Covid-19 Epidemic Still Expanding in KY With Hospital Utilization Increasing.

New reported weekly cases of Covid-19 continue to increase sharply. Yesterday’s new case count of 13,947 is the highest yet since the new less-aggressive case reporting system was put into place in early March and is nearly double the number of two weeks before.  This much lower than the January Omicron peak of some 80,000 weekly or the Delta peak last fall of 30,000.  However, the number of new cases reported currently is undoubtedly a considerable undercount due to changes in case identification and reporting protocols.

New weekly cases Covid-19 in KY reported 6-13-22. Assume an undercount.

Weekly Covid-19 cases reported since the Kentucky Derby. Semi-log plot suggesting exponential expansion.

The current increase in Kentucky cases appears to be having an impact on hospital census and the serious outcomes of ICU and ventilator use. These latter two indicators have been increasing for the past 4 weeks and are currently higher than they were in early April.  We expect the need for hospital services to follow case counts to some degree in a delayed manner.  Certainly it is no longer possible to say that deaths are decreasing!  Since deaths occur mostly after patients spend some time in hospitals, increasing deaths over the next weeks would not be a surprise.

Current Hospital Census reported 6-13-22.

Current ventilator utilization reported 6-13-22.

The current test positivity rate is still high at 12.1% but hopefully is stabilizing. The reported overall incidence rate has also remained mostly stable but is currently calculated at 24.4 average daily cases per 100,000 population.  Since individual counties with an incidence rate greater than 25 are considered to be in the red “high” category, this current statewide rate seems scary to me.  The state has not as of this writing published its statewide county incidence map.  Inspection of yesterday’s published table of individual county incidence rates reveals that 34 Kentucky counties are in the “red” with another 75 in the “substantial” range. There are no individual counties in the green “low” rate category. This is in distinct contrast to the CDCs Community Levels map of June 10 as reproduced on Kentucky’s website which shows the large majority of counties to be in the “green” with only 19 counties in the red “high” range. (I confess that the Community Levels maps remain of uncertain if not unknown utility to me!)

There is not much more I can think of to add today.  We may be tired of the Coronavirus, but the virus and its progeny are not yet done with us. I do not have access to sophisticated artificial intelligence software to model our Covid-19 future, but my educated guess is that things are going to continue to worsen before they get better. I hope to be wrong.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
Thursday Afternoon, June 14, 2022

Spring Surge of Covid-19 in Kentucky Expanding Exponentially

Fourteen weeks ago Kentucky’s Department of Public Health switched from daily Covid-19 updates to weekly reports, including to the CDC. Additional changes were made as to what categories of cases and tests would be reportable. These changes were made in early March, 2022 when the Commonwealth was largely recovered from the Omicron wave that peaked in late January but had not yet descended below the levels of cases, hospitalizations, or deaths occurring in the interval between the Delta and Omicron variants in early November. These three weekly metrics continued to fall until early last April when it has become clear that Coronavirus infections in Kentucky were on the rise again, indeed, in an exponential fashion. 

Spring Surge of 2022:
Beginning in early to mid-April, the Test Positivity Rate (TPR) and Overall Incidence Rate per 100K Population (OIR) began to rise progressively thus enabling the subsequent surge of new cases beginning in early May that has continued through the last report of June 6th. Last week’s TPR is higher than that of the previous 13 weeks, as is the OIR. The weekly new case count is higher than any of the previous 12 weeks. Since the nadirs of these three metrics of disease activity, all three have been doubling exponentially every three weeks.

TPR correlated closely with cases the entirety of the KY epidemic.

Probable cases no longer reported recently.

Semi-log plot of TPT vs. time.

Semi-log plot of new cases since early May.

