Friday COVID-19 Briefing

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Top news, reports and insights for today:

1. Daily headline summaries for Friday:

• Data shows signs the epicenter of the coronavirus epidemic may be shifting to the Midwest on Thursday while Sunbelt states saw new infections begin to decline while cases rise in Ohio, Kentucky, Tennessee, Missouri, Kansas and Nebraska (Reuters)
• The Trump administration abruptly required hospitals to stop reporting COVID-19 data to CDC and use a new reporting system set up by a contractor. That system remains plagued with delays and inaccuracies. Hearings and investigations now underway (NPR)
• Scammers are making millions selling bogus dietary supplements to treat and prevent COVID-19. NPR found over 100 supplements listed for sale on Amazon that make unsubstantiated and potentially illegal claims that they fight viruses. These include products sold by a company recently sued by the Department of Justice over fraud allegations related to COVID-19 (NPR)
• African-Americans are known to suffer disproportionately from COVID-19 in many ways. A recent study in 5 hospitals in Baltimore/Washington from March to May shows that Latinos had test positivity rates 5-times higher than whites and double that of blacks. The Latino community needs greater attention (JAMA)

2. New daily cases remain flat but “bouncy”, 3 states pass New York for cumulative rates of COVID-19; new case growth pops up in Northeast and Mid-west
    On Tuesday I noted that new daily cases seemed to have flattened. That trend has largely continued this week, although numbers have fluctuated substantially (See Figure A). The U.S. added 442,658 new cases last week, a rise of 11% in total. Over the last 3 days, new record high daily cases were set in Hawaii (124), Missouri (2,084) and Mississippi (1,775). Figure B shows the 1-week growth factors for each state indicating the ratio of new cases this week to the week before. They show something important and unexpected. Our attention has been on the Sunbelt states where the epidemic has been surging. For the first time in weeks, we see bigger hikes in new cases in the Northeast and Mid-west while cases declined in 6 Southern states. Connecticut added a startling 1,438 cases, tripling the previous week’s total. New Jersey also saw new cases more than double, prompting Governor Murphy to update quarantine advisories issued for travelers from 3 new states, Puerto Rico and Washington DC. CBS News in New York is reporting that New Jersey hospitals are bracing for a surge of new cases. New cases also rose by 20% or more in Massachussetts (+22%), Maryland (+23%), New Hampshire (+26%), and Rhode Island (+84). In the Midwest, Missouri (+53%) and Oklahoma (+72%) saw the largest spikes. Michigan (+20%), Minnesota (+14%), Nebraska (+16%) and South Dakota (+21%) all saw new cases rising. In the West, big increases were seen in small states as new cases surged in Alaska (+37%), Hawaii (+280%) and Montana (+33%).
    Figure C updates us on the overall rates of COVID-19 cases at least for that subset captured in our testing. A couple of months ago, it looked like no state could possibly catch up to New York. Now three states have a higher overall rate of cases per 100,000: Louisiana now has the highest (2,463), followed by Arizona (2,347) and Florida (2,148). As a region, the South now nearly matches the Northeast at 1,560 per 100,000 (compared to 1,582). In the South, only Kentucky and West Virginia have kept rates below 1,000 per 100,000, a feat also matched by 7 of 13 Western states and 10 of 13 Midwest states.
    The bottom line: While the flattening of new cases is good news, the whack-a-mole continues as falling new cases are offset by brush fires of transmission intensity breaking out in previous hot spots. Key factors appear to be lax social distancing associated with vacation travel and people staying indoors to avoid the heat.

