Daily COVID-19 Briefing: Wednesday

Top news, reports and insights for today:

1. Daily headline summaries for Wednesday:

• The U.S. death rate from COVID-19 per 1 million people just passed 340. That’s more than 100 times the rate in China (Time)
• A trend toward a “second U.S. virus wave” emerges in 22 states after reopening (Bloomberg)
• As harvest season nears, outbreaks seen among migratory farm workers in North Carolina, Florida and Washington. The federal government has not made safety rules mandatory, leaving it to farmer’s discretion (Politico)
• Half the states (including California, Florida, North Carolina and New York) are failing to follow CDC guidelines and reporting probable coronavirus cases and deaths, leading to inconsistent and inaccurate surveillance (Washington Post)

2. Back to where they started: Epidemiologic deja vu in 14 states that have matched or exceeded daily cases compared to April/May peaks
   The President continues to say and do things that suggest he believes the epidemic is over and behind us. A journalist sent me an inquiry yesterday asking my opinion on whether a second wave might be in our future now that the first one is over. A new poll suggests that about half the country thinks it’s time to get back to normal life.
   Huh? I remain puzzled and wonder what information people could possibly be looking at. Internationally, we have seen the epidemic move from country to country, rising and falling in the global whack-a-mole pandemic we are in. Months ago it was Italy, France and Spain in the hot seat. Now it’s Brazil, Peru, India, Russia and Chile. The same shifting is occurring in the U.S. as one state grows quiet as another surges. What strikes me when looking at the New York Times tracking data is just how many states seem to be right back where they were during the peak period of April and May. After looking closely, I believe there are 14 states that now meet or exceed the high water mark of daily cases. Take a look at the two image galleries below. The first one shows the 8 states where the recent 7-day moving average for daily new cases is higher (and in some cases much higher) than the peak in April/May. The second gallery is the 6 states where recent average daily cases are about the same as they were at the April/May peak. Some of these states are quite striking. Arizona averaged under 300 cases a day throughout April and May, and is now above 1,000 after an alarming rise starting May 27. Arkansas peaked at under 200 a day April 26 and has now risen to over 300 a day. California, North Carolina and Utah are all essentially on a continuous rise since the start of the outbreak with little notable drop off in new daily cases. Texas and Oregon both appeared to peak twice, with a corresponding dip in new cases in late May, but in both states, cases have surged to all time highs with continued transmission intensity. In the lower gallery, we see that Florida, Kentucky, Nevada, New Mexico and Tennessee, all had noticeable peaks in April/May, and all have seen resurgence of new cases back to about the same peak levels in recent days.
   The bottom line: Overall, new cases remain close to flat in the U.S., as many states are seeing sustained declines. However, the rest of the story is that 14 states are right back to where they were in the peak period of April and May and 8 of those states are setting new records. Texas, Arizona, Florida, Nevada, South Carolina and Mississippi were the most aggressive in reopening 2-3 weeks ago.

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  Arizona

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  Arkansas

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  California

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  North Carolina

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  Oregon

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  South Carolina

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  Texas

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  Utah

States where new cases are higher than April/May peak

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  Florida

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  Kentucky

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  Mississippi

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  Nevada

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  New Mexico

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  Tennessee

States that have matched earlier peaks

3. Not just increased testing: COVID-19 hospitalization rates rising in reopening states, mirroring trend in rising cases
   A story in Bloomberg highlights what the article calls a “second U.S. virus wave” emerging in reopening states. They mention that hospitalizations in Texas jumped 6.3% on Tuesday to 2,056, the highest total since the pandemic emerged. California hospitalizations are at their highest point since May 13 and have risen 9 of the last 10 days. This nudged me to go back to my favorite source of state-level data on hospitalizations from the COVID-19 Hospitalization Tracking Project at the University of Minnesota Carlson School of Management. While their data doesn’t cover all states, the figure and table below captures a few that have surging cases. The graph shows daily COVID-19 hospitalizations per 100,000 adults for 6 states. Since May 17, the largest increase has been in Arizona, where rates rose by 56%. North Carolina saw the second highest rate rise and 57%. Rates are up nearly a third in Kentucky, Texas and Utah. California is back to where it was in late April.
   Why does this matter: Tracking hospitalizations may be a more accurate window into the epidemic than other measures that depend on testing. These data show, I believe, that hospitalizations are rising in line with expectations of post-reopening increases in transmission intensity. The situation in Arizona is especially extreme.

