Record Numbers of New Kentucky Covid-19 Cases Continue.

We have not yet seen the corner much less turned it.

We anticipate artifactually lower new reported cases and deaths from Covid-19 disease due to holiday work schedules and fewer individuals being tested. New case counts may also be lower recently due to failure of at least parts of the reporting systems of one of the state’s major viral testing laboratories that has not yet been either acknowledged or confirmed by state authorities. If delays and incomplete reporting is the reason, we should expect the record-breaking catch-up counts of the last week to begin to drop, followed much later by a decrease in daily reported Covid-19 deaths. As of January 10, that has not yet happened.  At this point, until and unless we see major decreases in daily case and then death counts, we should assume that as is currently the case in many other places in the USA, we are in the middle of a rapidly expanding viral epidemic.  The evidence supporting this concern is summarized below and displayed visually on KHPI’s Tableau Public website.

New Record Highs for Daily Cases.
We expect in Kentucky and nationally that certain days of the week will have statistically higher or lower case counts than others.  For example, Sunday and Monday have been low-count days.  It is noteworthy that in each of the past seven weekdays save one, new record highs were set. The exception was last Tuesday, January 5th with 1693 new unduplicated cases. The last time a Tuesday count was lower than that was October 20th with 1297 new cases.  You can step visually through the counts by weekday here.

Weekly New Cases.
Counting cases by week is one way to average out day-to-day variation but even weekly counts are subject to holiday distortion.  [KHPI defines weeks as from Sunday through Saturdays.] Weekly counts began to rise sharply in October with a hiatus during Thanksgiving week followed by a corresponding jump upwards to 23,883 cases the following week beginning Nov 29th. For the next two weeks of December, weekly new cases fell modestly to 19,904 for the week ending December 19.  I would like to believe that short-lived downward trend was due to the more aggressive public health measures requested but, unfortunately, too often ignored.  The very next week was Christmas week when the weekly count ending Dec 26th dropped to 14,999.  It’s been all dramatically upwards since then with 26,427 cases the week ending yesterday, January 9th. 

Monthly New Cases.
Looking at new cases through a monthly lens tells the same story from a higher elevation. From a more gradual monthly increase in cases that began to accelerate over the summer, there was a sharp jump in the month of October to 38,379 with even more dramatic increases to 72,822 and 93,340 new cases in November and December respectively. The case-counts for the first 10 days of January have reached 34,244.  At the current rate, by the end of the month we would have 102,734 January cases. 

7-Day and 14-Day Rolling Averages of New Cases.
It has become obvious that even 7-Day averages of new cases are not exempt from artifacts related to data collecting and reporting.  For that matter, even a 14-Day rolling average has been all over the place this past month.  The current averages for 7-Day and 14-Day rolling averages as of yesterday set new Kentucky record highs at 3828 and 3326 cases respectively.  The extent to which the 7-Day average exceeds the 14-Day average can be considered a proxy for the reproduction rate of the virus. By this measure, our rate of epidemic expansion has been increasing for most of the last 3 months.  Indeed, rate of increase in the total number of Covid-19 cases has been increasing at almost the same rate since early Summer. Tinkering around the edges of an actively resisting public has not broken the back of this epidemic in Kentucky.

Case data as of January 10, 2021. Kentucky

Deaths.
The trends related to death pretty much track those of cases albeit delayed as expected.  Deaths in November and December were 423 and 754 respectively. There have been 239 reported so far in the first 10 days of January with many carry-over deaths from infections in December yet to be added to the total.

Immunization Against Covid-19.
As a 75 year-old guy, I plan to get my shot at the earliest opportunity.  I trust it will help protect me and those I care most about– including my readers and everybody else!  However, it is becoming obvious that the national roll-out has been under-planned, under-financed, and with the buck passed down to local authorities to take either praise or blame. Although it seems clear the immunization will largely protect individuals from the most serious effects of Covid-19 disease, it will take more time and study to determine the extent to which immunization prevents individuals from infecting others or how long the protection lasts. Even conservative experts predict that it will take much if not most of the next year to immunize everyone who wants the shots. It is not even a given we can reach the high degree of community immunization necessary to protect us all into the future in the face of a circulating and changing virus.  