Hospitals & Deaths.
It should be noted that in recent weeks, “probable cases” of Covid-19 are no longer being reported by hospitals which would result in lower case numbers.  Despite this, current hospital census for Covid-19 was higher last week than all but one of the previous 10 weeks.  ICU and ventilator rates remain relatively lower, but both these indicators of more severe disease are higher than any of the previous 8 weeks.  Deaths fell more slowly than cases since March but we must assume some lag in reporting is possible if not likely.

About the Maps!
In my opinion, the discrepancy between the CDC’s Community Level Map (6/3/22) and Kentucky’s own Current Incidence Map (6-6-22) only continues to grow. To my count, 92 (77%) Kentucky counties in the CDC’s community level map are in the green “low” community level. Another 21 counties are rated “medium” and 7 are in the “high” red category.  Kentucky’s incidence rate map reverses these proportions with 79% in the “substantial” and “high” categories for average daily cases per 100k population. Only 2 counties are in the green “low” category with another 23 “moderate” yellow.

Other Observations:
Since early April, the number of PCR viral RNA tests reported has actually increased from 40,000 to just below 50,000. In fact, PCR tests currently appear to be the major source of reported cases identified   In the past few weeks, as many as 78% of new cases can be attributed to PCR testing. As recently as mid-March, only some 20% of new cases were identified in this way! Changes in definitions and reporting protocols probably contribute to the increasing case-finding yields from PCR testing, but the difference is most compatible with the general assumption that most testing today uses antigen test methodology both at home or in offices and is not reported to public health departments at all. Kentucky’s actual new case numbers are almost certainly several multiples of what is being reported.

School is out for summer!
The number of new cases identified as being 18 years old or less exceeded 25% in March.  It has fallen progressively to a current 12%. There are any number of reasons for this decrease including the methods of testing used, but this metric has risen and fallen in parallel with the elementary and school years.  If the past is any indicator of the future, transmission in school will continue to be an important vector.

Can we make it go away?
I can only conclude that Covid-19 in its various son and daughter configurations is alive (if viruses can be said to be so) and well in the Commonwealth. Even the under-reported cases we know about are growing at rates that can be called exponential.  I believe that as individuals and as a community we have the ability to mitigate the physical and civic havoc this virus is causing. I wish I could be as certain that we will have the will, but this plague is not one that we can wish away.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
8 June 2022

Covid-19 Still Spreading In KY, But The Worst Outcomes Not So Much.

Presence of holiday weekend with big-time concerts and decreasing reporting protocols make forecasting iffy.

On May 31, the staff of the Kentucky Department of Public Health gave an online update to practitioners. Since there are no longer any weekly, let alone daily updates from the Governor’s Office, this well-done authoritative session, combined with the published weekly online updates from the KYDPH are now my best sources of information about Kentucky’s Covid-19 epidemic. Following are some of the highpoints
from Tuesday’s presentations.

Cases: The 7-Day total of new cases ending May 30 was 7140, the first decrease since the incremental current surge began 5 weeks before. I am not sure what to make of this as previous long holiday weekends were often followed by a period of lower testing and reporting. The number of PCR tests performed last week was essentially the same as the week before. The bulk of new cases reported has increasingly come from this subset of PCR tests reported electronically to the state. For the past 5 weeks, more than 60% of new cases presented to us and to the CDC came from PCR tests. Last week, the figure was 78%. This increasing representation from reported positive PCR tests is compatible with the large and increasing number of antigen office or self-tests that are not reported one way or the other to anyone.

I assume that at least some of the reported PCR tests originate from hospitals. In recent weeks, Kentucky hospitals are no longer required to report “suspected” cases of Covid-19, presumably to cull out individuals who come to a hospital for non-Covid reasons and are found to be positive. The actual number of new cases is surely several multiples of what is reported above. While it would be nice to be sure that a Derby wave of cases is passing, it remains to be seen what happens following the Memorial Day holiday with its large-scale music festivals and other public activities.

New cases for a given week.

