Wednesday COVID-19 Briefing

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Top news, reports and insights for today:

Starting in September, I will be posting my COVID-19 briefings twice a week on Wednesday and Saturday (instead of 3 times a week). Please continue to send me feedback and questions. Thanks for visiting my blog. -Thomas

1. Curated headline summaries for Wednesday:

• Pandemic seems to be leveling off in U.S., but numbers remain troublingly high, experts say (Washington Post)
• Former FDA commissioner and COVID-19 “influencer” Dr. Scott Gottlieb says a safe vaccine for the general population is “unlikely” before January 2021. You should believe him (MSNBC)
• New audio recordings of interviews with journalist Bob Woodward proves that President Trump deliberately deceived America about the threat posted by coronavirus (Vox)
• Many patients are avoiding seeking essential health care due to fear of becoming infected in U.S. hospitals. An important new study of a Boston Medical center that cared for more than 9000 patients over 3 months finds only a single confirmed case (and 1 possible) acquired in the hospital. This study suggests that tight infection control procedures mean that the chance of getting COVID-19 in the hospital is very small (JAMA Network Open)
• Young American’s often believe they are safe from coronavirus and that only old people are at risk. A new study shows that severe COVID-19 poses a larger risk of death in young adults than a heart attack in this age group (JAMA Internal Medicine)
• Early in the pandemic, there was a belief that an anti-malaria drug (Hydroxychloroquine) along with a broad-spectrum antibiotic (azithromycin) might be an effective treatment. Now, hydroxychloroquine has been completely debunked and rejected. What about the antibiotic? An important study from Brazil shows that azithromycin does not seem to benefit patients with severe disease who are hospitalized (The Lancet)
• A study of the effectiveness of a promising COVID-19 vaccine was just put on temporary hold to investigate a safety concern in a study participant. Believe it or not, this is good news. It means the slow, painstaking and careful process of testing the vaccine and paying close attention to every detail is working as it should and that the public can trust the process (Vox)
• Evidence mounts that White House officials are pressuring top Health officials to promote political messages instead of science. The latest: emails from a Senior HHS official demanding “Uncle Toni” Fauci downplay the risk of COVID-19 in children when he appears before the media (Politico)

2. U.S. daily cases plummet by half since Saturday; 18 states report 0 deaths on Monday, more than since 4th of July
    After spiking to over 50,000 cases on September 4, U.S. cases plummeted this weekend. After the Sunday/Monday slowdown, I wondered if the Tuesday numbers would spike back up. Thankfully, that number was lower than any Tuesday since June 9 (See Figure A). The weekly case total is 255,000, which is half what it had been in mid-August. The trend in deaths is similar with just 354 reported on Tuesday, the lowest numbers for that day since the epidemic started (Figure B). More welcome news: eighteen U.S. states reported zero deaths yesterday.
    So, what is there for a disease detective to worry about next? The answer may be in Figure C showing new case growth factors for the last week (>1 means cases are growing last week compared to the previous 7 days, <1 means new cases are shrinking). Thankfully, all Southern states are seeing slowing transmission intensity (except Arkansas). Risers and fallers are about even in the Midwest; it’s mostly good news in the West where nine of thirteen states are on the decline.
    The worry is in the numbers for the Northeast where six states are reporting rising cases. Two states recorded more than 30% jumps (Delaware and New Hampshire). Cases are up in Maryland (+15%), New Jersey (+5%), New York (7%), and Pennsylvania (+17%).
    What it means: The overall picture looks rosier today than in weeks. My newest worry is that cooler weather, cold season and a new round of coronavirus infections may be on the horizon in the Northeast, a region that has been calm for most of the summer.

Figure A

Figure B

Figure C

3. Nine states now with higher rates of COVID-19 infection then New York/New Jersey; worrisome jump in new cases in the Northeast
    Figure D3 shows you where we stand in a state-by-state comparison of the cumulative rate of COVID-19 cases (lab-confirmed cases per 100,000 population). I last showed you this graph a month ago when four U.S. states had eclipsed the rate of New York (Figure D2). Why does this matter? In the carousel of images below, look at where things stood on April 16 (Figure D1). Back then, New York didn’t even fit on the graph with an incidence rate of over 1,100 while no state except New Jersey was over 500 and the average was only 202. Now (Figure D3), seven states in the south and two in the West have passed New York. Since April 16, New York’s rate doubled from 1,100 to 2,265. Arizona skyrocketed from 58 to 2,831 cases per 100,000, a rise of 4,781%! Other stratospheric leaps happened in Nevada (+2068%), Alabama (+2,853%), Florida (2,838%), Georgia (+1,650%), Louisiana (+581%), Mississippi (+2,307%), South Carolina (+3,064%) and Tennessee (+2,537%).
   The bottom line: In the four and a half months since Tax day, New York state’s rate of COVID-19 infections doubled. Now, nine states have done what then looked impossible: surpassing New York. Those states saw cases climb an average of more than 25-fold. Politicians and public health authorities have failed the residents of those states.

