Author: P Hasselbacher

It is starting all over again!

Kentucky’s Covid-19 statistics were updated last Monday evening closing out the weekend days of Saturday and Sunday. All three of those days had the highest numbers of new cases reported for their weekday since the waning of the winter’s epidemic in early February, 2021.  The numbers reported on Monday were dwarfed by Tuesday evening’s report of 1,803 new cases and today’s of 2,583.  Current hospital and ICU utilization are similarly rocketing upwards with totals and at rates matching those of last November’s prelude to December’s epidemic disaster. Current numbers, including the Test Positivity Rate are also increasing in an exponential manner with doubling times measured in days, not weeks. Today’s Test Positivity Rate of 10.08 is headed for January’s high of 12.45.  The 7-day average of new cases exceeds the 14-day average by the largest measure since January also indicating rapid epidemic expansion. Deaths are beginning to creep up with 10 this evening.  It is not an exaggeration to use terms such as “on fire,” or “explosion” to describe the current state of Kentucky’s Covid-19 epidemic.  

Our state does not make historic county data available in a usable digital form to the public, but I must assume some of our counties are feeling a greater impact of expansion than the Commonhealth as a whole.  It gives me little comfort to consider that some “hands off” states like Florida or Texas are in a much worse position.  We know what is happening to us.  The issue is what are we going to do about it as individuals and as a community?  Let nature take its course?  We can do better.  I argue that we already know what works to mitigate the immediate and long-term damage of Covid-19 but lack the commitment to each other to stand united.

The reader is invited to review KHPI’s portfolio of data visualizations on its Tableau Public website.

How about that Delta virus?
Much is being written about how the CDC, other government entities, and business organizations are handling issues related to masking and other non-medicinal public health measures to combat the Coronavirus.  Some private entities now require immunization for employment or access.  Although it should not have been necessary as nationwide case data was speaking for itself, an analysis of a July Covid-19 super-spreader event in Barnstable County, Massachusetts put the issues right on the table.  A preliminary report by the CDC in their regular publication “Morbidity and Mortality Weekly Report” (MMWR) was made available to the public on July 30.  This and a slide deck of related internal CDC discussion are available to anyone. Let me know if these links do not work for you.

Summary of the CDC report of July 30, 2021.
Barnstable County includes all of Cape Cod which is famous for its Fourth of July parties and other celebratory activities that draw participants from all over. During the month of July, 469 cases of Covid-19 associated with multiple summer events were identified among Massachusetts residents.  Of those discovered to be infected, 74% were symptomatic.  These infected persons reported attending densely packed indoor and outdoor events that included bars, restaurants, guest houses and rental homes.  An initial outreach from the Massachusetts Department of Public Health revealed secondary transmission to at least 22 other states– so far!  This outbreak epitomizes the definition of a super-spreader event that was largely focused in a single party-town. 

Other observations from this outbreak have considerable relevance for the rest of us.  Of the 133 patients in whom the analysis was performed, 89% were due to the Delta variant.  Some 74% of cases occurred in fully vaccinated individuals!  Of the 274 vaccinated patients with these “breakthrough infections,” some 79% were symptomatic with the rest presumably asymptomatic carriers.  The viral RNA test used to diagnose Covid-19 disease or identify viral carriage can provide a measure of the amount of virus in the nasal cavity.  It was demonstrated that there was no significant difference in the amount of viral RNA in the noses of those who were vaccinated or not.  There were only 5 known Covid-19 patients who were known to have been hospitalized of which 4 were fully vaccinated.  There were no deaths reported at the time of the report on July 30, 2021. 

The CDC analysis describes a unique outbreak whose specific numbers, percentages, or rates cannot be generalized nationally but which are relevant based on solid epidemiologic and medical principles. For one thing, only Massachusetts residents were included in the analysis– out-of-staters were ignored. There was a detection bias such that symptomatic patients were much more likely to be included in the analysis. The demographics of the patients were not representative of the nation as a whole. They were much more likely to be male (85%), younger with a median age of 40, and likely whiter and better off financially in upscale vacation-destination Cape Cod.  My guess is that few of the infected wore masks.  Nothing has been reported about preexisting health conditions in the patients except that of the 5 known hospitalized patients, the single unvaccinated patient and 2 of the fully vaccinated ones had underlying medical conditions.