State	May 17	June 9	Change	% Change
Arizona	14.9	23.3	+8.4	+56%
California	10.3	11.4	+1.1	+11%
Kentucky	11.4	15.7	+4.3	+38%
North Carolina	6.3	9.9	+3.6	+57%
Texas	7.4	9.4	+2	+27%
Utah	4.8	5.9	+1.1	+23%

From the COVID-19 Hospitalization Tracking Project, University of Minnesota, Carlson School of Management, captured 6/10/20

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Daily COVID-19 Briefing: 4/30/20

Top news, reports and insights for today:

1. Daily headlines for Thursday:

• At least 31 states will reopen in the coming days as stay-at-home orders expire across the U.S. (CNN)
• As states move to re-open, none has met federal criteria: 14-day drop in cases (NBC News).
• L.A. County becomes first in California to offer testing to all residents as cases surge in the city (Los Angeles Times).
• Dr. Anthony Fauci (America’s Uncle Tony) says that a viable coronavirus vaccine is possible by January (NBC News).
• Georgia reopening: an experiment with lives at stake, puts working-class in the cross-hairs of the pandemic (The Atlantic)

2. States that never issued stay-at-home orders, and those that did so late, have steeper epidemic curves
   On April 19 I posted a graph that shows how states compared in the rate of case growth since the day of the 100th case comparing three groups of states among those with moderate-sized outbreaks. This compares the pace of the epidemic in states that issued stay-at-home (SAH) orders early, vs. late vs. never. Today I present an update on that graph after 10 more days of data (see below). It’s a busy graph, but contains I think very compelling evidence that SAH orders have been effective. The black line is the average growth across all states and DC. States below that line are below average growth in cases, states above that line have more rapid growth. All states start on the day they reached 100 cases. There are 3 big take home messages here.
   1. All states that adopted SAH restrictions before March 30 (solid lines) are growing cases slower than the national average. Wisconsin was above the black line until day 26 but has since remained below the US average.
   2. All states that adopted SAH orders after March 30 had more rapid growth than the US average except South Carolina and Nevada.
   3. Among states that never adopted SAH orders (dotted lines), 3 have seen dramatic acceleration of their curves. I have marked Nebraska, Arkansas and Iowa. In those states, on different days, their curves turned dramatically upward after a period of slower growth. This pattern is not seen in any state that adopted early. Utah’s inflection is less severe but still evident at day 35.
   The bottom line: These data suggest that stay-at-home restrictions have slowed the epidemic generally, that early adopting states have done better, and that states that never adopted have been vulnerable to dramatic periods of accelerated growth. This provides a template for looking over time at what happens as these restrictions are lifted.

3. U.S. deaths spike again to second highest daily total, new cases remain flat
   On Wednesday, reported COVID-19 deaths spiked again to the second highest daily total of 2,549, a rise of 5%. While the 7-day moving average, had showed a trend toward decline since April 21, the last two days have adjusted the trend back in the direction of rising deaths (top graph). Nine states matched or set new record high deaths, including 5 in the midwest (Iowa (12), Indiana (63), Nebraska (13), Ohio (138), and South Dakota (2)). In the Northeast, records were set in DC (15), Massachussetts (252) and Pennsylvania (479). New cases in the U.S. have passed 1 million rising by 3% on Wednesday by more than 25,000 (bottom graph). The 7-day moving average has been trending flat over the last week, however it remains unclear if this is flat case growth or flat testing capacity.
   What this means? The disconnect between the push from states to reopen and the story the data are telling is more striking every day. Neither deaths nor new cases show sustained declines. The White House continues to say we are on the cusp of getting past this epidemic. I have no idea where they get that assessment.

4. Brazil ranks second yesterday in new cases (behind U.S) raising concerns about South America as temperatures there fall
   On Wednesday, Brazil reported the second highest new case totals (6,462), a 1-day rise of 9%. The graph below from WORLDOMETER shows that new cases and active cases have been rising exponentially over the last two weeks. Brazil joins Peru, Chile and Mexico as nations in the top 25 in new cases. Of further concern, Brazil has tested only 1,600 per million, suggesting that these case totals may be severely under-estimated.
   Bottom line: So far, few have paid much attention to Latin America. This may soon change. As temperatures begin to fall in the southern hemisphere, all eyes will be on South America and Africa to see what happens when COVID-19 collides with an entire season of “normal” respiratory illnesses. Brazil is an especially important country to watch due to high population density, intense tourism and substantial areas of poverty. Brazil is also in the midst of a severe recession.

Accessed from WORLDOMETER April 30, 2020: https://www.latimes.com/california/story/2020-04-29/talk-of-reopening-grows-in-l-a-orange-county-despite-rising-death-toll

Daily COVID-19 Briefing: 4/7/20

Top news, reports and insights for today:

