Coronavirus Omicron is Running Wild in Kentucky.

How can we tell where it is headed?

Today is Sunday January 9. The last iteration of Kentucky’s Covid-19 epidemic data was issued to the public, (and presumably the CDC) last Friday. The next set of data will not be available to the public until tomorrow evening. That leaves a gap of three full day’s history of epidemic expansion that is already the fastest of the previous 670 days. [Although we can expect that the weekend reporting days of Sunday and Monday may be low, those days can be compared to pervious weekend days.] Daily detected new cases and the proportion of viral tests that are positive have never been higher in Kentucky by wide margins and are rising with exponential fury in a straight line since December 27. One of two major factors behind the present COVID explosion is the new Omicron variant that has been sweeping through the rest of the world and likely been in Kentucky since December. Omicron is by far the most is the most transmissible COVID variant yet to hit America. It is likened in virulence to measles which up to now has been considered one of our most infectious diseases. The second expansion driver was a holiday season in which we believed and may have been told it was safer to travel and visit with others– and we did! However, I believe we carried that permissiveness too far. For example, today’s Courier-Journal contained some holiday photos including a fun-looking party with dancing and consuming in which no mask was in sight, and UofL basketball game with all naked faces in the audience. The stage was set, and the virus was willing and more than able (as if we could ascribe to a virus with purpose).

A lot of major outcomes are still up in the air. We know that wildfire is not an exaggeration when we consider a virus that can double its hosts in a matter of days. There is evidence that Omicron does not cause as severe a disease as Delta or other previous strains. There may be more upper respiratory involvement and less pneumonia or systemic manifestations. People may not need to go to the hospital as frequently, and when they do may not need ventilators or die as often. There is so much COVID in the community that even people in hospital for hernia repair may test asymptotically positive. There is a wishful hope that the rapidly rising case counts will fall as quickly as they rose in an “ice pick” configuration rather than a broad months-long peak as previous surges did There is a speculative possibility that survivors of Omicron will be more resistant to reinfection of either the vaccine breakthrough or natural variety. Unfortunately, we already know that some of the effective treatments of Covid-19 are no longer effective or less so.

We already know that at least some the current antigen or take-home tests for the virus are not as sensitive. We know that infected persons may be symptomatic less often but not how much so. Neither are we sure yet how soon or how long infected persons, symptomatic or not, are able to pass their disease on to others. We already know that it easily infects previously vaccinated individuals or those who have recovered from “natural” infections. Omicron has not been around long enough to tell if there will be significant long-term complications. In effect, it is as if we are dealing with a new disease. Answers to these uncertainties will eventually emerge from coordinated public health investigations in homes, offices and hospital, and in the laboratory. Sadly, our neglected and fragmented public health and general healthcare systems have already shown their weaknesses. We will also learn from other countries with more integrated and universal healthcare systems that can collect information from large numbers of diverse individuals relatively quickly.

What will I try to do in the meantime?
Since the beginning of Kentucky’s version of the COVID epidemic, I have been collating the relatively limited data available presented at first every day, and more recently only recently 5 days a week to attempt to answer the question: How can we tell if we are winning? Readers of the previous 68 articles on these pages dealing with the epidemic will be aware of the data manipulations and visualizations I use to address this basic question. Categories of data used include cases, deaths, tests, hospitalizations, ICU and ventilation utilization, and two ways to calculate test positivity rates. For the past nearly two years these metrics have tracked each other in predictable ways. My previous estimations of trends have been mostly on the mark. When Monday’s numbers are made public, I will apply the same approaches I have been using to ask if we are winning yet. Right now, we are losing– and badly!

You can interact with up-to-date data yourself on KHPI’s Tableau Public website. I posted a few Tweets since my last article @HealthPolicyKY.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
President, Kentucky Health Policy Institute
Sunday, 9 January 2022

Here are a few figures from the data of January 7.

Both began to rise in November but took off right after Christmas.

Even with last Saturday’s end of week cases not included is highest in 2 years.

I will have more to say about COVID in people 18 and under later. It is clear that individuals in this school-age group contribute significantly to the totals. In early September these individuals made up as much as 32% of that day’s total discovered cases. Note large swings when school starts in August and at the beginning of winter break.

Coronavirus Starts New Year With a Bang and Record Highs.

Kentucky is emerging from the current major holidays of November and December in what is the third major surge of Covid-19 since our first case 653 days ago on March 6, 2020. We responded to an opening mini-wave that stabilized in early May 2020 with a moving 7-Day average of around 205 daily reported cases. We were plenty worried at that time and pulled out all the traditional non-pharmaceutical remedies we had available. That seemed to work even though there was much resistance to the disruption of our social order.

