New Cases Covid-19 In KY May Be At Steady State, But Deaths & Hospitalizations Are Not.

It has been more than two weeks since I posted a full update of Kentucky’s Covid-19 epidemic status. As I commented on the article in following days, data collection volatility, exacerbated by the Labor Day weekend, did not give me the confidence to opine one way or the other the direction of epidemic status. Available numbers as of the evening of Thursday, September 16 are compatible with the number of new cases entering an interval of steady-state, albeit hovering between 4000 and 4500 news cases per day which exceeds the rate of the darkness of last winter. That is not a good place to be.

[Addendum: Friday evening’s new numbers do not really alter the state of affairs or conclusions outlined in the following paragraphs and graphs. Specific detail is added at the end of this article.]

Covid-19. New Cases and Deaths in KY as of Sept 16, 2021. New “Plateau” of Cases or Notch?

The 7-Day average of new cases is playing leapfrog with the 14-Day average. When the 7-Day average is higher than the 14-Day, epidemic expansion is occurring. The numbers obviously vary greatly from day-to-day, inserting a large degree of uncertainty into predictability.

Case counts by day of the week for Thursdays, which are weekdays with reliably higher daily counts. Stable or not?

Daily new case counts on Thursdays.

I like to rely on semi-log plots of exponentially rising counts as a way to estimate the rate and direction of epidemic expansion. Since the end of August, the plot of daily new cases is trending to a horizontal line representing a steady-state of the numbers of new cases– even if they are bouncing up against 5000 or more a day! If we had continued at the rate of the previous few weeks, we would have been at 10,000 new cases a day. Surely such a possibility demanded effective interventions, even if unpopular.

School-age people.
As summer activities for children and young adults blossomed and students went back to school, the proportion of new cases 18 years old or younger reported each evening by the Kentucky Department of Public Health rose from a 7-Day average of 18% to over 30% in early September– a greater than 80% increase. This rise occurred in the midst of intense controversy about masking and vaccination of students, teachers, and school staff. Hmm.

Hospitalizations, ICUs or worse.
As would be expected, the number of deaths of cases emerging since July 1( as depicted in the first graph of this series above) is entering a more rapid expansion. It will take a while for a full accounting of those deaths to be finalized. The consensus of reports from hospital and other entities is that this newest expansion of hospitalizations and deaths (and in particular ICU and ventilator use) is occurring almost entirely in unvaccinated individuals and is related to the increased virulence of the current universally present Delta variant of the virus.

Hospital and ICU utilization for Covid-19 in KY as of 9-16-21
ICU (Red) and Ventilator (Yellow) utilization for Covid-19 in KY as of 9-16-21.

We expect Covid-19 deaths and hospitalizations to move in the same direction– albeit out of phase with each other. The sequence begins when individuals are exposed and get infected. Some get symptomatically ill. A smaller proportion of these require hospitalization and an even smaller number require ventilatory support. The odds of surviving being put on a ventilator vary considerably by reporting entity, but they are not what anyone would consider good. Against this context, achieving a “plateau” of hospital, ICU, or ventilator use is not a favorable sign if those facilities are already fully in use. This is happening in many places around the country including Kentucky. Some localities are operating under a formal “crisis status” in which the most difficult life or death triage decisions must be made. (I do not ever want to hear a politician utter the words “death panel” again to scare people into not supporting reform of our non-functional healthcare system!)

To conclude.
I believe Kentucky, indeed the nation, is poised at one of a sequence of tipping points in terms of the future of our Covid-19 epidemic and its consequent effects on our healthcare, social, and financial futures. I am unwilling to concede that we are doing OK. It troubles me that coordinated and informed responses to the virus do not yet exist. Our political system that should be looking our for our health and welfare interests has abandoned that responsibility to business and the private sector. I want very much to believe we can expect a rapid turn-around, but in all honesty I see things getting worse first.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
Kentucky Health Policy Institute
17 September 2021

[Addendum 9-18-21: A new set of Kentucky Covid update numbers was reported Friday evening. Numbers for Saturday, Sunday and Monday will not be available to me until Monday evening.

