In The New World Of Covid Tracking, Where Are We Headed?

COVID variants on the rise globally in an environment where public health interventions are being withdrawn, rejected, or otherwise unavailable – what could go wrong?

Recent data indeterminant as to direction of epidemic spread in KY.
Yesterday evening, Kentucky Department of Public Health published its Covid data for the week ending Sunday, April 24. The CDC published its most recent community level map as of last Thursday April 21. I confess I have no idea how to compare or interpret the data either within or between these two entities. The CDC’s map has all 120 of Kentucky’s counties in the green “Covid-19 Low Community Level,” as is indeed most of the rest of the country. Today’s CDC’s county map of actual disease incidence in Kentucky contains much missing data and is uninterpretable.

Kentucky’s home-grown report publishes data which; based on my understanding on how the data are collected, interpreted, and reported; seems internally contradictory. On the one hand, the number of new cases for the week has roughly plateaued at about 3000, but the test positivity rate has risen rather dramatically to 4.35 which is the highest since the first week of March! Please refer to the figures below for this and the remaining discussion.

Disease Incidence rates.
A different indicator of epidemic expansion in Kentucky is suggested by the overall state incidence rate published on the state’s own weekly incidence rate maps. I do not know exactly how the state calculates this result, but it has risen from a low of 4.09 cases per 100K on the report of April 11, rising over the next two weeks to 6.49 yesterday. Using the same definitions it has always used for Kentucky’s own county-specific maps; only 25 of our 120 counties are in the “Low” range, 87 are scored as “Moderate” (1 – 10 per 100K), and the remaining 8 rated as “Substantial” (10-20 per 100K).

The CDC website reports a state-wide incidence rate over the last 7 days of 65.8 per 100K. (Is this an error?) The New York Times, which still has access to county-specific data, calculates an incidence rate over the last 7 days of 10 per 100K of state population. According to the Times, over the past few weeks, some of Kentucky’s counties have been among those nationally with the highest new case incidence rates.

I do not know how to reconcile the differences in the national and state reports. What is perhaps the most transmittable human disease ever experienced in modern history, Covid-19 is expanding in the United States and worldwide. It appears to be expanding again in Kentucky. The test positivity rate, which in my experience has been a reliable and predictive indicator of epidemic expansion in Kentucky, is on the way up again.

What is happening in hospitals?
For what is worth, the number of individuals with Covid-19 currently hospitalized yesterday was at a low for the past 2 months of weekly reports. The CDC’s Community Level rating is based largely on hospital admissions for Covid-19 and hospital/ICU capacity. I do not yet have a good handle on exactly what formula is used. Many counties nationally and in Kentucky do not have an acute care hospital of their own. Therefore, the “county” map of Community Levels is based on hospital utilization in other places. The CDC has chosen to divide states into “Health Service Areas” that are not identical to Kentucky’s own COVID “Hospital Regions” nor to the Dartmouth “Hospital Service Areas” (HSAs) or “Hospital Referral Regions” (HRR) commonly used by health policy researchers or other government entities.

As an example of hospital utilization by Covid-19 patients in Kentucky, I refer to a report issued for the week ending September 3, 2021 when the Delta variant was active. (I forget how I came by it!) Kentucky had 90 acute care hospitals. However, 28 of these were Critical Access Hospitals, a special designation by Medicare which exempts them from some reporting requirements and still pays them based on their costs. However, by law they can have no more than 25 beds, no ICUs, and have strict limits on severity and length of stay. It should be no surprise then that the 28 smaller critical access hospitals had a total 7-day average daily census of only 60 adult patients with Covid compared to 2300 patients in the remaining 62 short term acute care hospitals. Of these 62 “regular” acute care hospitals, the ten hospitals with the most Covid-19 admissions made up 40% of their total. Nineteen of the 28 Critical Access Hospitals had no Covid-19 patients at all!

The limited distribution of hospitals dilutes the geographic precision of the CDC’s Community Ratings. This, on top of other changes in national reporting that impair the timeliness of data seem to me to handicap the ability of those responsible for the health of the public do keep up with the disease. Time will tell if we are on the right track.

Perter Hasselbacher, MD
Kentucky Health Policy Institute
26 April 2022

New COVID Tracking Procedures Have Changed. They will be less timely.

We were winning for a while, but we have been in this place before.