To what extent does vaccination decrease person to person spread?
In addition to the evidence of high transmissibility of the Delta variant, the frequency of apparent breakthrough infections in this specific population and the high viral-RNA lodes in vaccinated individuals raises the issue of whether vaccinated viral carriers, symptomatic or not, are capable of passing the virus to others.  I am unaware of specific information to settle this important issue, but it seems to me to be operationally reasonable to assume that some degree of transmissibility from the vaccinated is possible until disproved by a more structured analysis able to answer the question. Breakthrough infections are still considered infrequent in the general public– so far!

The observations from the Barnstable outbreak are relevant to and reinforce our understanding of the current state of our national epidemic.  What can happen in Cape Cod has the potential to happen anywhere else albeit to greater or lesser degree. We ignore the lessons at our peril.  I can only repeat the recommendations stated in the MMWR report that themselves are rather modest.

Recommendations from the MMWR Report.
“Event organizers and local health jurisdictions should continually assess the need for additional measures, including limiting capacity at gatherings or event postponement, based on current rates of COVID-19 transmission, population vaccination coverage, and other factors.”

“This investigation suggests that even jurisdictions without substantial or high COVID-19 transmission might consider expanding prevention strategies, including masking in indoor public settings regardless of vaccination status, given the potential risk of infection during attendance at large public gatherings that include travelers from many areas with differing levels of transmission.”

Current CDC recommendations and those of many public and private jurisdictions are in accord with the abovre. That may ultimately, indeed probably not be enough.

A highly virulent and perhaps more dangerous virus is circulating rapidly among us in Kentucky as it is in the rest of the world.  Other variants will certainly follow.  Vaccination of Massachusetts residents did what it was supposed to do by keeping people from getting very sick and by decreasing hospitalizations or death.  We are still learning about how the Delta variant will change things.  We should be receptive to changes in Public health recommendations and even requirements in response to a changing epidemic background. The epidemic was never declared by our public health services to be “over.”  Many of us would like to have believed that it was and acted accordingly. That was obviously premature.  The current CDC recommendations are reasonable and should be expected to change as the epidemic gets better or worse.  I got vaccinated at the earliest opportunity.  You should too.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
Kentucky Health Policy Institute
4 August 2021

[It Did.]

Yesterdays’s report totaled 1549 new cases of Covid-19. There has been no letup in reported New Cases, Percent Test Positivity, or Hospital and ICU utilization since the first week of July. Unless there are changes in behavior of Kentuckians, there is no reason to expect any change in this exponential trajectory. At this rate new cases are still doubling every 8-10 days. We all should know where that leads!

Yesterday I listened to a presentation by the Robert Wood Johnson Health Policy Fellowship program at the National Academy of Medicine of which I am an alumni. The title was “Communicating Science Effectively in the Time of COVID.” The program was well done, but sobering for me. The old scientist that I am works from a basic assumption that the facts will speak for themselves. Thus I spent much time unpacking state and national databases to describe what is happening in this epidemic and using that information to predict potential futures. That approach is obviously insufficient. It’s more complicated than that! Facts must be supplemented by stories. As I no longer take care of individual patients and am not part of the traditional public health apparatus, I have few stories to share. Others are doing that job for us. We need to pay better attention to our audiences. The challenge to act as a community instead of as individuals is great, but in my opinion one that must be faced as we learn to live with this first great plague of the 21st Century that isn’t going away soon.

The data speaking to me today tell me it is going to get a lot worse before we turn the corner again.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL

Unless one has been living in a cave these past months (or the modern equivalent of being totally off the grid) it is impossible not to acknowledge that the world, our nation, and our state of Kentucky are entering a sustained major surge in Covid-19 disease that has already shown its ability to duplicate some of the worst experiences to date for the pandemic. Since July 1, 2021, every reported indicator used to monitor new cases in Kentucky has been moving together in exactly the wrong direction. These include daily and weekly new cases and their 7- and 14-day averages, Kentucky’s calculated Test Positivity Rate (TPR), and rising hospital and ICU utilization. That the rate expansion of Kentucky’s epidemic is increasing daily is indicated by a 7-day new-case rate that exceeds the 14-day rate; and that since July 1, new cases have been rising exponentially with an estimated doubling rate of about every 10 days. These indicators put us in the same place we were in last summer before the nightmare of last winter’s holiday surges. Because the state has decreased its reporting days, the following graphics summarize the date only up to Friday, July 23. [See addendum at end of the article for update through 26 July 2021.]