New cases increased from Thursday to 5133, one of three times in the last 14 days in which counts exceeded 5000 of which twice occured in the last three daily reports. The 7- and 14-Day averages did not change appreciably. The 7-Day average still exceeds the 14-Day average compatible with epidemic expansion. The number for a Friday has been about the same for the last three weeks. A count for the past week will not be available to me until next Monday but is high. The semi-log plot of new cases remains horizontal describing a steady state of new cases. The 7-Day average of the proportion of new cases in individuals 18 and under remains high at 28.1%.

Testing: The 7-Day number of new tests reported which began rising significantly only in early August is 39,253. In June and until mid-July, daily test counts only occasionally exceeded 10,000. Friday’s 7-Day average of electronically reported tests was 12.9, down from a high of 14.6 on September 8. (There is a complicated but significant correlation of both the Test Positive Rate and number of new cases with the number of tests performed and even hospital census that deserves further consideration.)

Hospital, ICU, and ventilator utilzation for Covid-19 remain at the same high levels as they were last week.

Deaths are clearly on the rise with an additional 45 reported yesterday. This rising trend will surely continue for a while.

The KHPI Tableau Public portfolio of data visualization has been updated with Friday’s numbers as will be with next Monday evening’s.]

Kentucky’s New Daily Covid-19 Cases May Be Peaking.

As of Wednesday September 1, several lines of data point to a decreasing rate of new reported cases if not a peaking– albeit at record high levels. However, hospitalizations and deaths are expected to rise further!

It’s hard to be content with 4941 new cases Wednesday. Last week delivered the highest number of cases in any week of Kentucky’s epidemic, even higher than those of last December and January. Except for one aberrant reporting day on January 6, last week contained the two highest daily case counts for the entire 544 days of known Coronavirus in our state. The 28,850 new net cases added last week (from Sunday through Saturday) were 2,423 more than the highest week of last Winter! This August had only 618 cases fewer than the previously high month of month of January 2021. Today’s 7-Day average of new cases of 4,212 is the highest to date even with the low counts over the weekend. The 14-Day average is also at a record high.

Covid-19 Cases and Deaths as of 9-1-2021. Kentucky

7-Day and 14-Day Averages of New Cases.
When the 7-Day average of new cases is higher than the 14-Day average, the epidemic is expanding. When the 14-Day average is higher, the reverse is true. The difference between the two averages gives a measure of the the rate of expansion or contracture of epidemic spread. While the 7-Day remains higher as of 9-1-2021, the difference between the two is as small as it has been since early July. Until the last day of June when our epidemic was still shrinking, the 14-Day average was higher.

Comparison of 78- and 14-day averages of new Covid019 cases in Kentucky as of 9-1-2021.

The Test Positivity Rate also has been rising rapidly to new highs, but recently appears to be rising more slowly. However, it remains at record high levels. The 7-Day average of New Tests per day is at its highest level since November 22 and still rising. More people are getting tested. Testing more asymptomatic individuals will cause the test positivity rate to decrease.

KY 7-Day average of new Covid-19 cases and Test Positivity Rate as of 9-1-2021.
Daily Covid Tests with 7-Day average of tests as of 9-1-2021.

So why does this glass-half-empty analyst see a glimmer of a hope that things are slowing down? Since March of 2020 I have been slicing and dicing the daily basic reports of cases, deaths, testing, and hospital utilization data seeking a way to answer the question “are we winning yet?” This self-assigned task was made more difficult by the existing lack of an organized and uniform testing and data collection system in a Commonwealth underlain with multiple under-supported and semi-independent public health departments. Numbers varied dramatically depending on the day of the week or the presence of holidays. There were built delays in reporting to the state public health systems– sometimes dramatic ones! Large backlogs of tests, cases, and deaths were reported periodically. There were state and contractor computer system failures. No database of historical state epidemiologic data was made available to the public even when requested. I had to depend on outside organizations for things as basic as historic case and death tallies by Kentucky county. Against this background, let me outline why I think the hard-fought efforts of Kentucky’s Public Health Department and the individual citizens of Kentucky may finally be having a demonstrable effect despite well-organized political and ideological resistance.