I read this morning that some individuals seeking to be immunized in drugstores, supermarkets, or even by healthcare providers are being told these are accepting reservations only from “existing customers” who presumably will buy other items or remain “customers.”  Wrong!  To the extent can happen, I am much bothered.  Finding our way out of the plague of 2020 will require that all individuals living in America will have access to healthcare professionals who are responsible for them and are able to keep track of how they are doing.  At the very least, our healthcare and public health systems [Why are they not the same?] need to know who has been immunized and who is due for their second shot.  Are immunizations successful in preventing infection or reinfection?  From a public health perspective, we need to be able to tell if what we are doing for prevention and treatment is both safe and effective.  Please explain to me again why we do not need a national healthcare structure?  This is not the last pandemic we will face.

Conclusion.
Until we see some major decreases in new Covid-19 cases, deaths, and hospital utilization, we should expect that for at least the near-future, the worst is yet to come– vaccines or no.  I fear that Kentucky is not yet ready collectively to pull together to save either our bodies or the soul of our community.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
January 11, 2021

Backed-up Holiday Covid-19 Testing and Reports Now Coming Online.

  

Failed Reporting System May Add to Delays.

I intended to wait until the end of this week to present my usual Covid-19 status update.  I wanted to give our Kentucky testing and reporting system more time to settle out.  An initial dramatic fall in new case counts over the December holidays was expected both here and nationally.  As might be anticipated, Kentucky’s 7-Day average of new daily cases fell 40% from its post-Thanksgiving record high of 3387 new cases on Dec. 6, to 2021 new cases on Dec. 29.  (See figure below.) Some headlines around the country actually reported this as if it represented a turning of the epidemic tide when it actually largely reflected holiday delays in testing and reporting!  As of yesterday, Jan. 7, the 7-Day average of new Kentucky cases rebounded to 3150 with back-to-back daily counts of 5705 and 4889 for the two most recent days.  Given the very low relative counts of the three previous days, it is virtually certain that our 7-Day average will continue to soar.  The same scenario is playing out nationally.  “On fire” is a term often used.

7- and 14-Day Averages of New Covid-19 Cases in KY as of Jan 7, 2021.

Emerging new virus strains.
There are multiple reasons to heightened concern and to maintain public health measures more strictly than we are now. We must assume that the more highly transmissible variant of the Coronavirus that is currently plaguing England, France and other countries is already spreading widely in the United States.  One can reasonably speculate that to the extent of allowing the virus preventable time to evolve, the emergence of a more “successful” versions (from the viruses’ point of view) becomes more likely. This demonstrates evolution in action and it has not stopped!

Vaccines haven’t had enough time to have their overall impact.
While there are two vaccines available today with more to come, the roll-out has been disappointedly slow and most estimates are that months will be needed to cover the necessary number of people. The reasons for the slow start will be debated for some time to come.

Great treatments for sick people not yet discovered.
While initial studies of several treatments for Covid-19 showed some benefit for some patients, the benefits are marginal at best.  Some that were tried in the real world proved ineffective or worse.  Those whose professional expertise is to judge the quality of studies of the clinical effectiveness of Covid-19 treatments available to date are concerned. Suffice it to say that no “magic bullets” have yet emerged.

Hospitals and clinical systems overwhelmed in several states.
This is a real issue in some places and is requiring actual patient tirage.  Not all modalities are available to all patients.  Allocation of treatment settings and modalities are in some places actually being based on determinations of potential survivability. Some will legitimately and ethically  label this as avoiding futile treatment, while others will consider it rationing.  (The truth is we ration health care all the time in other ways.  Not everyone gets the full treatments available to most of us.)

Plateau or saturation?
In Kentucky the numbers of Covid-19 patients in hospitals and ICUS are as high as they have ever been but total numbers statewide are not currently rising in a major way.  One can call this a plateau, but the situation will be different for every one of the 100+ hospitals in Kentucky.  I am hearing from professional friends in Louisville that at least some hospitals with the greatest patient loads are struggling.  Additional intensive care beds are being set up in new hospital locations.  Hospital staff are under terrific pressures and limitations may be driven more by numbers of healthcare and other staff than the counts of physical beds. I do not have the necessary in-the-trenches information to offer an opinion about the sufficiency of current hospital capability. I do assume that individual hospitals face a different set of challenges, and that a flat utilization curve may represent both a sub-maximal “plateau” of acceptable capability or alternatively, saturation of available resources. 

