New cases reported each Monday have on average been declining but not nearly as rapidly as overall state incidence rates or test positivity rates. Indeed, these latter two metrics have been decreasing exponentially for the past 4 weeks. “Catch-up” counts of cases older than 30 days diminish the predictability of where we are headed. We are not improving as rapidly as other states. Whether we are approaching a to a still-too-high plateau or an “acceptable” endemic status of disease activity remains to be seen. The very real challenge of winter is ahead of us. Nonetheless, this week’s news is favorable and can be taken as evidence that we have been doing at least something right!
The decline in new case numbers in the state as a whole is reflected in a marked progressive decrease in the number of “Red” counties in the weekly Current Incidence Rate in Kentucky, from a total of 97 at the beginning of September to only 18 in this week’s report! Unfortunately all but three of the current red counties (with an incidence rate of ?25 per 100K) are clustered in the far east part of the state, especially in the counties recently devastated by floods. It is a historical truism that disease is often a fellow traveler following disaster.
Other Metrics of Disease: Deaths are not yet falling at 67 last week. Hospitalization census numbers looks like they are going in the right direction. The number of PCR (viral RNA) tests performed has increased a little and account for only 52% of all new cases identified– still a much lower rate than in past months that I do not understand. Noteworthy is another surge in new cases in school-age individuals ?18 years old. As long as the virus is free to churn away in our schools and colleges, we are unlikely to arrive at incidence rate we can more comfortably live with this winter. Too bad that the issue of masks and testing in schools became so politicized.
Wherever we are headed, we will do so together.
Peter Hasselbacher, MD Emeritus Professor of Medicine, UofL Kentucky Health Policy Institute 27 September, 2022
Kentucky’s homegrown Covid update published last Monday evening, September 19, might be interpreted as demonstrating an easing of the Commonwealth’s share of the pandemic. There was only a very small uptick in new weekly cases with more marked decreases in the Test Positivity Ratio and the Overall Case Incidence Rate. Nonetheless, a lack of concordance of these three interconnected metrics highlights the sorry state of data collection that is badly needed both nationally and in Kentucky. We are most assuredly behind the timeline in assessment of disease activity.
I recently expressed the widely observed concern that delayed case and hospital reporting following a major long weekend holiday would be followed by compensating catchup numbers. This has been the case earlier in Kentucky. Monday’s report of 9159 new cases was in fact higher than the previous week’s, but only by 85 cases– a 6.6% increase. I was therefore surprised to see the Test Positivity Rate fall by 26.6% from 16.3 to 12.0%. In the same direction, the Overall Incidence Rate across the state continued its dramatic 4 week fall from the high of 47.0 cases per 100K population in the report of August 29. In the past week alone the Incidence rate fell a further 25.6% from 27.0 to 20.1 per 100K. In my head, this does not yet compute because the formulas used to calculate both the later two metrics are based on new case counts.
Test Positivity Rate (TPR). According the Kentucky Department of Public Health (KDPH), “Positivity rate is calculated using electronically submitted PCRs from the past seven days.” It has been calculated this way for well over a year and has the advantage of simplicity, timeliness, and consistency. It is a simple ratio of the number of Covid-positive results to the number of PCR tests performed. However, not all tests are included in the calculation– only PCR (viral RNA) tests performed by laboratories that report their results to the state electronically. This means that vast numbers of positive tests such as from non-electronically-reporting labs, antigen testing at home or elsewhere, or clinically diagnosed cases are left out of the calculation. The TPR calculated in this way has correlated very well with the number of new cases over the past 2 years. In recent months, this version of TPR identified an average of 60% or more of the number of cases categorized weekly as “new.” Over the previous 4 weeks 70 to 80% were identified in this way but dropped dramatically this week to 54%! The total number of PCR tests performed (both negative and positive) increased very slightly in this current reporting week from 39,107 to 41,436 but this number remains substantially lower than the counts of the proceeding 3 or 4 months (See figure below.) The combination of a low number of selected PCR tests being reported and a lower Test Positivity Rate should have led to a lower number of new cases from this source. Where did the other 4205 “new” cases come from?