The last time I posted a Kentucky Covid update in the series was on February 26. Shortly afterwards, both the Kentucky Department of Public Health (KDPH) and the CDC dramatically changed their practices on data collection and reporting. Instead of focusing on the daily counts of new cases, deaths, tests, and hospitalizations, these major public agencies shifted to reporting only weekly summaries an emphasis on hospital utilization. Counting the number of new cases is considered a “back-up” process. Governor Beshear has “paused” giving Covid-19 updates in person to the public. Suffice it to say for now, I no longer have data available or compatible to enter my data analytic and visualization software. It is fair to say that public health experts have expressed considerable concern about the shift in data collection and policy making. I agree and perhaps will have more to say about this later. Last week, based on the KDPH weekly report of April 11, I started preparing this update

The good news was that over the previous six weeks of reported state data, there had been strong sustained trends downward in the number of recognized new cases of Covid-19 infection and hospitalizations. The number of new weekly cases dropped progressively from 12,010 in the report of March to 3117 reported on April 11. Compare this to the peak Omicron weekly count of over 80,000 at the end of January which was itself more than double the highest count of any previous week of our two-year Kentucky epidemic! Nonetheless, with an average daily count last week of 445 new cases, we were still well above the 7-Day rolling average of 142 in June of 2021 in the interval before the Delta surge when we thought we were finally in the clear!

Weekly deaths decreased from 275 in early March to 135 reported April 4 but took a turn upwards to 172 last week. Counts of deaths have always been both erratic and delayed.

Kentucky’s Test positivity Rate had continued to fall since the March 7 report but took a turn upwards that week from 1.97 to 2.28. The number of PCR tests performed over the last 6 reported weeks also was continuing to fall from 73,786 to 43,773. It must be assumed that a substantial portion of the fall in new cases was due to less traditional laboratory testing and the increasing use of unreported home or office test kits. The proportion of new cases in individuals 18 years old and under continued to hover between 22% and 25% over the 6 weeks of reports.

Hospitalization Utilization:
In its once-a-week reports to the public, the KDPH now reports a “Current Covid-19 Hospital Census” for a single day, presumably as of the day of the report. In the report of April 11, the census for Hospitalized, ICU, and “On Ventilator” were 198, 29, and 14 respectively and declining steadily. These numbers were well down from those of the last daily report on March 4 which were 782, 155, and 14.

The discussion above I would have emphasized that the weekly reports reflected the average of 120 individual Kentucky counties and obscured the wide range of the actual distribution of new infections statewide.

Two Different Maps.
Kentucky now offers on its Covid-19 website a map displaying “Kentucky COVID-19 Community Levels by County” produced by the CDC. This stratification is based largely if not entirely on hospital censuses of Covid-19 patients and the availability of beds to care for them. The map last week showed only a single county in the green “low level.” However, when the actual “Incidence Rate” of the number of new cases per 100,000 population is calculated, a very different and more troublesome picture emerges. For example, in last week’s report of the New York Times, of the top 20 counties in the nation with the highest incidence rates, 7 were in Kentucky! Kentucky’s own Current Incidence Rate map had 4 counties with substantial rates, and many more counties with moderate as opposed to low rates. In “hot spot” maps of Covid-19 activity, Kentucky has popped out nationally as a sore toe over the past few weeks!

Weekly report of Monday April 18.
In the busy holiday season that was last week, I never got around to posting the update. I would have summarized our statewide status as being on average in a relatively good place, but would caution that we had been in similar places before over the last two years only to face a rebound of the virus as we relaxed our public health initiatives both personally and collectively. I would have expressed some concern that new Omicron variants were spreading at an ever-faster rates around the world and in in our nation and were quite likely to do so in Kentucky. I would have pointed out that the Test Positivity Rate for Kentucky had begun to rise. Yesterday’s report reinforces my concern that we are on the rebound again. Cases are up in an environment that favors under-reporting. The test positivity rate is higher than it has been in the 4 weeks. I summarize yesterday’s data in the figures below. (KHPI’s data visualization is still online but is current only to March 4, 2022.)

Cases taking a turn upwards.

Test Positivity Rate has been a reliable predictor of increased cases to come.

If it seems to my readers that I am unsure what to make of the new national and public reporting initiatives, you would be right. Many things have changed at once and the CDC and the Commonwealth do not always agree in their definitions and methods. What is clear to me is that the parameters I have been tracking daily for the last two years and which allowed credible and timely predictions in the directions we were going are no longer available to me. One of my paths forward is to allow larger and better resourced entities (which somehow still have access to county-specific daily numbers) to carry the ball. I highly recommend the New York Times operation in this regard. The CDC website is also becoming more useful and provides some limited historical data. I anticipate some wrap-up of my Covid experience and concerns going forward with occasional ad-hoc commentaries when I feel I have something to offer. I plan to return to writing about some of other themes of this series which I have neglected but which have not gone away such as opioid abuse and the cost of medical and pharmaceutical utilization.

I wish to thank my readers who have encouraged my efforts.

Peter Hasselbacher, MD
Kentucky Health Policy Institute
April 19, 2022

Omicron Sr. Fading Into Kentucky’s Sunset. Future of Epidemic Remains Unpredictable.

There were glitches in the states ability to report last week, such that Thursday’s numbers were not released until Friday evening along with that day’s counts. Nonetheless, there was much to be pleased about. You can play with the numbers yourselves on KHPI’s Tableau Public website.