Figure A

Figure B

Figure C

3. U.S. COVID-19 deaths pass 140,000; daily totals continue to rise
    On Thursday, 1,231 Americans were reported dead from the SARS-CoV-2 virus. This caps a four-day run of more than 1,000 daily deaths and continues a trend of rising mortality that started around the 4th of July (see Figure D). The U.S. reported over 7,500 deaths last week, a cumulative rise of 6%, which is double the 3% rise seen the week prior to July 26. In all major data tracking sites, the U.S. has now exceeded 140,000 deaths. The U.S. remains the nation with the largest death total with more than twice that of the next two highest countries (Brazil and the UK) combined. Figure E shows the states that rose the most last week compared to the week before. As always, states with fewer than 25 weekly deaths are shown with a patterned bar since the ratios of two small numbers tend to be unstable. As expected, the most consistent region is the South, where despite an apparent peak in cases, deaths continue to surge. Weekly deaths rose by 20% or more in Arkansas (+24%), Florida (+27%), Georgia (+21%), Kentucky (+38%), Mississippi (+37%), North Carolina (+28%), South Carolina (+27%), Texas (+183%) and Virginia (+175%). Deaths spiked particularly in Kansas (+456%) and Delaware (+500%) although the absolute numbers are smaller. Deaths were on the rise significantly in Ohio (+22%) and Oklahoma (+51%) but fell in Illinois, Michigan, Missouri, Minnesota and Wisconsin. In the West, deaths rose in California (+29%), Idaho (+63%), Oregon (+79% and Washington (+49%) while holding steady in Arizona for the first time in several weeks.
    The bottom line: Consistent with the lag between infections, testing, and mortality, the summer surge in cases is now resulting in a rise of COVID-19 deaths. Importantly, we are still significantly below the peak of 2500+ deaths a day seen in April in May despite vastly more cases. This is because of the doubling of testing. While we were capturing approximately 10% of the total number of actual infections occurring in the population in May, we have now roughly doubled the number of daily tests from 40,000 a day to around 80,000 (see Tuesday’s blog). This expansion of testing as lowered the TPR from 10% to 8% allowing us to capture closer to 20+% of true infections. All this suggests that the overall mortality rate is likely fairly stable. The reality is that we had far more cases of active infection occurring in April and May than we knew – like 10-times more. The best performing model by Youyang Gu and colleagues, suggests that new infections in the U.S. peaked around July 16 and that deaths are projected to peak at just over 1,100 a day around August 13. We will see.

Figure D

Figure E

4. Two timely and important studies released about the role of schools: reopening this fall carries unavoidable risks
    Here we are in the middle of the strangest summer of our lives. Now is the time people are thinking about the Fall and what it will mean for schools. Should they reopen? Should they stay closed? Is online training even worth it? Why not let the kids go back to school given that they don’t seem to be getting very sick. I want to make you aware of two important and timely studies that have come out that bear on this issue and should be kept in mind as we lurch toward the Fall.
    The first study was published July 29 in JAMA by Katherine Auger and colleagues from Cincinnati. They looked at whether there was a relationship between the timing of state-wide school closures and COVID-19 infection and death rates across all 50 states in the period from March 9 to May 7. The analysis they did was a bit complicated but their approach was very solid. They found that state-wide school closures were associated with a 62% reduction in weekly cases and a 58% lower weekly rate of deaths. This doesn’t prove causation, but it suggests that despite the fact that school-age children are not the ones at highest risk of sickness and death, shutting down schools may have a substantial impact on the overall risk in the community. Children can be conveyors of disease directly by transmitting to more at risk groups. In addition, through the patterns of interaction and mixing that school requires, transmission intensity can increase among all age groups because of the increase in overall interactions in and out of school.
    The second relevant study came out in Eurosurveillance on July 21 and was done by researchers affiliated with the Jerusalem District Health Office in Israel. (Note: I apologize if either of these links are behind a firewall. I can’t tell. Let me know if they are and I can post the article). This study looked at what happened when schools were reopened on May 17 after being closed across the country in Mid-March. Considerable planning went in to the reopening plan; daily health reports, hygiene procedures, facemarks, social distancing and minimal interactions were all required and put into place. Disease detectives were put on stand-bye to monitor the situation. Despite these efforts, ten days later, the first significant outbreak occurred in an Israeli High School. After an official outbreak declaration, mass testing and contact tracing was undertaken. Overall, 153 students and 25 staff members were confirmed to be COVID-19 positive, yielding an attack rate of 13% in students and 17% in staff. This outbreak appears to have started from 2 initial index cases not related to each other that sparked the larger outbreak.
    What do these studies mean? In thinking about what we should do as a nation, these studies suggest two tentative conclusions, recognizing that we are only looking at 2 imperfect studies when we would like to have 200. The first is that open schools can increase the risk for entire communities, not just the students in those schools. We have good evidence that school closures were a vital tool for controlling the spread of influenza in 1918-1919. Cities that reopened schools suffered a worse fate than those that closed schools early and kept them closed. But coronavirus is not influenza and we are tempted by the fact that children seem to be at lower risk. But the JAMA study tells us that what happens in schools, doesn’t stay in schools. Returning to classrooms invites greater chance of community-wide transmission, leading potentially to higher rates of hospitalization and death. The second study warns us that even with the right planning and the best available epidemic control measures in place, outbreaks can happen in school settings and happen fast. Testing, monitoring and social distancing do matter and they do help, but the school environment is to some extent an unavoidable petri dish for infectious disease transmission.

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Daily COVID-19 Briefing: 4/29/20

Top news, reports and insights for today:

1. Today’s headlines for Wednesday:

• Coronavirus has now killed more Americans than died over 2 decades in the Vietnam war (NPR).
• Antibody testing demonstrates that COVID-19 is significantly more lethal than regular seasonal flu (Washington Post).
• Vaccine update: 90 candidate vaccines are in development against SARS-CoV-2, 6 groups now in human testing (Nature).
• At least 1,300 federal prisoners test positive as testing ramps up, 70% are in California, Texas and North Carolina (USA Today).
• Stay-at-home orders exact a psychological toll (Los Angeles Times).