Rate of COVID-19 cases per 100,000 by state, three time points

4. Quirky Qorner: What sparked the pandemic “legs race”? Peloton! Guess what, they just came out with an even more expensive fake bike for people to see in the background during zoom meetings
    You have seen it right, the peloton bike in the background during the zoom meeting. At nearly $2,000 bucks, they have been flying off the shelfs as home-bound weekend warriors seek to keep up with Joneses. Now, CNBC reports that the folks at Peloton have grabbed the epidemic bull by the handle bars, announcing an even more expensive model. The new “Bike+”, available Wednesday, will cost $2,495. Peloton, whose sales surged 66% after then pandemic started, saw stock prices surge on the news. The CEO told CNBC “We feel like we’re just getting started”.
   The peloton strikes me as the perfect status symbol for a national emergency where we are all worrying so much and working so hard and still seeming to go nowhere.

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Sunday COVID-19 Briefing

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Top news, reports and insights for today:

1. Daily headline summaries for Sunday:

• California smashed daily record for coronavirus deaths for the 5th time in a month (Los Angeles Times)
• After apparent success, Japan acted like the virus was gone. Now the island nation is facing a formidable resurgence (Bloomberg)
• People are apparently jerking off with their phones during the pandemic (Gizmodo)
• More than 200 kids (out of 600) tested positive for COVID-19 after attending a summer camp in Georgia at the end of June according to the CDC (CBS News)
• Assistant Health Secretary Adm. Brett Giroir says it’s time to move on from hydroxychloroquine efficacy claims telling “Meet the Press” there is ‘no evidence’ it works (HUFFPOST)
• President Trump slams Dr. Fauci over comments on coronavirus surge calling him “Wrong!” The President falsely claims the surge is because we have “tested more than any other country” (Slate)

2. U.S. daily cases appear to have peaked but 15 states still very hot; latest half million cases added slower than previously
   New daily cases remained erratic over the past several days (Figure A) with the 7-day moving average hovering around 65,000 a day. Testing supply shortages and delayed results reinforce the worry that this flattening may be more about testing shortfalls (see Top pick of the day). That should sound like deja vu to those who follow my blog. It’s especially concerning in light of the President’s tweet this weekend telling Uncle Tony Fauci that he is wrong about the reasons for the surge in cases (see last headline). I strongly suspect the White House is effectively suppressing testing to give the appearance of a flattening epidemic. We can look at the testing data in the coming week to see if this is true.
   If you believe the declining numbers, then it is encouraging that it took 9 days to add the latest half million cases, as the U.S. passed 4.5 million on Saturday (Figure B). This halts a trend of shortened intervals between each half million mark since early July. Despite this apparently positive development, new daily cases of 20 or more per 100,000 residents per day continue to be added in 15 U.S. states (Figure C). Despite some worrisome numbers from that region, no Northeastern state is currently above 15 new cases per day. However, only Kentucky, North Carolina, Virginia and West Virginia in the South are below that threshold. Florida and Mississippi are still over 40 while Alabama (+31), Arkansas (+25), Georgia (+33), South Carolina (+29) Tennessee (+36) and Texas (+27) are all over 25. Hot states in the Midwest include Missouri (+25) and Oklahoma (+28). Out West, progress seen last week in Arizona has vanished (+33) and California (+20), Idaho (+26) and Nevada (+34) remain hot.
   The bottom line: Encouraging trends in overall daily cases are off-set by continued high transmission intensity in 15 states. It remains unclear if waning cases are due to the epidemic or a slow down in testing.

