Turnaround not yet in sight. Cases exploding in smaller counties.
Last week’s (Sunday to Saturday, Aug 29) total number of new cases of Covid-19 was 4511, higher than either of the previous two weeks. The previous highest week (ending July 25 ) had a total of 4580 cases but probably included some as-yet unreported positive tests of the prior week. There is so much variation in the reported day-to-day numbers that it has been difficult to generate reliable predictive trends, but even following the abrupt surge of new cases that began in early July, the trend for both 7- and 14-day rolling averages can be perceived as worsening. The number of new cases is most certainly not going down. At our current rate of growth, the number of total cases is doubling every 34 days. Waiting in place for a better day will not serve us well! You can explore the interactive versions of the figures below and more at KHPI’s Tableau Public website.
Deaths still hovering at higher weekly numbers.
Last week 49 Covid-19 deaths were reported. This is less than the 62 deaths of the previous week which was the highest-ever weekly total since the pandemic began in Kentucky.
Tests per week.
The number of daily tests of all three current reported types has been hovering about 50,000 to 55,000. Nationally the ability to process and report tests has been under stress.
Testing Positivity Rate (TPR).
Yesterday’s TPR was reported to be 4.59%. I frankly do not know what to make of this calculation as it depends critically on the makeup of the population being tested and the number of tests done. The TPR is currently being used as an estimate of the disease in the general population. While in a gross sense at least some degree of correlation might be expected, surely we have little knowledge of the true incidence in the counties of Kentucky. I would argue that absent reliable population-based incidence studies, it is better to simply count cases and deaths to guide policy decisions. If testing is being prioritized for symptomatic or high-risk individuals, the TPR will necessarily go up even if there is no change in the incidence of the disease in the general population.
This calculation is the most labile of all those KHPI has been monitoring, to the point that even a 7- or 14- day rolling average is not precise enough. I am not sure how Kentucky’s Department of Public Health calculates this metric. KHPI’s calculation of the TPR based either on daily data or aggregate data is presented in the following figure. The reader can vary the reporting interval interactively on KHPI’s Tableau Public website. In the opening 2 months of Kentucky’s epidemic the daily TPR reached as high as 30 to 60%. The overall TPR, based on aggregate tests and cases, ranged from a rolling average of from 15 to 25%. Frankly of all the things we report daily, TPR seems to me to be the least useful. Please convince me otherwise!
Total hospital utilization was less than in early August, but ICU bed occupancy remained as high as it has been in recent weeks– that is to say near record levels. Reporting of hospital utilization has been fraught with problems. We do not seem to be overwhelmed as has occurred previously in other states.. Remember though that the bulk of ICU beds in Kentucky are in a handful of hospitals in our three or four largest cities! (I will report on the distribution of hospital beds later.)
Where are the new cases occurring?
New cases are accumulating in Jefferson and Fayette counties at their current accelerated rate. Since late July, the number of cases in Jefferson County doubled in 28 days– a reproductive rate that is increasing. However, in some of the counties with smaller populations or those with few previous cases, the number of new infections is frankly exploding. The posterchild for this phenomenon is Green County which went from 5 cases on July 5th, to 165 cases on August 29. The epidemic curve is currently in an interval of rapid exponential growth doubling roughly every 10 days and growing faster. I do not know what underlies this big shift but understand that there may be have been some interplay between long term care facilities and schools. A shift in accelerated reporting of new cases is also happening in Lewis Couty. Perhaps a reader can enlighten us. You can click your way through the epidemiology curves for every county in Kentucky here. It is my view that managing our epidemic requires that people on the ground need information geographically meaningful to them. The more granular and timely the data we can collect, the better we are able to react to emerging situations and to learn from each other’s experiences.
What is to come?
I confess to being worried if not frankly alarmed. Cases are on the rise again in European countries that enforced rigorous public health policy in their populations and suffered through the economic difficulties that resulted. People got tired of the effort and underestimated the durability of their local epidemics. In the United States we did not hunker down as hard and got even more tireder. I am tired too. Despite the complaints of many, we never really made the necessary community commitments to retard the epidemic. We backed away from enforcement in the name of unconditional individual rights. I learned from my own lobbying experience that is it much easier to block something than to do something new– no matter how much needed!. The efforts of lobbies of the triplet religions of Gods, Sports, and Politics are proving to be more influential than evidence-based science and medical experience. I would rather worship self-correcting science, and it is my opinion we are collectively paying the price for not doing so. I fear things will have to get a lot worse before public pressure will demand better. I will be happy to be wrong.
Peter Hasselbacher, MD
Kentucky Health Policy Institute
Emeritus Professor of Medicine, UofL
30 August 2020