Sunday, June 14, 2020

What Next With Covid-19?

What should we expect next with Covid-19?

Almost every state has reopened a least parts of their economies. Some states are returning to some sense of normalcy with the exception of very large gatherings. The New York Times has useful data on the reopening status of all 50 states.

Of course, any ban on large gatherings clearly did not apply to the protestors and rioters who took to the streets over the last several weeks.

For example, here are two pictures of a mass protest in Brooklyn today.





Of course, while this is going on what is Governor Cuomo worried about? Not enough social distancing in bars and restaurants in Manhattan and the Hamptons.




The reopenings and the mass protests has led some public heath experts to state that we could soon see a resurgence in Covid-19 cases nationwide. This is a particular concern in large urban areas which we have already seen are particularly vulnerable to the spread of the virus.

For example, Dr. Ashish Jha of Harvard said this on June 2 about his concerns about future outbreaks of Covid-19 due to the combination of the reopenings and the protests.

I do worry that a few weeks down the road, we will see increase in cases and potentially some outbreaks and really harm the communities that have been the subject of both racial violence and have been so disproportionately impacted by this virus.
We're really in a very difficult time. We're in the middle of a pandemic, at one of the worst public health moments in a century. The country is opening up. And then on top of that, you have civil unrest from long-standing racial injustices. Put it all together, and it's a very perilous moment for our nation.

Then again, 1,288 public health professionals, infectious diseases professionals, and
community stakeholders signed an open letter recently stating that it was more important to protest against systemic racism than it was to worry about the spread of Covid-19.

 ...as public health advocates, we do not condemn these gatherings as risky for COVID-19 transmission. We support them as vital to the national public health and to the threatened health specifically of Black people in the United States.

Of course, these same experts had argued a few weeks earlier that the protestors who gathered in state capitals around the nation to protest the economic lockdown were a dangerous threat to public heath.

How do they explain the difference between the two groups of protestors?

They argue that "white supremacy" is a lethal public heath issue that predates and contributes to Covid-19.  Therefore, protestors who wanted to be allowed to go back to work (protestors who were in their words were "predominantly white") are a public health threat while those who protest with Black Lives Matter are vital to the national public health.

It is all confusing to someone like me that is just trying to look at facts and evaluate the data on Covid-19.

Are we going to see a resurgence of cases or not? We will soon find out.

If we do, can the resurgence be blamed more on the reopenings or the mass protests? Or both?

We have already started to see media reports of spikes in new cases in various states. 

Let's look at the most recent data to determine where we are right now.

This chart from Johns Hopkins provides a great perspective on where we are nationally in that it shows the numbers of tests, the positive cases and the % of positives in one graph.

This is undoubtedly good news.

We are now doing around 500,000 tests per day nationally. Positive tests results have dropped to below 5% on a 7-day rolling average. Over 20% were testing positive during most of April.



Source: https://coronavirus.jhu.edu/testing/individual-states/usa



Testing volumes are up. Positive cases are down. These are both positive trends.

The data is particularly good in New York which unquestionably has seen the most severe impacts from the virus.

New York is now at a 1.4% positivity rate. It was close to a 50% positivity rate at one time.


Source: https://coronavirus.jhu.edu/testing/individual-states/usa


34 states are now at less than 5% positivity rates.

Source: https://coronavirus.jhu.edu/testing/testing-positivity



17 states are above the 5% recommended positive test objective.


Source: https://coronavirus.jhu.edu/testing/testing-positivity


Some are pointing to the increased cases that have appeared in Texas and Georgia which are two of the states that reopened earlier than most.  Will the mass protests that occurred in Atlanta, Austin, Houston and Dallas add fuel to the fire? We will see over the next 7-10 days.

Another positive sign is the CDC's dataset on Outpatient Illness Surveillance, which tracks patient visits to doctors and clinics for any symptoms that resemble the flu (including Covid-19). We are now seeing these visits even below the normal activity levels we usually see at this time of year. 

Compare where we are today with the high level of sustained activity we saw earlier in the year and up until the middle of April when it started to rapidly decline. These visits are now running below what they would usually be this time of year even with Covid-19 in the mix.


Source: CDC

Compare the national map ILI map from the week ending March 21 with the week ending June 6.


ILI Activity Map---week ending March 21, 2020
Source: CDC



ILI Activity Map---week ending June 6, 2020
Source: CDC


Why is this important? This surveillance data is monitoring those presenting themselves to health care providers with symptoms. Despite what we were told previously, more evidence seems to suggest that asymptomatic cases (those that never show any symptoms) do not result in much transmission of the virus due to low viral loads.

In fact, a new study out of Singapore suggests that there is very little transmission of the virus even in presymptomatic cases. Direct contact tracing of locally acquired cases showed that only 6.4% of the cases were transmitted that way. Further, the replication rate (R0) of asymptomatic cases was almost negligible--R0 of .1. This indicates the virus is 10x-20x more efficiently spread after symptom onset. What is the most effective way to avoid spreading the virus?---IF YOU HAVE ANY SYMPTOMS AT ALL STAY AT HOME AND QUARANTINE YOURSELF FROM OTHER PEOPLE. 