Overview of Aggregate New Cases and Deaths:
This has been KHPI’s summary graphic for over a year. With over 7-million viral tests counted, at least 474,444 unique cases of Covid-19 were diagnosed. Virtually all authorities assume this is a gross undercount. One might assume that counting deaths would be more accurate, but even the 7312 Kentucky deaths counted so far are surely an undercount of the actual mortality that can be said to have been caused by the Coronavirus. Large one-day increases in deaths reported in March and June attest to the fact that we did not have reliable timely systems in place to track Covid-19 deaths, let alone the excess deaths due to disruption of the healthcare system. Similar artifacts in reports of cases and tests occurred that complicated our epidemic surveillance and predictions. This epidemic caused more misery than illness and deaths alone. Social disruption was massive– and continues.

7-day Average Daily New Case and Death Counts.
Because reporting systems follow a calendar of days of the week and holidays, day-to-day variation in counts swings widely. Kentucky and much of the rest of the nation no longer issues reports over the weekends. It is now customary to use 7- or even 14-day averages to identify trends, albeit delayed and after the fact. Assuming little change in reporting systems one does not need sophisticated statistical analysis to discern a relentless increase in new cases since July 1. No such increase has been observed as yet in Kentucky as has been seen in other states, but as demonstrated by the figures below, hospitalizations and deaths reliably follow rising cases by weeks not days. (Note the artifactual spikes in deaths in March and June.)

Weekly Case Counts.
Another way to even out or average case, death, or test counts is to summarize counts by week or months. The figure below shows weekly (Sunday to Saturday) counts of new cases since March of 2020. The most recent week displayed of 4224 additional new cases as defined by KHPI but does not include cases from Saturday, July 24. Conservatively adding another estimated 900 cases would give a total of 5124 for the week. This is be the highest since February’s fall from our winter surge and puts us in the same place as September 2020.

Test Positivity Rate.
Kentucky uses a calculated positivity rate that is based on a 7-day average of certain electronically reported tests that are positive. This is different than raw daily positivity rates which are higher, but has the important advantage of being more reliable. The nearly vertical climb of the brown TPR curve is frankly scary. The 7-day average of new cases is dutifully following along behind.

Hospital Utilization.
Test Positivity Rate tracks along not only with new cases, but also with hospitalizations. The following graphic displays the relationship of TPR with reported “Currently In Hospital” counts since December of 2020 when the new method of calculating TPR was introduced. Everything was going in a desirable directing until this July. The relentless deviation upwards is not a direction in which we want to be going. (A similar plot of TPR against 7-day new cases looks very much the same.)

Below is KHPI’s usual graphic display of hospital and ICU census statewide. Censuses for both categories are unmistakably going up. Anecdotal reports from physician friends suggest things are worse. Note too that the majority of hospital beds are located in counties with larger populations. The new case rates in smaller counties of Kentucky with lower vaccination rates is now where the disease action putting more pressure on smaller hospitals or in counties where there is no hospital all! A few US states have currently reached full capacity. We do not want to be there.

We are experiencing exponential expansion of the epidemic!
These last slides depict the 7-day rolling average of new cases over time using a semi-log plot. Note that the left-hand axis in not linear, but logarithmic. This gives an advantage of allowing both small and large numbers to be displayed on the same graph. In addition, as has been explained before these pages, if the plotted points conform to a straight line in a semi-log plot against time, that the curve is rising exponentially. Ideally, raw unaveraged daily case counts should be plotted but day-to-day counts vary greatly including days with no reports at all. My best analysis of 7- and 14- day averages, raw case counts, and weekly counts suggest a doubling of every 10 days or so. Since July 1, The Test Positivity Rate has been doubling about every 10-12 days. These are not good signs in my view! If nothing else changes, we could be back in the thousands of case per day by the end of August.

What is driving these surges?
A new strain of Coronavirus, names Delta has rapidly become the predominant strain in Americas and globally. It is thought to be at least twice as infective as earlier strains and seems to cause more significant disease. The vast majority of individuals getting sick with Covid-19 today are unvaccinated. Existing vaccines obviously still work but continued vigilant studies will be ongoing including the need for booster shots. Younger people continue to make up the most rapidly expanding age group with symptomatic or worse infections.

Certainly, there are non-viral reasons why we are entering a new epidemic wave. Public health measures have been relaxed. Hot weather puts people back indoors. Large-scale public events are coing back. Epidemic fatigue and a desire for the good old days drives the behavior of many. Surely the major factor involved is the fact that large segments of the population in Kentucky remain unvaccinated for whatever reason, including personal or political choice. For them, the epidemic is starting all over again where they live, work, play, or go to school. They will take their contagion with them wherever they go and keep the epidemic cooking.