Figure A

Figure B

Figure C

3. NEW Analysis: 6 U.S. states are under moderate to severe strain in hospital capacity
   For some time I have been saying that we should be paying more attention to what is going on in hospitals to gauge the epidemic’s intensity. Daily cases and deaths can be skewed in lots of ways as we have discussed. But hospitals are where the epidemiological rubber meets the road! It’s only recently that the data has been available. It’s still not perfect, but we can at least start to look. I do so with a significant degree of caution however since hospitals have been sending their data to the White House instead of the CDC since mid-July. While that get’s sorted out, let’s see where we are. Figure D below is a new graph I made based on data covidexitstrategy.org. They have done a good job of data assembly and visualization on this topic. Their hospital data is coming mostly from the COVID Tracking Project, which is a most-trusted source in part because they are transparent and open about limitations. I did some background research on what constitutes a hospital system under stress. My classification differs a bit from the covidexitstrategy.org site: I am suggesting that a state where the overall capacity of ICU beds or hospital beds is at or above 85% should be considered under moderate-severe “stress” or the Red Zone. Because these are state-level summaries of incomplete data, these numbers will be constrained to never go higher than 95%. Given the decline in hospital utilization for elective procedures and non-COVID illnesses, it is striking that an entire state hospital system would be even near having 75% of ICU beds full. This graph reflects what news reports are saying. At least 6 states are in the Red Zone. Arizona is in the above 80% for both ICU and hospital beds being used. Alabama (91%), Georgia (91%) and Mississippi (96%) each have 90% of their ICU beds full leaving little room for error. States in the Purple zone (75-85% ICU occupancy) include California (76%), Nevada (77%), Kansas (80%), Arkansas (75%), Florida (83%), North Carolina (76%), South Carolina (77%), Tennessee (84%), and Texas (81%). Several other states were surprising. West Virginia has 75% of ICU beds filled and 74% of all beds. Delaware has 86% of all beds occupied and ICU occupancy of 72%. Pennsylvania also shows some stress at 76% ICU capacity. Rhode Island is of particular concern at 91% bed capacity and 83% of ICU beds full.
   The Bottom Line: It seemed like the U.S. had largely dodged a bullet in May when fears rose sky-high that states would run short of ICU beds and ventilators. As Wave 1 waned in May and June, it seemed that hospitals were out of the woods. But in recent weeks, the surge has caught up. Hospitals are reaching capacity in at least 6 states. Some states under stress are expected; others, like West Virginia, Delaware and Rhode Island have not been on the radar.

Figure D

Daily COVID-19 Briefing: Thursday

Top news, reports and insights for today:

1. Daily headline summaries for Thursday:

• Top medical journals the Lancet and New England Journal of Medicine have retracted articles that called into question the effect of experimental anti-malarial drugs hydroxychloroquine based on third-party data source that has now been brought into question (StatNews)
• U.S. COVID-19 cases have been slowly ticking up since Memorial Day (see graph below) (CNBC)

From CNBC.com: https://www.cnbc.com/2020/06/04/us-coronavirus-cases-have-been-slowly-ticking-up-since-memorial-day.html

2. Reopening resurgence? New COVID-19 cases surging in the South and West, deaths continue in hotspots across all regions
   Across the U.S. more than 147,000 new COVID-19 cases were reported in the previous 7 days, a cumulative rise of 9%. Over the last week, an average of 21,095 new daily cases were reported. This marks a flattening of the overall trend which had been falling in previous weeks. In my opinion, we are beginning to see the uptick in cases that had been predicted following state reopening. The top graph below shows percent rise in new cases in each state. We now have 4 states that added more than 25% to their case totals in the last week, there were no such states in the previous two weeks. In the South, notable rises were seen in Alabama (+18%), Arkansas, which along with Arizona leads the nation with 29% increase in new cases, Mississippi (+16%), North Carolina (+25%), South Carolina (+19%), Tennessee (+17%), Texas (+18%), and Virginia (+17%). In that region, only Louisiana saw cases rise less than 10%. In contrast, 9 of 12 states in the Northeast added 10% or fewer; states on the rise were Maryland, Maine and New Hampshire. The midwest, which had been the hot zone in previous weeks, had lower transmission intensity with 3 states higher than 10% more cases (Minnesota, Nebraska and Wisconsin). New cases continue to spike in Alaska (+24%), Arizona (+29%) and Utah (+21%).
   Turning to deaths (lower graphic), no state added more than 20% to their total death tally, however because deaths always lag behind cases, this is further evidence that a reopening-related resurgence has begun and that deaths will also turn higher in coming weeks/days. All regions had a mix of results both over and under the 10% threshold. The midwest and South had the higher fraction of states with bigger increases in deaths. States above 15% increase include Arizona, Iowa, Minnesota, Nebraska, Arkansas, Mississippi, North Carolina, Maine and New Hampshire.
   The bottom line: While I cannot say for sure, the overall trends this week suggest a reversal of the declining trend in new cases, suggesting the possibility that reopening-related resurgence of cases is beginning to be apparent. Regions of greatest concern are now the South and West.