2. U.S. deaths jump by 4%, more evidence of weekend reporting lag
   On Tuesday, an additional 2,173 Americans lost their lives to COVID-19, a rise of 4%. The data confirm a consistent pattern of lagged reporting of deaths on Sunday and Monday. About 1,000 more deaths were reported Tuesday compared to the two previous days. This emphasizes the importance of looking at 7-day moving averages. Eight states matched or set new record high death tolls, including Illinois (142), Wisconsin (19), Arkansas (6), Florida (83), North Carolina (36), South Carolina (15), Delaware (12), and New Jersey (398). Despite rising deaths, Florida will soon allow stay-at-home restrictions to lapse and Arkansas has not implemented such restrictions. In the last week, 12 states saw death totals rise by 50% or more (see bottom graph). Minnesota, New Mexico, Iowa, Alabama, North Carolina, Washington DC, Delaware, and Massachussetts all saw greater than 60% increases last week.
   What it means? Daily death totals are bouncing around. This requires us to look at longer time chunks. Sunday and Monday reports reflect systematic reporting delays. Death hot spots remain clear in all regions of the U.S.. These data show that flattening the curve has worked. It does not yet show that we are out of the woods as many wish to believe.

3. Countries vary dramatically in testing, high and low testing countries have lower death rates
   Here is a new way to look at international comparisons on testing and how it relates to mortality. The figure compares 51 countries that have done 100,000 tests or more, comparing tests per 1 million population (bar length) and the current COVID-19 deaths per 1 million (bar color). The data come from the WORLDOMETER site as of yesterday. Looking at both testing and deaths per 1 million population is a way of approaching an apples-to-apples comparison between countries of wildly different sizes and age structures. It’s in no way a perfect method, but I would bore you with the technically better adjustments and the pattern is largely the same. The top 12 countries have achieved at least 20,000 tests per million. All but Spain, Italy and Ireland have deaths per 1 million population of less than 200. The 11 countries that have tested fewer than 10,000 per million also have low death rates with the exception of France. Japan remains an enigma with extremely low testing and epidemic intensity. The U.S. is testing at half the rate of nations at the top like Portugal and Israel, both of which have low death rates.
   What this means: I can’t say that more testing explains low deaths in some countries. The picture is more complex. What strikes me most is how tremendous the variation is in testing rates even among developed Western nations. Hard-hit nations like the UK and France are testing a third less vigorously than the top testing countries. This far into the epidemic, I expected more consistency at least within Europe as the relative success of Germany and Denmark has been so closely watched.

4. Georgia: Where is the outbreak most severe? The answer might surprise you.
   Georgia has been on my mind lately. The governor has been aggressive in re-opening his state. As collective “quarantine fatigue” sets in, it is hardly surprising that states would want to restart their economies. I decided to have a look at the epidemiologic patterns there. Before looking at the graphs below, take a guess where the epidemic is the worst.
   Georgia is a state like many, with one major big metropolitan area, a few smaller cities, and a great expanse of rural communities and small towns. We are accustomed to thinking about states like Michigan (Detroit) and Illinois (Chicago) as examples of how COVID-19 is a big city problem. The top map shows total COVID-19 cases in Georgia by county as of Monday. Data come from the Georgia Department of Public Health. The dark area is Atlanta. But as epidemiologists, we prefer to look at rates of disease. That’s the lower map, which shows infections per 100,000 population. It shows something really different. The highest rates of infection in Georgia are not in urban areas at all. It’s a handful of rural counties in the southwest portion of the state where we find the highest infection rates, some are almost 10-times higher than the national average (now at 307/100,000). Turns out, the hardest hit county (Randolph) had a major cluster of 47 cases in a nursing home in Cuthbert. Nearby Dougherty county has been a national hot spot for some time with 1,498 cases and 120 deaths in a population of under 90,000. Reports suggest a range of factors that might account for this pattern. One county held a big grand opening celebration. Funerals have drawn big crowds in some communities. Many have high rates of poverty and health problems. Tests are reported to be unavailable still. The death toll has fallen heavily on African-Americans, who are a majority in several hard-hit counties.
   Bottom Line: According to the Washington Post, of the 20 U.S. counties with the most COVID-19 deaths per capita, five are in southwest Georgia. And this is the state that rushes to reopen first? May and June are likely to be about COVID-19 in rural America.

COVID-19 total cases by county in Georgia. Accessed from GA Department of Public Health on 4/28/20: https://dph.georgia.gov/covid-19-daily-status-report

COVID-19 infection rate (cases per 100,000 population) as of April 27. https://dph.georgia.gov/covid-19-daily-status-report