1. It’s time to separate from social distancing
   The term social distancing has been etched into our collective consciousness as deeply as the SARS-CoV-2 virus has entered our collective bloodstream. It has served its purpose as a rallying cry to national action (albeit later than optimal). However, the term has negative overtones that now warrant reexamination and the search for alternatives. We have learned that viruses compete for hosts in the dog-eat-dog battle of natural selection. We have also learned that the same forces that drive the spread of pathogens also drive the spread of words, ideas, and crazy theories; in short memes. Thinking about the deeper meaning of the term social distancing, I re-read an opinion piece from the New York Times on March 14 by Eric Klinenberg, a sociologist from New York University. Klinenberg is well-known for his ‘social autopsy’ of the Chicago heat wave of 1995; he documented that death depended in part on whether vulnerable citizens had strong social connections. He reminds us that in times of crisis, social solidarity saves lives. Evidence is growing that widening the physical distance between us is a life-saving necessity to flatten the curve and slow the pace of the epidemic. Social distance is another thing entirely. The term social distancing can serve as a justification for self-interest, everyone for themselves. This leads to hoarding at the store, pulling back from civic obligation, and an impulse to circle the wagons, precisely at a time when we should be expanding our sense of collective inter-dependence. Can we achieve greater physical separation and closer social connectedness? It’s time to consider replacing social distancing as a meme. I wish I had a better term.
2. U.S. COVID-19 deaths rise unevenly, hot spots emerge in states that refused to take action
   The news cycle is dominated by projections of peaking cases and deaths. How much of this is wishful thinking is hard to say, but the data is telling us a complicated story. The figure below shows change in COVID-19 deaths by state and region. It shows increases in deaths over the past three days as a percentage of all deaths in that state since March 1. As we welcome what appears to be peaking deaths in states like Washington, California and New York (although today, that state reported a new record high 731 deaths), hot spots appear on the horizon in other states. States above the 100% line have seen deaths double in the last three days. These include Alaska (+100%), Iowa (+127%), Missouri (+105%), South Dakota (+100%), Wisconsin (+108%), West Virginia (+100%), and Maryland (+107%). Importantly, two of these hot spot states have refused to issue stay-at-home orders (Iowa and South Dakota). Missouri waited until April 6, Alaska and Maryland waited till the end of March (3/28 and 3/30 respectively). Utah still refuse to order its citizens to stay home and has seen an 86% rise in deaths over the last three days. Predicting the next hot spots is complicated by regional variation in the undercounting of COVID-19 deaths. Deaths occurring among patients with pending tests aren’t counted, and deaths in prisons and nursing homes are largely missing.
   What this means? The focus has justifiably been on the hardest hit states. Cases and deaths may be reaching a plateau in those states, but deaths lag behind cases. Today’s deaths were infected 2 weeks ago. This virus is a super-predator; when available victims get harder to find in one area, it will move to the next. Alaska, Utah, Iowa, Missouri, South Dakota, Missouri, West Virginia and Maryland are in the cross-hairs of the disease. The governors of some these states will have to answer for their refusal to act or for delay in taking action.

3. Spain passes Italy with the highest crude death rate; Europe continues to be the epicenter of the pandemic
   The graph below shows just how widely scattered the crude fatality ratios are in this pandemic. The bars (calculations are mine) are COVID-19 deaths per 1 million persons as of Sunday in 61 countries with at least 1,000 total cases. Spain has surpassed Italy at 282 deaths per million. Eight countries have death rates of more than 50 per million. These figures reveal just how devastating the epidemic has been in Europe, with 9 of the top 10 countries. The distribution of death rates is so heavily skewed that the mean (22) is more than 10 times larger than the median (2.0). No body knows yet why these rates vary so widely. At very least, we can say that big differences in how countries are counting deaths is one factor.
   The bottom line: Europe continues to be the bulls-eye of this pandemic. It remains to be seen if the death toll is so high there simply because the current wave of the outbreak arrived on European soil first. If true, other parts of the world will be catching up to Europe in the coming weeks and months.

4. SARS-CoV-2 exploits existing social inequities: African Americans are being impacted disproportionately
   An article from the non-profit newsroom ProPublica on April 3 by Akilah Johnson and Talia Buford presents compelling evidence that the coronavirus is not an “equalizer”. In Milwaukee, where blacks live 14 fewer years compared to whites before the epidemic, half of its cases and 81% of deaths have been African Americans, even though the county is only 26% black. Michigan’s population is only 14% black, but African Americans make up 35% of cases and 40% of deaths. Few states are keeping track of the epidemic’s toll by race/ethnicity (and the CDC is not), but two that are (Illinois and North Carolina), show that African Americans are being disproportionately infected and suffering more severe disease and death. The reasons are many. Just as the SARS-CoV-2 virus exploits weaknesses and biases in the body’s own immune system, it also exploits existing social divisions and inequities. Generations of mistrust in public health authorities fueled early rumors in the black community that African Americans were somehow immune. When stay-at-home orders were issued in hard-hit cities, a painful legacy of government restrictions against minorities led to pushback. The coronavirus is a predator, seeking vulnerable targets. Because African Americans suffer disproportionately from heart disease, diabetes, high blood pressure and obesity, they are now paying a higher price. All of this is compounded by lower access to testing and treatment.
5. What this means? If the U.S. and other nations are committed to flattening the curve and preventing suffering and death, coordinated and centralized action is required to direct resources to address the needs of vulnerable groups, not just individuals. The virus that causes COVID-19 is an effective predator, seeking to exploit the weaknesses and vulnerabilities in our society. That should make communities of color the center-piece of our countermeasures, not an afterthought.