Daily COVID-19 Briefing: Saturday

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Top news, reports and insights for today:

1. Daily headline summaries for Saturday:

• Nineteen states this week set new highs for coronavirus infections recorded in a single day (Axios)
• White House has blocked CDC Director Redfield and other officials from testifying on school reopenings (USA Today)
• FDA approves pooled testing for coronavirus, promising to increase testing efficiency and reduce backlogs (Axios)
• 85 children under age 2 tested positive for coronavirus in 1 Texas county (NBC News)
• Studies in both the U.S. and U.K. show evidence that several candidate vaccines show early signs in Phase II studies showing they produce an immune response. Still, the highest hurdle remains as drug makers move to initiate Phase 3 trials in coming weeks (BBC News)

2. New daily high case records set Thursday and Friday. Deaths rising. Increasing transmission seen in all but 5 states
   New record high daily case totals were established on Thursday and Friday, with more than 145,000 cases reported in two days (Figure A). This brings total U.S. cases to over 3.5 million. A half million cases were added in just 8 days, faster than any previous period (Figure B). At the state level, while the nation has been watching a Arizona and Florida, community transmission this week is increasing across the board. Figure C shows one week growth factors (ratio of cases in last 7 days to the previous week) by state. All but 5 (46 of 51) states are increasing. Unlike last week, cases are rising again in the Northeast, where new cases rose by 20% or more in Washington DC (+21%), Maryland (+51%), New Hampshire (+30%), and Rhode Island (+50%). All states in the South saw cases rise by 10% or more, lead by Alabama (+43%) and Virginia (+46%). Transmission increased in all Midwest states except South Dakota. The largest 1-week rise was in the West, lead by Colorado (+96%), Alaska (+58%), Montana (+66%) and Nevada (+42%). Thankfully, new cases finally went down in Arizona by 2%. The trend toward rising deaths continued as 936 deaths were reported Friday (Figure D). Still, the number of deaths remains far lower than the peak period in April and May despite twice the number of cases.
   What does it mean: Instead of summer suppression, we see summer surge. Deaths, thankfully remain lower than cases would suggest. This tells us that we are capturing a larger percentage of the true cases in our testing. Instead of isolated state hot spots, transmission is intensifying more broadly across all states and regions than at any time in the past.

Figure A

Figure B

Figure C

Figure D

3. The summer story: The rest of the nation catches up with New York and New Jersey
   Over the last few months, I have been repeatedly checking the overall rates of confirmed COVID-19 infections per 100,000 population by state to see how the epidemic’s distribution has shifted. Disease detectives look most closely at rates (rather than raw numbers) when comparing different places. The graphs below show state rates at 4 different time points. Three short months ago (Graph A), New York and New Jersey were “off the charts” at 1,143 and 848 cases per 100K. No other state was above 500, the national average was 202 and it seemed that New York would never be exceeded. By memorial day (Graph 2), New Jersey doubled and New York neared 2,000, while the national average rose to 541. Rates were still 4 times higher in the Northeast compared to the West. One month ago, it was clear other states were catching up (Graph C). New York and New Jersey saw new cases finally subside, just as the surge erupted in the Midwest and South. The Northeast was still 3-fold higher than the West, but there were now 8 other states over 1,000 and two were outside the Northeast (Illinois and Louisiana). With this context in mind, the picture has changed dramatically over the last month (Graph D). Infection rates in the Northeast are now only 2/3 higher than the west. Arizona had just 58 confirmed COVID-19 cases per 100,000 on April 16. Yesterday, they had all but matched New Jersey at 1,903. The average infection rates in the South were 1/10th of those in the Northeast in April and will soon be about the same (1,165 vs. 1,513).
   What does it mean? Three months ago, many were convinced the epidemic was a crisis of the greater New York region. We waited for the summer to deflate the epidemic so we could get back to normal. That has not been the story. Instead, the success of the Northeast in curtailing the epidemic and flattening the curve has been more than matched by the inability and unwillingness of other states to halt transmission. While it was unthinkable 3 months ago, the rest of the nation has rapidly caught up. There is no evidence that the new hot spot states have learned from the successes of New York and New Jersey.

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  Graph B: May 31

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  Graph A: April 16

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  Graph C: June 16

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  Graph D: July 17

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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.

2. 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.
3. 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.