The following chart from Johns Hopkins  (via @EthicalSkeptic) also shows that hospitalizations are dropping nationally at a faster rate than new confirmed cases. This may indicate that newer cases are less severe, possibly indicating that the virus is weakening. It may also suggest that more of the new cases are attacking younger people with stronger immune systems that do not result in hospitalization.





There is a lot of positive news in this data.

However, will we see these favorable trends reverse in the near future?

The next week to ten days should tell us a lot.

The protests began May 26 in Minneapolis and spread across the country beginning on May 27. They appear to have attracted the largest crowds in the the first few days of June.

We are now just about two weeks removed from the period when the crowds in the streets were the largest. In that Covid-19 generally has an incubation period of 2-14 days (with an average of 5 days), if we are to see a spike in cases it should come over the next week.

We are also generally at least 2-4 weeks into reopenings for restaurants, bars and retail in most parts of the country.

If we don't see a spike in cases in the next week or so, I think it will be very hard for any governor or public health official to defend any further statewide lockdowns. We may see targeted actions where there are local flareups but I don't believe we will see a repeat of the prior lockdowns. The credibility will no longer exist with the public to justify these types of actions.

Credibility that is lost is gone forever. We clearly saw that in Ohio this past week when the Public Health Director, Dr. Amy Acton, resigned her post. Acton, along with Governor Mike Dewine, had received a lot of praise early on for their proactive steps in dealing with Covid-19. 

I supported the measures that Acton recommended until the end of March. It made sense to me to be cautious since there was so much we did not understand about the virus, However, as we got to the end of the initial lockdown period the models no longer were supported by the data being reported. Acton predicted that Ohio would see 10,000 new cases per day at the peak. I saw nothing in the data being reported that would suggest anything close to that. Nevertheless, Acton (and Dewine) doubled down on the lockdowns. 

This is what I wrote at that time ( March 29, 2020) before citing my reasons that I thought their models were wrong.

I must admit when I first heard that number (the 10,000 cases/day) it was hard to process it. I am not an expert epidemiologist or public health expert. I know that exponential infection rates are hard for the mind to process. However, I am a numbers guy and I have to tell you that at first glance that model does not pass the smell test to me.

I could be 100% wrong. This might prove to be the dumbest and most misinformed blog post I have ever written. However, let me give you are a few reasons that I question that conclusion.

I was not wrong. The highest number of cases Ohio ever saw was 810 in one day.

In fact, we later found out that a majority of the Ohio cases were coming from just two sources---nursing homes and prisons. Acton and Dewine clearly knew that but chose not to disclose this highly relevant information until later in order to support and extend the lockdown orders.

As of June 10, 71% of all deaths from Covid-19 in Ohio have been of those residing in nursing homes. This is another data element that was never highlighted by Acton until many, many weeks had passed.

Acton and others who kept telling us to follow the science did not do it themselves. They seemed to be more interested in supporting their policies than following the science to adjust their policies as more was learned about the virus.

On the other side of the ledger, President Trump is starting his political rallies this coming Saturday. Dr. Anthony Fauci stated that any large group gathering is "risky" and a "danger" at this time. Fauci referenced the upcoming Trump rallies as well as the protests we have seen the last several weeks in making those comments.


Trump rally in Minneapolis, October, 2019


One thing is for sure. If cases are identified as coming out of a Trump rally we will never hear the end of it from the national media. It is doubtful you will ever see a connection made with any cases that come out of the mass protests. It is much more likely that new cases will be blamed on the reopenings. 

However, if there are minimal ill-effects from the Trump rallies it could be a huge psychological boost to the entire country in getting back to normal and enhancing Trump's re-election prospects. 

Would I be willing to do the same thing right now if I was in Trump's shoes? I probably would want to  hold off on any rallies until after July 1 so I could see the Covid-19 case counts in the wake of the mass protests before proceeding. However, I am undoubtedly more conservative (and cautious) than Trump.i
Of course, take into account the fact that Trump is a billionaire and President of the United States and I am writing a marginally successful blog when determining who has better judgment.

It is another example of how Trump is different than the normal politician. This is what I wrote about Trump on this subject a couple of years ago as he was embarking on his diplomatic efforts with Kim Jung Un of North Korea.

People can say a lot of things about Donald Trump. However, they cannot say that he is afraid to be great.

Most Presidents never become great because they are typical politicians. They try to play both sides. They are afraid of offending anyone. They don't take strong stands. They are risk averse. They don't put themselves out there to succeed...or fail. In short, they are afraid to be great.

Greatness does not follow when taking the easy road. It only graces those who are not afraid of the challenge on the hard road.

Success is never assured. Trump may fail bigly. However, he is not afraid to be great. That in itself is a rare commodity. Keep that in mind as you listen to those who criticize Trump.

You cannot be great unless you are not afraid to be great.

What's next with Covid-19?

We will soon find out.

And what we discover could have a meaningful impact on the path leading to the November election.

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