Wednesday COVID-19 Briefing

Top news, reports and insights for today:

  1. Curated headline summaries for Wednesday:
  • Trump does better in COVID-19 ravaged states than expected. Exit polls show voters worried about the economic effects of lockdowns if the encumbant lost. Many voters fell victim to the false belief that policy makers must choose between public health and the economy (see Main Point 3). Meanwhile, the economic damage of the pandemic have been much less in the countries that have controlled the epidemic best (VOX)
  • A study from Mount Sinai found that SARS-CoV-2 virus was circulating in New York city in February, weeks before the first case was noticed. The study also shows that as many as 22 percent of New York City residents may have been infected, still far from the herd immunity threshold (BGR)
  • Dr. Deborah L. Birx, who has carefully straddled the line between science and politics as she helps lead the Trump administration’s coronavirus response, delivered a stark private warning on Monday, telling White House officials that the pandemic is entering a new and “deadly phase” that demands a more aggressive approach (New York Times)
  • A study of cell phone data shows that people who live in low income neighborhoods are not able to social distance to the extent those who live in affluent communities. Socioeconomic barriers to social distancing is part of why COVID-19 disproportionately impacts residents of low income communities (Nature Human Behavior)
  • Federal officials add pregnant women to high risk groups after CDC study finds that COVID-19 increases risk of preterm delivery and the need for intensive care (New York Times)
  1. U.S. cases keep climbing, crashing through 9 million. Latest million took just 2 weeks.
     It took three months for the first million U.S. official COVID-19 cases to be identified and tallied. From 8 to 9 million took just 2 weeks, the fastest million thus far, and a further indication that the coronavirus outbreak continues to accelerate (Figure A). As the U.S. edges toward 100,000 cases a day, more than half a million cases are being added each week (Figure B). A part of the current rise is due to increased testing. However, Figure C shows the trends in daily cases (red) and daily tests (blue) averaged over 7 days since September 1. The inflection point in cases happened on October 2, starting a rise from 42,000 daily cases to the current levels above 85,000. In that time, tests rose from 1.03 million a day to 1.24 million, a jump of only 16%. Since October 2, daily cases doubled while testing increased less than a quarter. Testing actually rose faster in September, while cases were fairly flat.
    Figure D is our old friend, the state daily case growth-factor situation. Where are cases rising fastest? The Midwest and Northeast, where only Oklahoma and Vermont are seeing weekly cases fall. In the Midwest, weekly cases grew by 50% or more in Iowa (+70%), Kansas (+85%), Michigan (+59%), and Minnesota (+61%). Showing no light at the end of the tunnel, weekly cases are still rising in North Dakota (+46%), South Dakota (+22%) and Wisconsin (+14%). Despite this, President Trump won or leads the election results in all these states except Wisconsin, Minnesota, and Michigan. In the Northeast, 9 states saw weekly cases grow 20 percent or more, led by Maine (+116%). Those who follow me will recall that I showed you a map over the weekend indicating that case explosions are tracking with the arrival of super cold air (e.g., Maine, Montana, Idaho, the Dakotas and Colorado).
    Bottom line: Cases are surging substantially in the U.S. which is only marginally a result of rising testing. At the current rate, adding a million cases every 2 weeks, the U.S. may reach 13 million cases before 2020 ends. There is no end in sight to the surge of cases in the Midwest and Northeast in particular. The Trump administration may win another term because of the epidemic, not despite it (see Headline 1).
Figure A
Figure B
Figure C: From COVID Tracking Project:
Figure D
  1. Government actions to control the epidemic AND maintain economic health can work: the German case
    I vish to talk about Djermany (silly accent). As I process my own reactions to the election, I am struck once again by how wrong the polls and pundits were. Most experts believed that the recent surge of cases in battleground states would hurt the President at the polls. That was largely not the case. There was no Biden landslide spearheaded by worried swing voters in the hard hit states. Trump won the Dakotas, Iowa, Montana, Idaho, Utah, Kansas, Nebraska, and Missouri, all states that have been on fire with COVID-19 in recent weeks. Exit polls indicate many voters were worried that a Biden win would mean further economic harm from tougher lockdowns. In other words, it looks like the coronavirus actually helped the President.
    That idea, that policy makers must choose between the competing goals of controlling the outbreak and supporting the economy, appears to underly this phenomenon. It is, sadly, a widespread view that such a choice is necessary, that controlling the virus means hurting the economy. Of course, that was a key part of the President’s messaging. However, the data tells us a very different story. That’s why I want to talk about Germany.
