Covid Epi Weekly: Turning the Corner on Covid in the US—Into an Oncoming Tsunami of Cases, Hospitalizations, and Death
October 23, 2020. You know what’s NOT tired of winning? Covid. Covid’s not tired of winning. Unless we up our game, Covid will keep winning, keep spreading, keep killing Americans—preventably.
Test positivity is increasing in ALL age groups. Positivity in people over the age of 65 increased from 3.6% five weeks ago to 5.2%—a 44% increase. Five weeks ago, the rate in young adults was 50% higher than in those over 65; last week the rate was just 20% higher. This confirms that what started in the young didn’t stay in the young.
Cumulative hospitalizations for adults over 65 in the US:
1 in 300 White people
1 in 120 Native American people
1 in 110 Latinx people
1 in 87 (!) Black people.
The emergence of Covid has exacerbated racial injustice in health. Black and Latinx communities already had less access to health care. The inadequate protection of essential workers, many of whom are Black/Latinx, has also magnified inequities.
Years of life lost is a good way to measure the burden of a public health crisis, though it’s far from perfect. There have already been 2.5 million life years lost, more than 13 years for every one of the 225,000 people who have died from Covid. Think of the joy, happiness, and meaning lost for each of those 13 years. Each of those 2.5 million years.
A working paper published in June by former NYC Health Commissioner Dr. Mary T. Bassett showed the same pattern: Black and Latinx people in the US make up 33% of adults but 74% of early death. This is horrifying. Valid responses to this information include rage and action.
Other than Northeast, this map is bleak.
Although it’s clear that there is a worsening situation in the US, we’re flying blind as to exactly how and where Covid is spreading. Test positivity is less informative than it was before. Case rates are an even worse indicator. The record 85,000 infections reported for Friday represent only about 20% of all infections. The failure of federal leadership means we’re not tracking the right indicators.
Take a look at the Dakotas. Neither state has a mask mandate. They are losing to Covid. The reported rates are slightly higher in North Dakota (1,000 vs. 800 per million a day), but when corrected for test intensity, South Dakota has about 4x the rate of North Dakota and 20x the rate of the Northeast. In other words, South Dakota looks not as bad, but it’s actually much worse.
Increasing cases in Alaska suggest that colder weather may favor the virus. In the classic Art of War, Sun Tzu defined five factors that determine success or failure in war: moral influence, weather, terrain, leadership, and strategy. In our war against Covid, the US is not organized for success in any of those 5 - we’re zero for 5 at present.
Parts of Europe are also getting hit hard. Places that didn’t drive cases down enough to find and stop clusters face the ever-present risk of explosive spread. Some countries didn’t flatten the curve sufficiently (Spain, France, Italy, UK, Belgium) and some did (Germany, Norway, Finland).
Economic pain is real, and deadly. We are all impatient to resume activities we miss, but the reality is there are things we won’t be able to do until we control the pandemic. Here’s more evidence the virus, rather than control efforts, is what’s suppressing economic recovery. “It has almost nothing to do with regulations.” Paraphrasing James Carville, to fix the economy, it’s the pandemic, stupid.
Balance is key in our response. We must apply more granularity to our “circuit breakers” to stop Covid. Yes, we’ll have to adapt our lives for the foreseeable future. But there are a lot of activities we can and should do, while taking steps to reduce risk. Schools, healthcare, workplaces, stores can open more safely. Spending time outdoors is great. On the other hand, travel from places with high Covid to places with low Covid is a recipe for spread. Restaurants, bars, and indoor get-togethers amplify the virus and we’ll need to figure out how to do this as safely as possible.
The higher the peak, the longer it lasts. The lower Covid goes, the longer it takes to come back. As we sow, so shall we reap. Hyperbolic discounting is not in our favor here. As night follows day, hospitalizations and deaths follow cases, which follow letting our guard down.
Civic responsibilities include not harming (e.g., infecting with coronavirus) others, staying informed, paying taxes, participating in your community. And VOTING. We released materials on voting more safely. I like the message below. Please spread the word.
Covid Epi Weekly: Harrowing Holidays
It’s hard to imagine a worse confluence. Cases are surging in much of the US. People are tired of the limitations the virus is imposing. Economic harm is real, painful, and persistent. And White House communications have continued to mislead, divide, and deny.