Case counts vary rather predictably depending on the day of the week. For example, since March 1, 2021, daily counts have on average been lowest by half on Mondays, followed closely by Sundays, rising considerably on Tuesdays, reaching a weekly peak on Wednesdays, and then gradually decreasing through Saturdays. Beginning in early July, each day of the week had case counts markedly higher than the same day of the previous week. This changed beginning Monday, Tuesday and Wednesday of the current week when the weekday counts are similar to those of the preceding week. (You can click through the individual weekdays on KHPI’s Tableau Public data visualizations.)

Semi-log plots.
Simply inspecting curves of aggregate case counts or even rolling averages on the usual rectangular/linear graph paper is not particularly helpful right now. The curves still ascend in a near-vertical manner. That is what exponential growth looks like. Plotting exponential or rapidly rising data in a different way can give useful insights. Graphing new cases as a function of time using a logarithmic scale for cases and a linear scale for days allows the same plot to include both small and large numbers. Furthermore, a simple linear regression on such a plot yields a straight line when the rate of exponential growth is not changing. This can allowing some degree of forecasting the future. For example, during last July, new daily cases were doubling about every 10 days! I predicted then we could hit 5000 cases per day by early August which was pretty much on target. During the weeks of August, semi-log plots of both daily cases or rolling averages have begun to fall noticeably below the predictive trend line. During August, the doubling time of daily cases lengthened to 17 days. Instead of reaching 10,000 cases per day by early September as July’s data would have allowed, and if nothing else changes, we could still reach that number by the end of September. A “plateau” or bending of the curve is simply not good enough! Hopefully Kentucky’s citizens will continue to make effective responses to our common predicament. Eventually, even if we do nothing as some would recommend, the epidemic wildfire will burn out– but as with the forest fires of our western states and elsewhere in the world, at what cost? We are asking people to do hard things. We have to support them.

Semi-log plot of daily new cases as a function of time as of 9-1-2021.

Below is another view plotting new cases in a semi-log manner but using the 14-Day average of new cases to smooth out the curve. Over this two month interval, the curve first rose and then fell below the trend line.

14-Day average of new Covid-19 cases in Kentucky plotted in a semi-log manner. July and August 2021

I have nothing reassuring about hospital, ICU, or ventilator utilization to write about at this time. All three of these markers of severe infection are worse than ever. Hospitals and their staffs are being crushed. Deaths are already clearly on the rise. Given the passage of time for individuals to move thorough the stages of infection, hospitalization, and ICU to death, we have not yet seen those numbers peak. It is the unvaccinated who are filling the hospitals and dying. A leveling off of the ICU or ventilator curves at high levels would be seen when there are no ICU beds or ventilators left to use!

Hospital and ICU Utilization by Coronavirus patients as of 9-1-2021.

While I am hoping that this apparent decrease in the rate of our epidemic explosion is real, I would like to see a few more days of data to be confident. Complicating matters is the upcoming Labor Day weekend with its celebratory events and holiday-related delays in public health reporting. The fall season will present us with predictable venues for the spread of infection including schools, colleges, concerts, and sporting events which bring the vaccinated and unvaccinated alike together for education and entertainment. It could be the Fourth of July all over again! These are wild cards that upend the usual making of odds. It would be nice to win a few hands for a change. It would also be nice to feel like someone or some entity was still looking out for our benefit! Kentucky’s legislature has taken charge of day-to-day public health management and that makes me feel very much unsafe.