Deaths: The 37 deaths reported are by far the lowest in a long time. Previous exposure to Corona virus antigens through infection or vaccination is protecting people from the worst outcomes when infected by the nearly ubiquitous OmicronJunior strain (BA.2) which is more infectious but perhaps less deadly –to the young and vaccinated anyway.

Hospital Utilization: Current hospitalizations jumped up significantly after Derby but have been falling for the past two weeks. We are told that some of this is due to suspected cases not being included in the counts. Both current ICU and ventilator numbers have been bobbing up and down at low levels for the last 6 or 7 weeks. That is good! I would like to think that these tallies are among the most reliable available to us. These would be low for the same reasons that deaths are. We are told that hospital reporting of Covid-19 is getting better across the board with a new system. These good numbers are not evenly distributed throughout the state for reasons discussed in earlier articles. Some hospitals are feeling Covid pressure in their bed- and ICU availability.

The case and other counts above comprise the total for all 120 counties for a week. However, more than half of our counties had substantial or worse incidence rates over the last 7K days. Eight of those are at a “high” level with more than 25 cases per 100K. The current incidence rate for the state as a whole is 23.8 cases per 100K- almost high. (I am not sure at this moment whether the time denominator here is per day or per week.) In any event, the state-wide incidence rates of new cases these last three weeks were the highest since early March when weekly reporting became the state’s standard. The Test Positivity Rate is still climbing relentlessly, now at 11.21%. We are still churning out new cases!

Overall Incidence of New Cases per 100K population.

Vaccinations: Kentucky as a whole is not one of the most vaccinated states. We have done best in our “older” at-risk population older than 50 or 65 years for both the regular series and boosters. The KYDPH presentation offered good evidence that having a primary series completed gave protection against becoming a recognized case and remarkable protection against becoming a death statistic! Those receiving at least one booster were at 15.7 times lower risk of dying. More than 60% of cases of deaths were in the unvaccinated population. We are told that 90% of deaths of individuals under 60 years old were unvaccinated. That is a lot. Receiving a booster gave even more protection. It remains the case that most deaths occur in those older than 60. To prove the protective point, 68% of those older deaths were in the unvaccinated elderly.

Upwards of 50% of employees of nursing homes are still unvaccinated. Explain to me again why vaccination of hospital workers, nursing home staff, or prison guards for that matter should not be subject to mandatory vaccinating? This virus is killing our grandparents! It wasn’t family visitors that brought most of the virus into the old folk’s homes.

Booster shots for all eligible individuals are recommended. Extensive tables and decision tree charts are offered for providers. The different relevant variables of time, age, specific vaccine and the like are almost impossible to keep in my head. I personally got a second booster before an international trip earlier this month. It give it credit for keeping me alive and out of the hospital!)

CDC Community Level Indicator Maps: I still don’t know how to use these mostly green-colored county maps. While there are 4 counties in the most recent Community Level Map that are in the red, only one of these is also red in the Current Incidence map summarized above. (Surprising to me, for the first time, I heard the Community Level Map described as a preview of what it yet to come.)

Most recent Current Incidence Rate.

Most recent Community Levels map.

Multisystem Inflammatory Syndrome in Children : One of the worst outcomes of Covid-Infection in children and some adolescents is the poorly understood MIS-C. Kentucky has had some 114 cases of MIS-C since the onset of the epidemic. Most are unvaccinated. Fortunately this complication is rare. Fewer than 1% of MIS-C patients die. However, they can get really sick, including need for ICU and ventilators (63% and 10% respectively). There remains much to learn. Non-white kids get more than their share of MIS-C. In my mind this is just another reason why everyone (of any age) deserves access to the same high-quality healthcare system. This is decidedly not the case presently where there are too many undertreated and overtreated people alike!

Therapeutics- Paxlovid Rebound: There was much presented about treatment of early Covid-19 infection including Paxlovid. “Rebound” of symptoms and recurrent test positivity can occur shortly after the 5-day course of the drug ends. Fortunately, people seem to do fairly well in the end. “Rebound” may be more common than predicted for this and similar treatments and needs to be monitored more closely including whether or not the rebounder is still infectious!

