treatment front: a peer-reviewed study from a randomized clinical trial of remdesivir shows that while survival was not improved, COVID-19 patients in the treatment group had a shorter recovery time compared to placebo, making this the first drug to be shown to be effective as a treatment (New England Journal of Medicine)
• A new poll from AP/NORC shows only half of Americans are ready to resume pre-epidemic activities like going to the movies or a sporting event. This helps explain why allowing businesses to reopen has not translated into widespread resumption of business activity. From the article: “Americans fear spreading or contracting infection, so much so that they’ve overwhelmingly participated in social distancing measures. They tell pollsters by wide margins that they fear lifting those restrictions too soon much more so than too late. ” (Vox)
• Leading experts believe the CDC’s new lowered projections for hospitalizations and deaths are too optimistic, signaling that politics may be driving the science, rather than the reverse (NPR)

2. U.S. Cases remain flat, continuing an overall whack-a-mole pattern
    On Thursday and Friday, May 20-21, the U.S. reported about 49,000 new COVID-19 cases. One month ago, on April 21-22, there were 55,000 new cases. On the same 2 days in March there were 14,000 new cases. While cases may have peaked in the U.S. for now, the epidemic is still generating approximately the same number of new daily cases as it did last month. The graph below shows a generally flat trend in new cases since May 11. There were 155,836 new cases reported in the last week, rise in cumulative cases of 10.9%. If the U.S. were to continue to increase cases by 10% a week for the next month, there would be 2.5 million cases by June 21.
    The lower graph shows how cases are growing by state over the last week. Twelve states saw cases grow by 10% or less last week. However, 38 states had more than 10% growth and 4 saw growth of greater than 25%, equivalent to a doubling of cases in 4 weeks (Minnesota, North Dakota, Arkansas and North Carolina).
    Bottom line: These graphs basically say that while the news continues to be good in the states that suffered the worst initial waves (New York, New Jersey, Louisiana and Michigan), the situation is best characterized as continued whack-a-mole, not a general waning of the epidemic at a national level.

3. Modeling update: The spread of coronavirus has not slowed in 24 states
    The modelers have been taking it on the chin in recent weeks, with numerous headlines detailing their ups and downs. As today’s Top Pick of the Day reports, modelers from the Imperial College of London are now projecting that COVID-19 may be spreading at epidemic rates in 24 states, particularly in the South and Midwest. This is based on the latest version of their model, described in Report 23, which now includes anonymous cell phone data capturing changes in people’s movement patterns. Their model shows an effective reproduction number (R_t) of greater than 1 in Texas, Arizona, Illinois, Colorado, Ohio, Minnesota, Indiana, Iowa, Alabama, Wisconsin, Mississippi, Tennessee, Florida, Virginia, New Mexico, Missouri, Delaware, South Carolina, Massachusetts, North Carolina, California, Pennsylvania, Louisiana and Maryland. Nationally, they estimate that about 4.1% of American’s have so far been infected; it’s about 17% in New York. That means even New York is far from herd immunity. Their report says “…the epidemic is not under control in much of the US”. The figure below was taken from this report; it shows the probability that each state has an R_t of less than 1, meaning the epidemic is controlled. Green states have a high likelihood, purple states are low. These data don’t support the idea that the epidemic is going away with warm weather. The hot spots (with the possible exception of Minnesota and Iowa), are, well hot.
    What does this mean? The debate continues to rage about the utility of these models. The Imperial College model has proven to be among the best performing models we have. The addition of real-time travel data has the potential to enhance it’s performance. If correct, their model predicts that if travel continues to increase in some states at the current rate, cumulative deaths may double over the next two months.

Page 9 of Report 23, Imperial College London