“Uncounted” New Cases. In 10 of the previous 13 weekly reports, the increment in the number of [aggregate] Total Cases increased by amounts larger than the number of New Cases reported for that week. I referred previously to such cases as “uncounted.” I assumed that in part these included “catch-up” cases whose onset of disease occurred well before the cutoff date of each weekly report. In fact, my assumption was confirmed by an annotation by KDPH attached to its reports: “Cases reported more than 30 days after occurrence are included in cumulative totals only.” The delay in reporting is an obvious example of the archaic public health systems we work with nationally and in Kentucky. (A similar phenomenon occurs with deaths as large boluses of numbers work their way through the belly of the python that is our complex death-reporting system.) In this most recent week’s report, the increment in total cases matches exactly the number of new cases. We must assume there have been more new infections than we know about at this time.
“Incidence Rates are defined with slightly different different language by KDPH on its reports and maps. For the table of “Incidence Rates By County,” it is the “Average daily new cases per 100,000 population based on previous seven days.” For the weekly “Covid-19 Current Incidence Rate in Kentucky” published Monday evenings is a fuller description: The seven-day incidence is calculated by taking the total number of unique cases in each county over the past seven days, divided by seven to get a daily average, divided by the U.S. census bureau county population and multiplied by 100,000 to get the incidence per 100,000 people. The cases counted each day are based on the date an investigation was opened in the National Electronic Disease Surveillance System. Duplicate cases are removed before the calculation, so each positive case is included only once.” The Overall Current Incidence Rates printed on the table and the map are identical. This week’s reported rate is 11.73% per 100K, down 25% from the previous week of 26.97 and by nearly 50% from the 39.72% per 100K in the report of September 5!
The published Overall Incidence Rate has indeed dropped dramatically. So has the number of counties “in the red” (defined as those with a county incidence rate greater than 25 per 100K). The number of red counties tracks closely with overall incidence rates. The number of “high” red counties in the last 4 reports has decreased sequentially: 104, 97, 65, to the current 41. Interestingly, the number of red counties in the most recent “Community Levels by County” map of the CDC was 45. In both maps the large majority of counties with these higher incidence rates are in eastern Kentucky– some very high. The current New York Times analysis of the states assigns Kentucky a 7-day average case incidence rate of 28 per 100K in a three-way tie for highest in the nation with West Virginia and North Carolina.
Absent the historical raw data by county and any daily numbers at all, I do not at present understand an apparent discordance between the number of cases, test positivity, and incidence rates. For example, with respect to incidence rates, the number of new cases this last week hardly changed at all from the week before and the population of the state is essentially unchanged but the incidence rate dropped bigtime. The answer probably lies somewhere in the weeds of how terms are defined and the day-to-day mechanics of how cases come to the attention of the public health departments, how long it takes for local agencies to report centrally, how long it takes to enter the data into the state’s and the CDC’s analytic systems, and how long it takes to publish the results. To my eye it is clear the path is tortuous, loses much information, and takes too long to be as helpful as it needs to be.
Other Metrics in the Current Report: Current hospital census is nominally down from 584 to 456, as is ICU and ventilator utilization. How many of these actual human beings are in the hospital because of Covid or admitted for other reasons with an incidental positive test is unknown. The death count is back up to 80 per week, slowly rising since July, but much lower than the nearly 300 to 150 or so in March through early May.
To conclude this interim analysis, I want to take the optimistic position that Kentucky’s part of the pandemic is on average throughout the state simmering down, but when it started, how fast it is changing, and where it is going is not yet as predictable as I would like before we abandon all the simple things we can do to mitigate the ongoing significant damage to our collective physical persons and pocketbooks. It is obvious that in some parts of the Commonwealth that the Coronavirus is still having its way with us. We are as a whole no safer or healthier than the sickest in our midst. That is the principal that underlies the whole concept of public health. What happens in one county does not stay there.
Peter Hasselbacher, MD Emeritus Professor of Medicine, UofL 22 September 2022
Yesterday’s COVID-19 update from Frankfort reported a considerable drop in the number of new cases which is necessarily reflected in a decrease in the overall incidence rate. However, the September 12 report spans Labor Day weekend and the subsequent following week. The drop in identified and reported cases was not matched by a decrease in hospitalizations, ICU/ventilator utilization, or deaths. The number of Kentucky counties mapping as red (high) with current incidence rates of greater than 25 per 100K also fell substantially from 97 to 65 counties, but this measure is also dependent the number of cases identified within the previous 7 days. While providing a glimmer of good news, confirmation of any downward trend needs to be confirmed over the next few weeks. Previous experience in Kentucky’s pandemic demonstrated the impact of holidays and weekends on the state’s ability to provide timely and complete numbers– the Achilles heel of Kentucky’s public heath enterprise constrained as it has been by legislative restriction.