Testing:
The number of reported tests for Coronavirus in Kentucky have been declining significantly since the end of November. Last week was the lowest in several months even as eligibility for individuals to be tested has been expanded to anyone who wants one.  I am not well informed about who is getting what type of test or where, and what is being reported or not. I do know that there has always been considerable volatility in daily reports by the Commonwealth.  For this reason, Kentucky has been calculating a Test Positivity Rate as 7-Day rolling average of a subset of daily tests but using only tests for the gold-standard PCR- viral RNA, and only those submitted by testing companies that report their results to the state electronically. That Positivity Rate has been rising significantly and is currently almost 12%.  (For most of December it was between 8 and 9%.)  This figure provides a rough estimate of the incidence of viral infection in the community, but its calculation is critically dependent on who is being tested and the completeness of reporting. If only symptomatic people are tested, the percent positive will be high.  If asymptomatic people are tested, the percent positive will be low.  Unfortunately, a failure of the result -reporting system of one of Kentucky’s major testing vendors broke down as recently as last week.  I do not know if this has been reported previously so I do so below.

Broken Reporting of test results to individuals by Bluewater Diagnostic.
On Monday morning, Dec. 28, with some minor upper respiratory symptoms and perhaps an overabundance of caution, I drove to the drive-through testing center at Southeast Christian Church in Louisville, one of two local state-promoted testing sites available to people without an appointment. There were perhaps understandable parking-lot navigation issues.  I was screened for symptoms and relevant contact and health insurance information.  Administrative matters included hand-carrying the paper data-collection forms to computers housed in small trailers adjacent to the line. (It was, after all, a parking lot.)  I think things went as smoothly as could be expected and I was able to leave about 3 hours after I arrived. When I asked, I was told that I would receive the results by email or text 4 days later– Thursday, Dec 31.

By late Thursday afternoon (New Year’s Eve), I had not yet received any result and was looking at the long holiday weekend ahead and anticipating a longer wait. My physical symptoms had cleared rapidly.  I have been very careful about avoiding exposure to the virus, but I had been to my doctor’s office the week before and do not live alone so I was anxious to know the result.  I could not find a phone number to call.  Looking through Bluewater’s website, I found a browser-based form that I could fill out to request my test result.  I uncharacteristically noted in the form that I was a physician and disappointed that a test result was being delayed to the point or eliminating the diagnostic or epidemiologic value of the test at all. 

I was both surprised and pleased in very short order to receive an understandable email telling me that my test was negative. This first communication was obviously a “generic” email generated from the personal information I gave. This impersonal report was followed up quicky by a personal email apologizing for the delay and addressing my professional concerns. I was told that the usual turnaround time was 48-72 hours, but that “recently” the company had to start sending out results manually to respond to website queries due to “our Sphere system being down.”  There were hopes to have a “new and updated system up in the next week or so.”

I do not know what the “Sphere system” is, a statewide system or one used only by Bluewater.  Perhaps the inability to report results automatically was limited to individuals (or physicians) like me.  However, it occurred to me that if the reporting problems extended to reporting to the Department of Public Health, that the daily reported numbers would have been inaccurate.  Daily numbers of tests and positives would be artifactually lower than was the case. Depending on how many results from self-referred or asymptomatic individuals like me tested around the state in outpatient settings were excluded fom the calculation of Test Positivity Rate, that statistic would be unrepresentative– indeed likely artifactually high.

I do not know when the reporting failure began, or when or if it has been repaired. I have not yet seen any reports on the issue.  Yesterday morning I emailed both principal media relations officers in the Governor’s office to notify them of what I had found.  I asked if the Governor’s office knew about the reporting problem, if so, how long had it been going on; and most importantly if the failure carried over to electronic reporting of daily test counts and results to the Department Public Health. As of this writing, I have not had a reply but I will keep trying.