Peter Hasselbacher, MD
Kentucky Health Policy Institute
Emeritus Professor of Medicine, UofL
1 September 2021

Unbridled Individualism Overwhelms Kentucky Hospitals With Covid-19 Admissions.

It’s January all over again in August– except for the temperature!

Tuesday’s New Case, Test Positivity Rate, and Hospital data continue their sharp rises equaling or exceeding the worst days of the epidemic in January. There are no reliable signs of things slowing down.

New Cases.
The number of new cases reported yesterday was 4,638. Of these,29% were in children and teenagers 18 and under. This was by far the highest number of Tuesday cases since the beginning of the epidemic, higher even than the 4,127 cases reported last December 1. Similarly, Monday’s new case count of 2,596 was the highest ever for that day. The counts of the previous Thursday, Saturday, and Friday were in the range of the worst of last winter’s surge.

KY Covid-19 Cases and Deaths as of 25 Aug 2021.

The 7-Day New Case Average is 425 cases higher than the 14-Day Average indicating a rapid rate of epidemic expansion exceeded only by one anomalous day in early January. There were 23,196 new cases last week (Sun to Sat), exceeded only marginally by 3 weeks last December and January. To visual inspection, the plotted curve of new daily cases shows its sharp upward climb to be unchanging. The Test Positivity Rate reached above 13% last week, the highest ever. All of these indicators are compatible with our entry into the worst of Kentucky’s surges– and this with a much-reduced percent of population still susceptible to recognizable infection!

Predictably, the number of deaths daily is noticeably rising. It takes weeks to months for the classification and recording of deaths to work its way through the system. We cannot predict at this time how bad it will get. The unmitigated disasters we are seeing with Covid-19 admissions to hospitals foretells much sorrow remains yet to come.

At no time during Kentucky’s version of the pandemic has the number of inpatient Covid-19 patients in our hospitals and ICUs been greater. As ICU utilization has increased, so has the number of patients on ventilators– 338 yesterday. (In May and June that number was usually under 50.) There are no signs of increasing hospital utilization slowing down. By all reports, Kentucky’s hospitals are collectively overwhelmed. Patients are younger, sicker, and unvaccinated. Virtually all of the ICU and ventilator patients have not been vaccinated. Analysis of deaths around the world following surges tells the story of “excess deaths” due to the undercounting of cases, and avoidable non-Covid deaths of individuals encountering lack of access to medical care for both preventative or acute conditions.

KY Hospital and ICU Covid-19 Utilization as of 25 Aug 2021

Is there any good news?
Many Kentuckians have on their own began to apply the successful public health measures that broke the back of the mid-winter disaster. I am seeing more masking on the street and in stores. Some private and governmental requirements for vaccination or masking are in place but these are vulnerable to change. At least one vaccine has received full FDA approval. Some school districts see the tidal wave coming and are requiring masks. (However masks alone will not do what is needed. Some schools or districts are already having to shut down in-class teaching because of the inevitable intrusion of Coronavirus in the classrooms. This is what unavoidably happens in schools, workplaces, nursing homes, and prisons.)

A semi-log plot of daily new cases since August 1 shows a tantalizing drift toward a lower rate of exponential growth, but we are still in an exponential growth phase. The Test Positivity Rate has not changed much the last three days after a relentless climb. Daily tests reported have been rising since July. People are playing attention! However, any sign of stabilization of new disease spread could evaporate over the course of this week. It is premature to declare a “plateau.” The full events of the Summer-surge on hospital utilization and deaths have yet to play out.

The politicization of epidemic health care is not playing out well. Kentucky’s Governor and our public health system’s ability to effectively intervene is being hamstrung by Republican party legislative and other opposition that has so far not offered alternatives other than to let the fire burn out. I suggest that the nation is burning up in more ways than failed management America’s epidemic of Covid-19.

The usual full updated of interactive data visualizations can be viewed on KHPI’s Tableau Public website.