Things got a little better for a while, but the rolling average never dropped below 126. The Fourth of July holiday and entry to the summer season began a gradual but progressive rise in cases that never really ended. Cases (and deaths) exploded beginning in early October 2020 from an average of 760 per day, to twin peaks of 3412 and on December 5, 2020 and January 12, 2021 respectively. This initial major epidemic surge was caused by the original Alpha variants. Vaccines became available to high-risk individuals and by mid-January 2021 to adults older than 65. For this and other reasons, daily case numbers began to slowly decrease to a daily average of 146 by the end of June 2021. We thought we had won and many, including myself, moved back closer to a more “normal” lifestyle. However, Covid-19 had not disappeared elsewhere in the world and if it is anywhere, it is a risk everywhere!

Cases and deaths since beginning of Kentucky epidemic.

Curves for Cases and Positivity Rates are in the “going straight-up” mode.

7-Day Averages of new cases (green) and test positivity rate (brown) as of 12-29-21.

Beginning again around a second Fourth of July 2021 and for the rest of that summer, the arrival of the Delta variant spiked a second major surge of Covid-19 with a new record high on September 5th of 4383 average cases per day. We were once again scared and promoted primary vaccinations and boosters hard. Many but not all began to live more cautious lifestyles again. The delta peak passed but never really had a chance to fall to previous baseline counts. The lowest we reached was 1131 average daily cases in early November. Since then, as chronicled in these articles, there has been a relentless increase in both the test positivity rate and the case count that follows closely viral prevalence in the community. There was little or no “plateau” of cases. By mid-December, both metrics literally exploded with the most recent available single-day numbers on December 29th of 14.5% and 5513 cases respectively. These are the highest daily values since Kentucky’s epidemic began. Investigations are ongoing, but this third major surge probably initially involved residual Delta variant but is being hijacked and fueled by the new and extraordinarily contagious Omicron variant as is happening worldwide. An increase in hospitalizations accompanied these rises. What happens with respect to deaths and long-term disease morbidities remains to be seen. There is no indication yet that cases have peaked. I do not believe they have.

How severe are the cases?
The definition of having a “severe” complication of Covid-19 usually includes requiring ICU or ventilator care. Along with an increase in overall hospital admissions for Covid-19, ICU availability is becoming saturated throughout the state. As of the most recent tally on Wednesday, December 29th of the state’s 10 regional Hospital groupings, 8 had >90% “ICU Capacity in Use” and 6 with >95%.  Compare this to the first Wednesday of November when these figures showed only 4 regions with >90% and 1 with >95%.  (Recall that an effective ICU capacity implies that the beds have the staff to care for the patients.  Medical staffing is a big problem nationally and I am not currently aware of how Kentucky defines “Capacity in Use.”)

[Addendum 1-3-22: Marissa Plescia and Molly Gambele ranked states with hospital workforce shortages in today’s Becker’s Hospital Review. Of the 16 states with at least 25% of their hospitals currently experiencing critical shortage as of 12-28-21, Kentucky ranked 9th with 32% of its hospitals. There were another 21 states that expected to be in the shortage category within a week. Seems to me that we are in trouble!]

Below is what the raw daily case counts look like since July 2021.

Nothing benign about the hospital utilization curves below.

Current Hospital and ICU Bed Occupancy by Covid-19. 12-29-21
Testing has not changed much overall in recent weeks.

Flying blind for a while.
How bad is it really and how bad will it get? It is hard to tell. We are in something of a data desert now. Cases have been rising faster than we are able to count or report them. Looking at other states and the rest of the world, we still have a way to go in the wrong direction. The most recent Kentucky numbers reported in the state (and to the CDC?) were on Thursday, December 29. Kentucky and several other states stopped reporting on weekends. The numbers for last Thursday through next Monday might be available as early as Monday evening, but it will surely take longer to fully catch up with what is happening in the real world. Elsewhere, the Omicron variant has been associated with a doubling rate of Covid-19 cases that is measured in a few days, not weeks. In addition to the usual data collection and reporting anomalies related to the workweek, several major fall and winter holidays exaggerated reporting delays at the same time greater interpersonal epidemic spread is assumed. To make matters even more uncertain, the recent tornado disasters in western Kentucky have placed extraordinary demands on our existing public health services. Disasters like that one create breeding grounds for spread of disease that will reliably make Covid-19 matters worse. I would do a disservice to speculate further based on the limited data available to me.

Many questions remain to be investigated by public health scientists and officials.
Is Omicron disease milder? (It certainly is much more transmissible. Initial evidence suggests that fewer people get severely ill from lung disease and that hospitalization will be less frequent– at least for vaccinated people.) Will current treatments be as effective? (Some are not!) Are children more vulnerable? (There are reports that more children are being admitted to hospitals.) What are the long-term consequences of Omicron infection? How effective are our current vaccines? (Vaccinated people appear to get milder cases and fewer hospitalizations.) Will this spike be our last? (We thought that first two major surges were the last!)

As usual, I have updated KHPI’s Tableau Public website with the most recent numbers. Using the various filters, you can explore the data for yourselves using different days, weeks, months, or ranges of dates. I will attempt a more comprehensive update later next week when more data is available. I have to assume things will not be pretty.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
January 1, 2022 (First time I write this new year’s date!)

Kentucky’s Covid-19 Epidemic Expanded Relentlessly During Past Two Months.

