New study of 5700 hospitalized COVID-19 patients in New York City shows only 30% had fever on admission (JAMA Network)
Young people with COVID-19 are having strokes, suggesting the virus may be causing dangerous blood clots (Washington Post)
U.S. Cases trending upward, nearing 1 million. Midwest states surging The new case graph below shows that infections in the U.S. are trending upward, based on the 7-day moving average curve. Nearly 35,000 new cases were reported yesterday, a cumulative rise of 4%. I’ve tweaked the graph so that Sunday and Monday reports are a darker shade, to emphasize a pattern I pointed out earlier in the week about lagged reporting over the weekend. That is why the 7-day focus is preferred since it balances out weekly variation in ascertainment. It is likely the U.S. will be the first country to pass 1 million cases next week. Globally, the U.S. has more than 3 times more cases than Spain, which ranks second in the world. However, in terms of prevalence (proportion of the population infected) the U.S. at 2,948 per 1 million population ranks behind Spain (4,847), Belgium (3,981), Ireland (3,901), Switzerland (3,358), and Italy (3,269). However, keep in mind that U.S. testing remains lower than most nations (except Belgium and Spain). Seroprevalence studies remind us that there may be 10-times more infections than we are now aware of. The bottom graph shows 1-week growth in cases by state and region. Two midwestern states (Iowa and Nebraska) have doubled cases in that time. Substantial increases were also seen in Kansas (+71%), Minnesota (+56%) and Ohio (+52%), making the Midwest the latest apparent regional hot spot. Notable rises were also seen in the South (Arkansas and Virginia) and the Northeast (Massachussetts, Maryland and Rhode Island). Growth in new cases was less than 20% in New York, Maine and Vermont.
USA Today article by Susan Miller, posted April 26, 2020.
For months we have known that a larger list of symptoms should be considered when characterizing this new infection. The CDC has however been slow to move past the original three symptoms: fever, dry cough and shortness of breath. Finally, an additional 6 symptoms have been added. All have been on my symptom checklist since early March. This change comes on the heals of a major JAMA report showing that only a third of patients hospitalized for COVID-19 had a fever on admission.
Today’s bite-sized, handpicked selection of important news, information or science for all who want to know where this epidemic is going and what we should do.
U.S. Cases rise by just just 13%, so where are the next hot spots? On Friday, just over 32,000 cases were added, a 1-day rise of just 13%. Cases are now doubling every 5 days. I don’t know yet whether this is a slow down in the actual epidemic or whether we have hit the limits of how fast we are testing. California still has 60,000 samples waiting to be tested and 45 states aren’t reporting “pending” tests. While New York continues to lead the nation with over 113,000 confirmed COVID-19 cases, the overall fraction of U.S. cases there continues to fall, sitting currently at 38%. New York logged an 11% rise in cases on Friday. Other states recording big jumps were New Mexico (+23%), Alabama (+20%), Connecticut (+29%), and Pennsylvania (+20%). The graph below shows the total accumulated cases by state. There are 7 states at or near 10,000 cases including California, Michigan, Florida, Louisiana, Massachussetts, New Jersey and New York. These are the states that are already on our radar screens. But, remembering that we are usually a few days behind in this epidemic, these numbers don’t tell us where the next hot spots are likely to be. For that, take a look at the next graph, which shows growth in new cases over the past 3 days as a percentage of total cases. This graph shows a different story. There are 21 states that have seen 50% growth or more in the last three days. Five states have seen 70% growth including Pennsylvania, Louisiana, South Dakota, Oklahoma, and Idaho. What does this mean? As all eyes focus on coastal states like California, New York and New Jersey, the next hot spots are likely going to be in the Midwest and South, where 13 of 26 states have seen recent rises of 50% or more. Idaho and Louisiana are top contenders for the next epicenters of the outbreak. Other states to watch include Michigan, Nebraska, Oklahoma, South Dakota, Alabama and Texas.
The CDC continues to get it wrong on symptoms A friend of mine just texted to say she was feeling badly and had a tele-visit with her doctor. She said her symptoms were not “COVID related”. When I asked her why, she said she didn’t have the “classic” symptoms, no fever and no respiratory symptoms. She did have a loss of appetite, chills, fatigue and body aches. The epidemiologist in me wants to scream when I hear this. As the Top-pick-of-the-day article points out, the messaging around the symptoms of COVID-19 remains confused and problematic. In my opinion, the CDC has done some things well and other things have been mishandled. That is to be expected when tackling a new disease. One area that is particularly worth discussing is case definition based on symptoms. At this moment, the CDC website still lists the same three symptoms: fever, cough and shortness of breath. This is a big problem. That was based on a study of just 44 patients in China very early in the outbreak. That list should have been ditched long ago. We now have plenty of better data that shows that there are more than a dozen symptoms that should be considered. Take a look at version 6 of my own COVID-19 Symptom Checklist. The SARS-CoV-2 virus impacts different people in different ways depending on age, time since infection, risk factors, genetics and a host of things we are just learning about. As many of 1-in-5 infected persons don’t have a fever. One-third of patients have gastrointestinal symptoms rather than respiratory ones. Fatigue is much more common than shortness of breath (especially early on). Some less common symptoms may be especially useful for identifying COVID-19, like pink eye, loss of sense of smell or taste, and stomach problems. Other symptoms may be especially good for predicting who is going to have very severe disease (like sudden confusion or chest pains). Why this matters? There are probably tens of thousands of Americans who have COVID-19 but think they don’t because they don’t have fever, cough and shortness of breath. Those people are not considering themselves infected and are probably infecting others for that reason. We can and must do better on case definition.