Peter Hasselbacher, MD
Kentucky Health Policy Institute
Emeritus Professor of Medicine, UofL
25 August 2021

[Addendum 26 Aug 2021:
Wednesday evening’s update from Frankfort was not encouraging. The 4,849 new cases reported was the highest for any Wednesday since a single aberrant day in January. Thirtyone percent of the new cases were in individuals younger than 18. The 7-Day average of new cases was only 200 fewer than the maximum on January 12. The reported 65 new deaths is the highest daily tally ever excepting those days in which a backlog of deaths was added all at once. (There was no such qualifier notice on yesterday’s report sheet. The Test Positivity Rate as presently calculated of 13.2 is the highest ever . Hospital and ICU and Ventilator utilization are still at record highs. All this is decidedly not good. Pizza and circus is not going to help.

Less awful numbers include a steady gradual climb in the number of people getting tested. The rate of exponential rise (still high) may be marginally decreasing but hardly enough to turn any corner.

Wednesday’s numbers have been updated on KHPI’s Tableau Public website using the link just above.]

Kentucky’s Covid Epidemic Running Uncontrolled So Far.

Without further changes in public behaviors, at this rate of epidemic expansion, Kentucky can hit 10,000 new cases per day by the end of August.

Yesterday, Friday August 13, there were 4009 new cases of Covid-19 reported in Kentucky. The last time more than 4000 cases were reported was January 14 when we were still in the worst of Covid times of the Commonwealth. The highest daily report of new cases to date was 5705 on January 6. Review of daily case reports, test positivity rates (TPR) and Covid-19 hospital utilization all reveal that we are circling back from the lowest indicators of epidemic activity back to the highest in a matter of only 6 weeks.

The usual displays of daily, weekly, and monthly cases, deaths, and tests are available on KHPI’s Tableau website. Below are three different data visualizations that show were we have been, and where we appear to be going.

Relationship of 7-Day average new cases to Test Positivity Rates, KY.

Beginning last October, both TPR and new cases rose to their peak values in December and July of 2020-21. By June 2021, the availability of vaccines and at least some adherence to public health measures drove both measures down to the lowest levels of the entire epidemic. We were feeling good about things. Masks came off, people got together, vaccinations stalled, and the Delta variant entered the scene. Much faster than most of us (including me) could imagine, we have in the span of only 6 weeks rocketed back to the worst of our Kentucky epidemic experience.

Our hospitals are getting clobbered. The corresponding plot below puts us right back into December-January territory. This is going to hurt!

Relationship of Test Positivity Rates to Covid-19 hospitalizations, KY.

We will not have additional case and death updates until next Monday evening. I have to trust the good sense of Kentuckians that we are buckling down again in the interest of protecting health and our economy and keeping ourselves and our children in school and the work places. However, unless nothing else changes, and based on actual daily reported cases since last July 1, we are on a path to disaster.

Semi-log plot of Covid-19 Cases per day against time. July 1 to Aug 13.

[Plotting cases against time on a semi-logarithmic graph turns a curved exponential line into a straight one. The straight line shown below is highly statistically significant even with the day-to-day variation in case counts. (R-squared= 0.83, p= 0.0001.)]

As impossible as we would like to believe, this projection (which has proven accurate so far) would forcast 5000 new cases by August 19, and 10,000 by August 28, doubling every 9 to 10 days. We have the tools available to lessen the damage and put us back on a glide slope to a more normal way of life. The CDC, national and Kentucky public health officials and healthcare providers, the Kentucky state school board, colleges and universities, and private employees are taking matters into their own hands by enforcing pubic health protections and even mandatory vaccination. Our Governor and his cabinet are trying mightily to guide us out of this wilderness but are opposed by self-serving individuals and political entities within the state offering nothing more than a let-er-rip approach. The graphic above shows where that will take us if we do nothing. We are not lemmings. I believe that the better and wiser angels of our nature will guide us out of this nightmare.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
14 August 2021