This week we will reach a milestone of 800,000 reported new cases of Covid-19 in Kentucky. All public health experts agree that this is a substantial undercount. Despite that there were 5 days of undercounting new cases over the Thanksgiving holiday weekend, and that a rolling average is by definition always hostage to its earliest days, the 7-Day average of new reported KY cases has been rising in an unrelenting fashion since November 5th.

However, our epidemic expansion began weeks before that. For each given weekday (i.e. a Wednesday) the most recent daily count for that day of the week has been higher than the that of the previous 7 to 9 weeks. Last week’s total new case count exceeded by far that of the previous 8 weeks reaching 52% of the highest weekly count of any week during the 628 days since Covid-19 was recognized in Kentucky. The most recent upward trajectory of new each new daily case count has been steep.

Other indicators of epidemic expansion are consistent with this increase in daily new case counts. The number of new cases tracks very closely with the Covid Test Positivity Rate (TPR) whether calculated daily, or using the KY Department of Public Health’s indicator of the 7-Day average of percent of tests reported electronically that are positive. The current “official” positivity rate has been above 9% for the past few days. (The maximum reported rate of 14.2% occurred as recently as last September 8th.) The TPR has been rising sharply. The 7-Day new case rate is surging past that of the 14-Day rate also indicating rapid expansion. The current gap between the two of 463 cases is the highest so far in the course of Kentucky’s epidemic. Cases plotted semi-logarithmically reveal our current expansion of both cases and the TPR to be formally exponential, albeit at a doubling rate of around 4 weeks.

Impact on hospitals.
With the expected few days of delay, current hospital census attributed to Covid-19 has been rising progressively since November 8. The number of patients hospitalized with Covid-19 that require Intensive Care Unit or ventilator support both tracked overall hospital census closely for the duration of our epidemic and are doing so now.

Accurate and timely counts of death due to Covid-19 are not available due to the structure of our healthcare system. There is however, no doubt that daily reported deaths are rising at a trajectory not that different than observed during the surges of last winter and fall. To the best of my ability to assemble such data, the current death rate in Kentucky from Covid-19 exceeds that of all types of cancer combined!

What, Me Worry? (Mad Magazine, 1952-2018)

The “sky is falling down” approach to informing the public about risk is generally considered to be less than maximally effective if not objectively undesirable. However bad things sometimes do fall out of the sky. The current iteration of SARS-CoV-2 is such a bad thing. It will join the historical list of the worst pandemics of all time. Just as the plagues of 14th Century altered the structure of society, so will things unpredictably never be the same again for us.

Why did the previosus surges in cases go down?
We in Kentucky and in our nation weathered and partially reversed 3 or 4 earlier epidemic expansions of Covid-19. I would argue that our effectiveness in climbing down from these mountains of cases and deaths cannot be attributed primarily to better medical treatments, or from the restrictions enforced in myriad ways by political or public health authorities. Rather, our temporary successes were due to a reality that citizens like you and me recognized and believed that something bad was happening to us. We were motivated to more carefully protect ourselves, those we care about, or even the communities we live in. We listened to what we thought was the best advice available to us (sometimes even if it was bad advice). The sum of all the big and little things we did– even or especially if they were hard to do or sustain– made a difference.

“Fear is the mind killer” is a favorite trope from Frank Herbert’s novel and Dune movies. There is however a difference between fear and concern. I believe there is sufficient evidence that we need to be concerned and to act accordingly.

I may add a chart or two to this entry at a later time. The entire portfolio of updated data visualizations is available on KHPI’s Public Tableau website where you can interactively query the data behind this series of articles.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
7 December 2021

When Is a Covid-19 Epidemic Plateau Not One?

Possible answer: When new cases and the Percent Test Positivity Rate progressively increase for 12 days or more. 

I do not have much more to add to my comments of November 13 but will allow the data to speak for itself.  Yesterday’s announced 2195 new cases is the highest daily count since October 14.  Yesterday’s case count was higher than any of the previous 4 Wednesdays.  Given that this week’s 3 remaining weekdays through Saturday comprise those with historically higher counts, it can be projected that the total number of new cases this week will exceed those of the previous three or even four weeks.  Since the number of daily tests has been fairly stable, increased testing does not explain the increase in case numbers but the progressively increasing Test Positivity Rate helps.  Hospital utilization is creeping up and along with ICU and ventilator utilization and deaths will eventually follow wherever new cases go.  Elsewhere in the world and in some other US states, that place is another winter surge.

I am personally being very careful to follow good public health measures including getting a booster vaccination, wearing a mask indoors in public, and limiting my exposure to groups. I recommend the same to everyone else.

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

Data on this overview plot of cases and deaths and all those graphs below current to 11-17-21.

7-Day average new cases exceeding 14-Day average indicating epidemic expansion.

New case counts for individual Wednesdays.

Test Positivity Rate and 7-Day average new case counts rising for last 12 days at least.

Weekly new case counts. Most recent week includes only Sun. through Wed.

Hospital and ICU utilization through 11-17-21.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
18 November 2021