    You may have heard that the U.S. is not the only place where coronavirus is surging. Europe is dealing with another big wavelet as well. Have a look at Figure E below, taken from the European Center for Disease Control and Prevention (ECDC). It shows new case growth per 100,000 population for the two prior weeks as of October 28. This map startled me. It’s very handy to be able to see patterns at the sub-national level, similar to what I do every day with U.S. states. As a thought experiment, let us say that it is true that what national and state governments do to control COVID-19 is pointless and unimportant. If that were so, we would not expect new case rates to vary along national borders. Instead, as was more or less true very early in the pandemic, the spread of disease would not honor national boundaries. Look at Germany and its neighbors. Not only is there clearly a spatial patterning of new cases that follows national boundaries, but Germany is completely surrounded by areas at the highest level of transmission on the scale including France, the Netherlands, and Belgium to the west, Austria, the Czech Republic and Poland to the east. Similarly, Portugal outperforms Spain, Scotland looks better than the rest of the U.K., and Sweden is doing worse than its Scandinavian neighbors Finland and Norway. Greece is doing better than Bulgaria in the last 2 weeks. The best performing European nation right now is Estonia, where only 73 COVID-19 deaths have occurred and their incidence rate (402 per 100,000) is one fifth what it is in the U.S. (2,946 per 100,000). Germany has set an example for the rest of Europe and the world using a combination of stringent control measures (closing schools, banning gatherings over 50, mandatory masks) as well as highly targeted testing and contact tracing. The result is that they have outperformed their neighbors, the U.S. and much of the world consistently and dramatically. All told, the Germans have 712 cases and 13.1 deaths per 100,000 compared to the U.S. rates of 2,946 and 72.2 cases and deaths. The U.S. COVID-19 death rate is five and a half times higher than the German rate. National policies matter and make a big difference.
    Now, let’s consider the question of trade-offs between the economy and public health. That’s where all this started. For that, we need one more figure, this one from OurWorldInData. Figure F plots COVID-19 deaths per million (vertical axis) against economic decline in the second quarter as percent drop in GDP compared to the previous year. If it’s true that countries have to choose between public health and the economy, then this graph should show that the countries with the highest death rates should have less economic damage, and that countries with low death rates should have paid the price in terms of bigger GDP losses. This graph tells the opposite story. The countries that kept the disease most in check (Taiwan, South Korea, Lithuania, Nigeria, Norway and Finland have had the least negative economic declines, all well-below the United States. On the other hand, the nations with high death rates (>400 per million) including Belgium, the UK, Italy, France, Mexico, Spain (hidden behind UK), Sweden (next to USA) and the U.S., all (except the U.S. and Sweden) experienced GDP losses of 12% or more. Among big, diverse, industrialized democracies, Germany kept its deaths down among the lowest, and at the same time, has an economy that has suffered less than Canada, France, Italy, Spain, Belgium and the United Kingdom. Wunderbahr!
    Bottom Line: What countries do matters. The evidence strongly shows no trade-off. Countries that have controlled the pandemic the best have seen less economic damage, not more. Allowing the coronavirus to run rampant without control measures causes more economic damage.
Figure E. Weekly new case rate map from the European Center for Disease Control and Prevention.
Figure F:
  1. Quirky Qorner: North Dakota now has 151 cases a day per 100,000, the highest in the nation by far. Yesterday, the 8th district of the North Dakota House of Representatives elected Republican David Andahl who earned triple the votes of his democratic opponents. The problem: Representative Andahl died of COVID-19 in October
     I have been wondering what it’s like to be in North Dakota right now. By every measure, the outbreak is out of control in that state. Newsweek tells us today that the voters of North Dakota, despite how bad things are COVID-wise, gave President Trump twice as many votes as Biden. CNBC reports today that North Dakotans have also elected a man who died of COVID last month. My heart goes out to the family of Mr. Andahl, but it seems that North Dakota continues to go down the coronavirus rabbit hole.

Daily COVID-19 Briefing: Thursday

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)
  1. 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 Rt>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.
  1. 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

Top pick of the day: Friday

How the virus won

Graphically intensive moving-picture presentation of the U.S. COVID-19 epidemic seen from above by Derek Watkins, Josh Holder, James Glanz, Way Can, Benedict Carey and Jeremy White, posted online at the New York Times, June 25, 2020.

If you ever think about the big-picture of how we got to this moment in the U.S., what we did wrong as a nation and how things went so badly, take 10 minutes to walk through this fascinating timeline of events for a 50,000-foot view that provides some deep and troubling lessons.

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.