To conclude this abbreviated article:
I updated the Tableau Public website with the state data as of January 7. For now, I can only reiterate my opinion from the previous article that it will take another two weeks of reporting cycles to determine with confidence where we are headed. I believe our public health efforts so far have been effective and I fully support the efforts of our Governor and Director of Public Health.  For reasons outlined above and others, I think we need to be more rigorous rather than less. It bothers me to see photos in the papers of college basketball games out in the state with crowded stands and few visible masks. I am concerned that promised actions of our legislative majority will reverse the gains we have made. The Dogs of Disease are still stalking among us.  To set them free of their leashes can only lead to disaster.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
January 8, 2021

The New Year Turns For Covid-19 In Kentucky. What Will The Final Talley Show?

I updated the KHPI Covid-19 Tracking files through yesterday’s December 28 numbers. The full profile of data visualizations is available on KHPI’s Tableau Public Website. If one assumes that data collection and reporting have proceeded in unchanged manner since mid-December, the data would be compatible with having turned a corner with respect to new cases. It is possible such an assumption could be partially correct. The same cannot yet be said for deaths or hospital utilization, but we expect those latter markers of epidemic activity to lag behind the identification of new cases. December deaths were in fact markedly higher than previous months.

However, it would be irresponsible to think that nothing else was going on and experts around the country point out that it will take another week or more for things to become clear. In the first place (as with weekends) data collection and reporting around holidays is incomplete or delayed. It cannot be assumed that people are lining up to the same degree to be tested. Indeed, fewer tests were reported recently. What we do know is that people are traveling more over the Christmas holiday in greater numbers than at any time since last March. I have not yet seen a report or prediction that family or other gatherings would remain the same or lower over Christmas or New Year celebrations. Indeed, it is generally assumed there were increased opportunities for the virus to spread at home and elsewhere in the community.

For these reasons, I count myself among those who want badly to believe that things are getting better in Kentucky but do not yet see conclusive evidence that this has happened or is sustainable. We enter a new year with relaxed public health guidelines and continuing public resistance to following even what had been recommended by those who know and care. The effects of effective vaccines will take a while to become apparent. I have little more to offer for now.

Let us all wish for our better angels to help sing in the New Year with us.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
29 December 2020

New Covid-19 cases per day. KY, 12/28/20 with 14-Day averages.

Kentucky’s Third Wave of Covid-19 Showing Pause.

While other states are still talking of being “on fire” with Covid-19 and of having their hospitals swamped, Kentucky may be seeing some relief, at least in the rise in the number new cases daily.  The same cannot yet be said about the number of deaths or a heavy burden on the healthcare system and the professionals staffing it.  Although some good news and hard earned, we remain at a tipping point.

New Cases.
The wide variation in daily case counts attributable to existing workday schedules for data collection and reporting makes day-to-day comparisons unreliable if not misleading.  The use of rolling averages certainly smooths out the daily variation but at the cost of always being up to 14 days out of date.  However, the workflow through the weeks appears uniform enough that comparisons for any given weekday can be meaningful.  KHPI’s online epidemic profile has added a user-selectable filter to its visualizations of new case counts that pulls only the counts for any given weekday (i.e. Saturday).  In these comparisons, for every individual weekday, case counts have been slowly dropping over the past 3 or 4 weeks. However, these new cases remain much higher than before the epidemic surge that began in earnest in later October.  The overall case count of 19,904 for the week beginning Sunday, Dec. 13 is also dropping compared to the previous 3 or 4 weeks but remains much higher than the total of 11,739 for the week of Oct 18 and certainly more than all weeks prior to Sept 27.  New cases for December (already at 61,523 as of Dec. 19) are on track to set a new monthly record. 

Number of new Covid-19 cases on Saturdays only as of 21/19/20.
Number of total weekly new Covid-19 cases as of week ending 12/19/20

A declining number of new cases is also reflected in a 7-Day rolling average falling faster than the 14-Day average, and a leveling off below the trend-line on the semi-log plot of those data. These and all other data mentioned in this article data can be viewed on KHPI’s Tableau Public website.  I have no doubt that this downward trend is in part due to the re-application of broader public health measures.  It also likely reflects the expected natural history of Coronavirus exposure for the cohort of individuals who contracted their disease during the Thanksgiving holiday week. 

Continue reading “Kentucky’s Third Wave of Covid-19 Showing Pause.”