Cases and rates still falling nicely.
Seven-day averages of New Cases and Kentucky’s overall Test Positivity Rate continue to fall in parallel, approaching where they were in early December 2021. The 7-Day average of new cases continues to fall faster than the 14-Day average– another good sign. Each individual weekday’s count of cases is demonstrably lower than the same weekday of previous weeks, often dramatically so. Semi-log plots of new cases demonstrate an increasingly more rapid fall in the rate of new case accumulation. This is all good, but over 2000 new cases per day should not be considered good enough.

7-Day Average New Cases and Kentucky’s Test Positivity Rate. Whys does the TPR lag the drop in cases? both are 7-Day avarages?

7- and 14-Day averages of New Cases in KY as of 2-25-22.

Testing down but still considerable.
Fewer Kentuckians are presenting themselves for testing in places where the results are reported to Kentucky’s various Public Health Departments, but a 7-Day average of around 30,000 is nothing to sneeze at. It has been a demonstrable fact that the number of cases discovered is linked strongly to the number of tests done. That is to say, the more tests performed, the more cases will be discovered. We must assume that there are more cases of Coronavirus infection in Kentucky than we have counted, be they symptomatic or not.

Number of all types of cases reported daily with 7-Day Average as of 2-25-22.

Test positivity rate calculated in different ways going down too.
The Test Positivity Rate as calculated by the KYDPH was in the single digits Friday at 9.9%, the first time since the onset of the Omicron surge in December. The positivity rate calculated daily from all types of tests is also less than 10. Still, this means that one out of every 10 Kentuckians who get a test outside of their home is actively infected! Disturbingly– at least to me– is that for Kentuckians 18 and under, one in four of these school-age individuals who have their test results reported to the state are infected with the current strain of Coronavirus and have been since last summer.

Number of new cases reported daily in Kentuckians 18 and younger as of 2-25-22.

Hospital and ICU bed utilization continue to fall progressively as does ventilator utilization for COVID-19 patients. It is fair to say that hospitals and their staffs are still under considerable pressure, some more than others. Still, this is another good sign that what we have been doing as a community is working. [Nag warning- We could be doing better!]

Because we are still under the peak of accumulating new cases, what will happen with deaths remains indeterminate. The most elderly of the vulnerable have either been infected, died, or been vaccinated. Mathematically, even if the Omicron is not as deadly at Delta or Alpha, this means that more of the dead yet to be counted will be younger than we have experienced up to now.

7-Day averages of new cases and reported deaths in KY as of 2-25-22.

We will not know the future until it becomes the past.
The Omicron strain of the virus is not the most recent one. A related variant [which I dub Omicron Jr. until or unless it gets a new designation] has proven itself globally to be more contagious than Omicron just as Omicron proved to be more infections than Delta. It is already present in all 50 states. That means inevitably that it will show itself all over Kentucky. The impact and outcome of this most recent round of whack-a-mole epidemic management remains to be seen. There is no doubt in my mind that traditional and new public health initiatives have been effective in fending off this most recent plague. Government and public health officials have been under tremendous political and social pressures to back away even from the basics and are doing so. There will be surges to come of this and other infectious diseases. We need to be able to see them coming and able to react. Dismantling our public health system or limiting the few tools we have available to protect ourselves is the last thing we should be doing. What we do or restrict now will shape our available responses for decades to come.

It is frankly frightening to me that we as a community seem to be willing to normalize where we are now. Wearing a mask and not coughing in your neighbors’ face will kill neither you or your neighbor. Coronavirus– in whatever disguise it appears now or in the future– can and will.

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

Omicron Cases In Kentucky Still Falling Sharply But Remain Higher Than During Delta Surge.

Friday’s announced number of 4693 new cases of Covid-19 continues its sharp and trend downwards from a peak of 16,130 on January 21st. The 7-Day average of 5502 net new Omicron cases peaked at 12,226 on January 26. The last time the 7-Day Average was this low was on January 5. The Commonwealth’s 20.1% Test Positivity Rate of electronically reported cases on Friday is following the same trajectory as cases. Both these metrics remain at higher levels than at any point during the four months of the Delta variant surge last summer and fall. Friday’s case count is likely underreported because the number of tests reported that day and the Friday before were relatively low but the trend is undeniably strongly downwards. How much lower and at how fast remains to be seen.

Reported daily Covid-19 cases (Fridays) with overall 7- and 14-Day averages.

Reported Hospital and ICU censuses seem also finally to be decreasing but I have no feel for what it is like to be either a patient or a healthcare employee in our hospitals. Not all are in the same shape. Deaths may be ticking up but based on past ability to track Covid-19 deaths in a timely manner, it will likely require several months for an accurate picture to emerge. I will try to tackle the matter of hospitalization with or for Coronavirus at some future time. It is not as simple as some make it out to be.

Continue reading “Omicron Cases In Kentucky Still Falling Sharply But Remain Higher Than During Delta Surge.”