3. Question from an alert reader: what’s the difference between CFR, IFR and crude mortality ratio?
   I got a very thoughtful question from a visitor the other day. I thought I would report that here in the hopes it may be helpful to others. Here is the question:  
    I’m confused by terms IFR and CFR. I like your “crude death rate” but no one else seems to use the term. And my confusion comes you use CFR the way most others use IFR (IFR seems to be defined by most studies as the real infection rate over the real death rate). The CFR seems to be defined, at least in the media, as the confirmed cases over confirmed deaths. I’m not an epi person, so looking for some clarity. Is your use of those terms idiosynchratic? 😉 thanks, JK.
    My answer: Thanks so much for your insightful and alert question.  Epidemiology has always been what I call a watering hole rather than a formal field.  It’s a thought style more than a particular discipline.  We are a loose federation of oddballs from medicine, statistics, social science and virology that gather around common problems more than around solidified doctrine.  We get used to the idea that important concepts may go by many different names.  We acknowledge that sometimes it’s worth fussing about names and sometimes it’s not.  In this case, I haven’t yet decided.
    The key conceptual challenge underlying this naming issue is simple.  When estimating a population risk parameter (the probability of death given disease), we seek an estimated probability or rate where the error in measurement of the numerator and denominator are similar within reason.  In this case, the numerator is deaths from COVID-19 and the denominator is all people who have had COVID-19 and were thus at risk for death.  With a pathogen that sickens almost every case/infection, such as Ebola or MERS, the distinction between CFR and IFR is rather academic.  That’s because the ascertainment rate (the probability that all cases/infections are captured by surveillance) is high, or is at least about the same as the ascertainment of who has died of the disease.  However, with a disease in which there are a large number of inapparent or hidden cases/infections, then the error in the numerator and denominator are no longer in the same ball park.  
    What is paramount is the need to keep two types of estimates in mind and keep them separate.  One is for the death rate in the cases we know about given the surveillance we are doing.   The other is the “real” death rate among all those who have the disease regardless of our surveillance.  Both numbers have value but we can’t make the mistake of assuming one is an estimate of the other.  For myself, I find it more useful to distinguish the case fatality rate (deaths among all cases/infections) as against the crude death ratio (cases among those we know about conditional on incomplete testing).  I like this language because the two labels make it clear just how different these numbers are and makes clear how inferior the latter is (it’s called “crude” after all).  Others distinguish between CFR and IFR under the premise that “cases” are what we know about in hospitals and testing labs and “infections” are the larger domain.  Call me old school but all cases are infections and all infections should be cases. The big challenge is finding a label that captures not only the mild cases but the sizable fraction (perhaps 25%) of infected persons who are entirely asymptomatic.  If that’s what people mean by “infections” then I am ok with that, but infection seems to presuppose some sign of illness.   I taught for 30 years and generally speaking, the term cases has always meant disease events regardless of ascertainment.  So, I find the distinction between cases and infections to be insufficiently clear to rely on the CFR/IFR distinction.  
    The real problem here is that the WHO and CDC have both contributed to the problem by referring to the crude mortality ratio as the CRF.  That has been a big mistake in my view.  In classic infectious disease epidemiology, the CFR has been the preferred term for what others call IFR.  The result is that many people lost confidence in epidemiologists because they knew that the WHO estimate of “CFR” (at 5.4%) was wrong due to the undercounting of infections in the denominator.  That’s something that we have yet to recover from.  I believe we should reserve the term CFR for the better, more important and reality-based estimate of population risk.  But as usual, I am in the minority.  I’m happy for the time being to assume that what others call IFR is CFR for me and what others call CFR I will call crude death ratio (CDR).  Confused yet?  Perhaps this is a debate we should be having.  Thanks for your keen insight.  I apologize if my answer is not entirely satisfying.