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: 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

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.