Daily COVID-19 Briefing: Thursday

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Top news, reports and insights for today:

1. Daily deadline summaries for Thursday:

• U.S. daily coronavirus case count crosses 50,000 setting a single day record as some states reverse course on reopening and hospitals were hit by a surge of patients (Wall Street Journal)
• Experts suggest a plastic face shield, if properly fitted and warn, has advantages over cloth masks for use by the public and should be used more widely (JAMA)
• The American Academy of Pediatrics issues guidance in favor of reopening schools in the fall. Guidance stresses that children do not appear to be driving the epidemic, are less likely to be infected than other respiratory illnesses and that in-person education is better than online teaching (American Academy of Pediatrics)
• Italian researchers studied nearly all residents of one town before and after lock-down. Main results were that 40% of those infected never developed symptoms. None of the children in the study became infected. Those with and without symptoms did not differ on viral load. Half of those infected had cleared the virus 2 weeks later. The lockdown was very effective at halting transmission (Ars Technica)

2. U.S. enters new dangerous phase, smashing previous daily high record new cases, decline in deaths stops
    I have said for months that a return of widespread community transmission with R_t>1 was inevitable by July 1 given that states reopened recklessly. However, the ferocity of the resurgence in cases has caught me and many experts off guard. I apologize for showing you 4 different graphs for today’s briefing, but the story they tell is chilling. The first graph is our usual epidemic curve of new reported lab-confirmed COVID-19 cases by day. A record high 52,554 new cases were reported yesterday, the first day with more than 45,000 cases and 16,000 more than the peak set in late April. For the first time since the epidemic, the U.S. reported more than 300,000 new cases in one week. In just 7 days, the U.S. reported more infections than were accumulated from the start of the epidemic until April 4. The U.S. now has more than 2.6 million reported cases, 26% of all cases on the planet and twice as many as Brazil, still ranked second.
    Deaths flatten: The second graph shows daily deaths. This remains a mystery. The 7-day moving average has been falling since Memorial day. In the last few days, that decline looks to have stopped. Yesterday, Arizona, a state on the front edge of the case surge, reported a spike in deaths with 88, a rise of 100% from the previous day. Arizona, Iowa, Oklahoma, South Dakota, Kentucky, Texas, Virginia, and Rhode Island, all have seen deaths rise by 20% or more in the last week. I believe we will see deaths rising sharply in the states where cases first started surging.
    Cases increased last week in all but 3 U.S. states: The next graph shows the weekly growth factors by state. Nationally, the U.S. had it’s first week with 300,000 new cases. Astonishingly, the growth factors for last week compared to the week before are >1 in all U.S. states except Rhode Island, New Jersey and the nation’s capital. Weekly cases rose by 50% or more in Alaska, Idaho, Montana, Kansas, Florida, Georgia, Louisiana, Mississippi, and Tennessee.
    13 States reported more than 15 new daily cases per 100,000 population last week. The last graph shows the rate of new daily cases last week. Arizona continues to be the most extreme, now reporting more than 47 new cases per 100,000 every day. That is the highest rate we have seen anywhere at any point. In the South, 9 of 13 states are above this mark, which is 3-times higher than the 5 cases per day per 100,000 benchmark for low transmission. Florida, Georgia, Louisiana, Mississippi, South Carolina and Texas are all over 20. Only 1 Northeastern state is over 5.
    The bottom line: The U.S. epidemic is out of control with no end in sight.

3. U.S. capturing about 2/3 of the true number of COVID-19 deaths
   We already know that deaths from COVID-19 are undercounted for a variety of reasons. We also know that an accurate tally of the death toll is very important. As I have emphasized here before, our best tool for understanding the true mortality picture is to examine deaths from all causes using the best available data and comparing the numbers from 2020 to previous yearly averages. This allows us to capture excess deaths above what is expected in a “normal” month taking seasonal variation into account. It’s not perfect, but it is closer to the truth than our current count. Previous studies using similar methods have found that the ascertainment rate (% of true COVID-19 deaths that are counted) is about 50%. Over time, we hope that will improve. Yesterday, a new study was published by my former colleague and friend demographer Steven Woolf and in JAMA that adds important new information. They used a state-of-the art model to estimate total excess deaths that are probably COVID-19 related. This includes cases where COVID-19 is mentioned on the death certificate, but also more indirect causes. They specifically examine rises in deaths above temporal trends in past years that may reflect those who died because they didn’t seek care for existing problems, had exacerbations of chronic diseases, or may have succumbed to secondary distress (e.g., drug overdoses). Their main finding is that in the 8-week period from March 1 through April 25, about 65% of the excess deaths likely related to COVID-19 were actually counted as such. That means, the remaining 35% of deaths were not counted. The 5 states with the most COVID-19 deaths experienced large proportional increases in deaths from non-respiratory underlying causes including diabetes (96% increase), heart disease (89%), Alzheimer disease (64%) and cerebrovascular disease (35%). New York City, which reported the highest number of COVID-19 deaths, saw a 398% rise in the number of heart disease deaths. The graph below, taken from the paper, shows that in the 5 hardest hit states, a significant jump in deaths can be seen in March and April of this year for heart disease, diabetes. Smaller but still substantial increases happened for stroke and Alzheimer disease as well. Diabetes deaths rose from 40% to more than doubling depending on the state.
   The bottom line: The true number of COVID-19 deaths is probably about 1/3 higher than our current numbers suggest. If true, the U.S. now has an estimated 177,000 deaths rather than the official count of 131,000. Significant numbers of people are dying of non-respiratory manifestations of SARS-CoV-2 and are not being counted. States vary widely in the accuracy of their counts.

From Woolf et al, JAMA Published online July 1, 2020. doi:10.1001/jama.2020.11787

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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

Daily COVID-19 Briefing: 4/26/20

Top news, reports and insights for today:

1. Daily headlines for Sunday:

• Dr. Michael Osterholm, a must-watch expert, says COVID-19 testing is in crisis right now (NBC News, Meet the press)
• CDC finally expands case definition, adding 6 new symptoms. This should have been done in early March. (USA Today)
• All eyes are again on Italy as it starts to re-open. Is it too soon? (Wall Street Journal)
• 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)

2. 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.