Other Infectious Diseases: Updates were offered for Pediatric Acute Hepatitis of Unknown Etiology. Kentucky has reported 3 or 4 cases so far. Practical advice was given to providers about when and how to report suspected cases. This illness remains globally as a big and serious mystery. We can be reassured that our public health team is on the case. Legislators– give them the financial and other support they need to protect our children Don’t mess it up.

Monkeypox: A good review of the global and national situation was given. There are cases in the USA but none yet recognized in Kentucky. There is no reason to believe it will not show up. This is an infectious disease related to smallpox. It has evolved new mutations at an unexpected rate. What damage is does and what we can do about it remain to be seen. Consideration is being given whether there is a role for smallpox vaccination. Just one more emerging virus making its way around the world when we need it least, or a predictor of what is yet to come in our unsettled planet? Explain to me why we do not need a strong public health system integrated into the healthcare system we all use?

Influenza is making the rounds with an atypical cycle beginning mid-March instead of the usual January or February. Now that we are increasingly letting our respiratory-illness guards down it remains to be seen what will happen. Last year’s vaccine was not a good match for the strain that emerged. Good thing we were taking care of respiratory business in general and that total case numbers were very low. Still, immunization for influenza this fall is recommended. I will get my shot. Covid and Influenza will still be with us along with their fellow lung-loving travelers. As the Game of Thrones books and TV series warn, “Winter is Coming.” Winter brings respiratory diseases which when I was an intern in 1972 and long before were named as “Captain of the Men of Death.” They still are, even in the best of times.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
Kentucky Health Policy Institute
3 June 2022

SARS-CoV-2 May Also Have Been a Winner at the Derby!

New cases Covid-19 up sharply in May. Hospital utilization and deaths not so much –at this time.

Following the first Saturday in May, reported weekly new cases of Covid-19 are taking giant steps upwards. Jefferson County leads the state by far in new cases. Jefferson County’s current incidence rate reported on 5/24/22 was 52.1 per 100K population compared to 23.4 for the state as a whole. Although the test positivity ratio had been creeping up for several weeks before, it is impossible to ignore the likelihood that Kentucky Derby activities fueled a smoldering fire.

Current hospital and ICU utilization, or deaths have not yet followed in the same direction. Hopefully because of our at least partial degree of vaccine protection and personal choices made by many, these adverse outcomes will not rise as much. In my view, the CDC’s “Community Levels by County” graphic of 5/20/22 that accompanied Monday’s state report is two weeks out of date and 1000 miles distant in the rear view mirror. It does not inform me personally in any meaningful way and seems to understate what is happening locally where meaningful response can be focused. Covid-19 is blossoming worldwide and in the United States in large measure from spread of the Omicron Jr. variants and spotty use of public health precautions. Why would it not get worse here as well?

I was out of the country the first weeks of this month. That is a story as yet untold. We need to maintain a healthy respect for the degree of personal, social, and economic disruption that this pandemic is capable of delivering. The massive movement of huge numbers of people around a troubled globe will surely affect us in our Commonhealth. Even as I write this, new infectious agents or presumed infectious agent syndromes are becoming apparent. Monkeypox, the polio-like syndrome of infantile flaccid paralysis, and acute severe hepatitis in children are examples of illnesses that an already busy public health system must investigate and confront. Old standard childhood and adult infections diseases are blossoming as well as vaccination programs and routine medical care have been disrupted.

At times like these I can only dream of a coordinated national health system under whatever name or structure one wishes to give it. Otherwise, we will continue to be dollar short and more than a day late.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
May 26, 2022

[Addendum 5/27/22: Reading in today’s Courier-Journal about the commercial impact of the two massive local concerts this holiday weekend, a further “booster” to new cases would not be unexpected!]