Bottom line (almost) up front: there IS one thing that can stop Covid. For months I’ve said there isn’t one thing, but there is. Not masks. Not travel limitations. Not staying home. Not testing. Not contact tracing. Not isolation. Not quarantine. Not even a vaccine.
It’s TRUST.
Around the world, the best predictor of controlling Covid is social cohesion: the understanding that we’re all in this together. We’re all safer when we all mask up, stay home when we’re sick, support contact tracing, and, eventually, get vaccinated. No group can get the infection without endangering other individuals and groups.
That’s why the unspoken advocacy for herd immunity by this White House is so revealing. “Protect the vulnerable” sounds great. But doing that while allowing the virus to spread among the young is an impossibility. It’s a scientific blunder emanating from a philosophical error.
When we understand we’re all connected, we can win. Let’s prioritize getting services to people and communities most in need. Let’s protect ourselves, our families, our community. There’s only one enemy: a virus. White House divisiveness is the best ally the novel coronavirus could possibly have.
Now, the disheartening numbers. Detected cases are up three times more than testing. Testing is up 8.6%, while cases are up 24%. What’s more, test positivity has risen from 6.6% to 7.1%. Saying cases are up because of more testing is like saying gravity isn’t real. This is an informative, though depressing graphic from The Covid Tracking Project.
Here’s a good way to show that cases are increasing much faster than testing by state. Case growth has been much higher than test increases in all states. (The published data from Mississippi has been whipsawing.)
Reported cases fluctuate by day. Generally, see lower case numbers over the weekend because of fewer office visits and tests. The weekends are time off for many people, but not for the virus. Paying attention to the seven-day average of reported cases is more useful.
Hospitalizations are, of course, increasing following case increases. It’s shameful and inexcusable that the federal government is not publishing data it has on the pandemic. NPR obtained a recent daily report from the US Department of Health and Human Services, and here’s a screenshot showing hospitalizations increasing:
Will deaths increase? Does night follow day? Of course. We ardently hope that deaths won’t increase as much as in the past, due to better care, fewer overwhelmed hospitals, and the use of dexamethasone and possibly other treatments. But only time will tell. Deaths follow case increases by about three weeks.
Wisconsin is a bellwether … including for Covid deaths. The state has seen a huge increase in Covid deaths. Many other states, sadly, aren’t far behind.
As an epidemiologist, I think a lot about numbers. This week, two numbers made a big impact on me: 13 and 9.
● 13 is the number of years of life lost on average for each of the 230,000+ Americans killed by Covid.
● 9 is the number of people, on average, grieving for each of those deaths.
These represent millions of tragedies, most of the preventable.
We public health specialists must never underestimate the health and social impact of economic harm. We’re heading into a dark winter. We can limit harm with more outdoor activities, open schools, social connections, and shopping. And by reducing indoor maskless contact in poorly ventilated spaces.
I’ve shared some bad news so far. Here’s some good news. 9 of 10 people understand the importance of masking up. Those who don’t are a small, misguided minority. Masking up correlates well with lower case counts. Mask mandates, if done well, boost mask use and save lives.
The increase in telemedicine is also good news. Primary care is the most important part of our health care system, but it’s also the most underfunded and neglected. If we get regulation and reimbursement right, telemedicine will be an important part of fixing primary care and our health care system.
An interesting data survey summarized by Covid Exit Strategy shows that in states with more than 90% mask wearing, less than 20% of people know someone who is sick. In states with 80% or less mask wearing, 30-54% know someone who is sick. Look at the top and bottom places here—the gap is striking!
One of the many, many failures of this administration’s response to Covid has been insufficient protective equipment for health care workers. It makes me SO ANGRY. We’re sending our troops into battle without the armor a competent government would have provided.
Case increases lead to a vicious cycle: longer test turnaround, overwhelmed public health, less isolation of infected patients, more cases. If we reduce cases by wearing masks, watching our distance, washing our hands, and avoiding risky indoor spaces, we can create a virtuous cycle: fewer cases, better contact tracing, and enhanced ability to stop spread.
Why harrowing holidays? Thanksgiving in Canada. The country has struggled with case increases, division, attempts to undermine science, and denials of reality. Even countries which have done relatively well are now struggling. The US, with a completely failed federal response, faces potential devastation.
“Ending the COVID-19 pandemic”? The claim in this White House letter is Orwellian.
The reality is the pandemic won’t end anytime soon. But maybe, soon, there will be an end to the completely dysfunctional national response.