Other independant updates not as prromising. The New York Times continues to collect and analyze a more extensive set of data. Currently, the nation as a whole is in the middle of a gradual decline in new cases. The Times’ assessment of the pandemic in Kentucky reveals a devastating picture. Among all 50 states, DC, and the territories, and as of the beginning of this week, Kentucky is reported to have by far the highest case incidence rate at 70 per 100K followed by West Virginia with 42. Our statewide hospitalization rates are the fifth highest, and deaths the third. With respect to case incidence rates, among all the individual counties in the nation, five of the 10 highest and nine of the 20 highest are in Kentucky. I have no way to resolve the discrepancy between the Times’ numbers and our own, but it remains indisputable that Kentucky’s weekly report does not include very large numbers of cases. For example, the number of PCR tests done in the last week was 27% fewer than the previous week. I present illustrative charts below that led me to a conclusion that it is not yet time to declare success.
New Cases Identified and Reported:
The chart above shows the raw counts of new cases identified within a predetermined earlier period. This is clearly an undercount. The following chart shows the difference between each week’s reported “new” cases and the weekly increment in the aggregate total number of cases. Thousands of cases are identified too late to be reported in a timely way.
As expected, the state-wide overall incidence rate pretty much tracks the number of new cases. The differences between counties reman considerable. As has been the case for some time, a major hot-spot in the nation for Covid-19 infection is the Appalachian parts of Kentucky, West Virginia, Virginia, Tennessee, and North Carolina.
The Test Positivity Rate decreased a more modest 11.5% from the previous week to 16.3%. The last time the TPR was lower than this in the report of July 4, another national holiday.
The number of PCR viral RNA tests performed from which the TPR is calculated dropped a considerable 26.5%.
In recent months, some 70% of new cases have been regularly identified using PCR testing. [Home testing and antigen testing are not being accounted for separately at all, but likely are in number used more than PCR tests.] Surely the reported number of new cases is lower in part due to fewer tests being done. One does not find what one is not looking for!
The current hospital census is reported as 584 showing little change over the previous 8 weeks. The charts for ICU and Ventilator utilization look pretty much the same.
The number of new reported deaths has not changed much. We expect hospital utilization and deaths to lag the number of new cases. Given that the objective our current national strategy of pandemic management is to limit these complications, victory cannot be claimed until these sequelae of coronavirus infection are acceptable. I do not think they are now.
Community Activity vs. Case Incidence Rates. The most recent Community Activity Level map shows many yellow and even some green Kentucky Counties. A recent one-week change in Jefferson County from red to yellow is being used as a justification to eliminate a mask mandate in public schools. (I hope this is not premature as individuals 18 years and younger have recently made up as much 38% of all new reported cases statewide!) The community level is calculated using data and a formula not available to me but takes into account case incidence rates, and hospital utilization within service areas associated with hospitals outside our state line in states with overall incidence rates that are lower than Kentucky’s. If our incidence rates are artifactually low, so will be the assessment of our Community Levels.
Having had Covid-19 myself at least twice, no one wants this epidemic to fade into more of a manageable endemic infectious illness than I. I do not see that we are there yet. I will get the new bivalent booster as soon as it becomes available and urge the people I care about do the same. I will continue to wear a mask in public spaces. I do not think that makes me a bad person!
Peter Hasselbacher, MD Emeritus Professor of Medicine, UofL 13 September 2022
Our body politic is tired of dealing with COVID-19 and has been for some time. The push-back from so many directions, the effectiveness of a variety of both medicinal and non-medicinal interventions, and the reality that a majority of us (including me) have already been infected by existing strains of the causative virus has led us to a posture of dialing back virtually all disease mitigating measures. This change in approach showed up “officially” in a revised set of relaxed recommendations from the CDC related to fundamental public health measures including masking, testing, isolation, and the like. All this in the face of the facts that people are still getting sick, still entering hospitals, and still dying. The fact is that in a world where Covid-19 is perceived to be part of the woodwork of society, there is a level of disease mortality and morbidity that we implicitly accept. The same tradeoffs of benefit against harm exist across virtually any other public policy or individual decisions we make.
Our Current Posture: Is Kentucky – the “United we stand, divided we fall” state – making the right Covid choices? That we are divided in so many ways is not a matter of debate. Readers of these articles will appreciate that I and others have significant reservations on how we as a state or nation have handled the current epidemic or on our ability to handle other contemporary or the inevitable future public health issues we face. Kentucky is among the states with a “do nothing” legislature. I think it is showing.
Kentucky as a Covid hotspot. The New York Times has one of the better Covid-19 update scoreboards. Somehow, it still manages to publish daily county-specific counts of cases, deaths, hospitalizations, immunizations, and other relevant information. As of yesterday, Kentucky was not in a good place. We lead the nation with an average daily recent case incidence of 55 per 100K, behind only Puerto Rico and Guam. Our daily average hospitalizations put us at #6. In a map of disease “hot spots,’ Kentucky stands out like a sore thumb. In a listing of daily new-case incidence rates for all US counties, the top 4 are in Kentucky as are 9 of the top 20. Even before the disastrous recent floods in southeast Kentucky, those counties as a group had the highest burden of new cases in the state. The social and economic disruption resulting from the flood puts those folks at even higher risk of illness of all sorts.
While it can be argued that matters are “stabilizing” or even declining nationally, we are currently within the ranges of the previous two years that were deemed unacceptable. Hospitalizations and deaths continue to rise, albeit slowly. Data collection, never optimal, has deteriorated in completeness and timeliness. I do not know what to make of Kentucky’s own home-grown date collection. Since March of this year, Kentucky updates its Covid-19 data only once a week on Mondays and does not provide a state-wide county or date-specific database available for independent public analysis. I have been doing the best I can for this series of articles by combining each weekly report into an Excel file that I make available here. An initial look at this week’s Kentucky numbers may indicate that we have stabilized over the past 4 weeks, it certainly cannot yet be said that things are trending better and the limitations of our ability to capture accurate and timely information become even more apparent. I present some graphic updates below.
New Cases: In its report of August 15, the state posted a weekly count of new cases of 14,409. This new case number has hovered around 15,000 per week for the past 4 weeks. For the past week, this translates to an average of 2058 new cases daily.
Incomplete reporting: It can be assumed that for a variety of reasons that the number of New Cases as tallied does not reflect anywhere near the actual number of people who get infected. A second look at how Kentucky reports its cases reveals the ongoing weakness of our statewide identification and reporting systems that is shared widely across the nation. As part of its weekly summary of new cases, the state provides a running “Total of Cases.” In 7 of the 9 weeks of reports since June 20th, the increase in the aggregate counts of Total Cases exceeded the number of New Cases. The combined number of “New Cases” in past 4 weekly reports was 60,599 but the increase in aggregate Total Cases was 13,482 more than that – an amount of nearly a week’s worth of recent counts. These additional cases included those presumably identified and reported centrally to the State’s Public Health Department too late to be included in the counts of the individual current weeks. In my thinking, this means that we missed an opportunity to recognize the onset of an exponential rise in epidemic activity. Of course, if we lack the tools or willingness to do anything about it, this delay or incomplete capture of cases may not make much of a meaningful difference. Below is a chart of the weekly increment in Total Cases since mid-March. At least some of the peaks of the last 4 weeks would have shown up in a chart of daily New Cases.
Test Positivity Rate: Our Test Positivity rate remains high at 18.5% and in not going anywhere fast. In any case, this represents only a convenience sample of those getting tested for the virus by PCR RNA methods and reported electronically to the state. The number of individuals being tested weekly by PCR tests on which our TPR rate is calculated has not changed much over the past 4 months and may be declining.
Overall Incidence Rate: The number of New Cases per 100K population statewide as calculated is 35.3 per 100K and has been decreasing for the past 4 weeks from a high of 42.9 but remains quite high. A map of counties “in the red” on the state’s current Incidence Rate Map has been looking a little better in general, but 92 counties (77%) are still in the red with some counties consistently with very high rates leading the nation.
Hospitalizations: Current hospitalizations remain high and are slowly increasing as counted. It cannot be said that infections from the current viral strain are clinically trivial. New strains will come which may be better or worse. More of my friends are getting infected or affected. How about yours?
Deaths: A background drumbeat of deaths continues.
In closing, I must confess that I am losing confidence in my ability or anyone else’s to judge where we are headed. I see the same shortcomings playing out in our current handling of the Monkeypox epidemic as were exhibited for the COVID one – or for that matter earlier epidemics from which we failed to learn or were unable to prepare for the next. The world is tuning inside-out in many geologic, environmental, and social respects. Such turmoil over the ages has been associated with disease and other disaster. We in our 21st Century United States are not immune from the old or new troubles.
Peter Hasselbacher, MD Emeritus Professor of Medicine, UofL Founder, Kentucky Health Policy Institute