Can we do anything about the firestorm that is coming?
Recommendations about renewed emphasis on mask wearing have been made by Kentucky’s public health officials. Mandates about mask wearing have not been made because it is assumed that even this mild government requirement would not be effective because mandates will not be followed! I suspect armed insurrection is also a legitimate concern.

Our public health officials nationally and in Kentucky make the rational and defendable point that with the availability of vaccination against Covid-19 available in America, that we could stop the epidemic largely in its tracks. (People in less developed countries wish they had this option at all!) A reasonable person might ask the question that if vaccination is so effective and acceptably safe, why is it not being mandated just as immunizations for school are mandated? I recently read that a few bats were found around Jefferson County that had rabies. I learned that all dog and cat owners in the county were mandated to have their pets immunized against rabies in order to protect the health and safety of our human residents. What will it take to apply a parallel decision for us humans to “promote the general Welfare” against epidemic diseases? That is a discussion that exceeds the space in this article. My fear, and frankly my prediction is that Covid-19 will again have its way with us and things will get a lot worse– real fast. One can only hope that as a community we come to our senses sooner rather than later and recognize the reciprocal obligations we have to each other, individually and through our government.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
President, KHPI
July 23, 2021

The full current portfolio of KHPI’s data visualizations is available on Tableau Public. These interactive graphics enable the user to select ranges of dates or otherwise focus on selective data.

Addendum 27 July 2021:
As of yesterday evening’s state Covid updates for the previous three weekend and Monday days, it is clear that Kentucky’s explosive, indeed exponential surge of its epidemic continues unabated. This is true of new cases, hospital and ICU utilization, and Test Positivity Rate. The total daily number of new tests and deaths remain stable. At the current rate of epidemic expansion, unless public behaviors or something else changes, we will hit a 7-day average of 1000 new cases per day by August 1 and 2000 cases by August 10th or so. (Raw new-case counts will reach these levels days before the 7-day average.)
Peter Hasselbacher, MD

Plateaus do not last forever.

As we approach the end of this pre-Derby Week and a change of seasons, the best we can say about the status of Kentucky’s Covid-19 epidemic is that our rapid decline of new cases has ended and that our case and hospital utilization rates have “plateaued” –albeit at levels well above last Summer’s or before last Fall’s epidemiologic explosion. Of concern are early hints of renewed epidemiologic expansion. Daily new case numbers and Kentucky’s calculated Test Positivity Rate are both inching up. The 7-Day average new case number is beginning to peek above the 14-Day curve– another hint of epidemic expansion. With two reporting days left this week, we are on track to match the 4000-plus weekly case numbers of mid-March. Kentucky’s current situation largely mirrors the national situation, but we are in a better place than states and regions where the Covid-conflagration has reignited. Our vaccination programs are going well and from my person-on-the-street perspective, much self-imposed masking and social distancing practices can be seen. In my opinion however, we remain vulnerable to things we cannot control– or choose not to.

Kentucky still contains viral hotspots as judged by national criteria. New cases arise throughout the state ready to breakout again. The more contagious viral mutations roam freely among us. We are travelling and encouraging out-of-state visitors again. The fact that no vaccine or disease treatment is perfect, permanent, or risk free is likely to interrupt vaccine administration programs for those who would benefit most– and that indirectly includes all of us! We are all tired of the restrictions the virus has imposed on our lives which have impoverished us both emotionally and financially. Many of us are in denial or have given up trying to do what history and science tells us is effective to bring the current plague under acceptable control. We continue to have unacceptable differences in access to the healthcare and social support necessary to maintain social cohesion and justice necessary to maintain the health of the body politic.

Where we go from here is indeterminable. We will only know when we get there. When I was asked last week if I thought it was safe to run a proper Kentucky Derby, I did not have a supportable answer one way or the other. It was and remains my opinion that another disease “surge” is more likely than not. More to the point, we lack the tools or surveillance structure to demonstrate that a given large-scale event is “safe” or not. If cases flair again, how do we tell if it was a Derby, returning Spring vacationers, out-of-towners, new viral strains, or anything else? Certainly other large-scale events are still being postponed.

My belief is that we should continue on our present course and that it is very premature to let our full guard down. I agree with incremental steps. I could even support more mandatory vaccinations or other requirements for full participation in societal events such as school or employment. I cannot find fault with the recent CDC decision to take a close look at a rare complication of the Johnson & Johnson (Janssen) and AstraZeneca vaccines. Nothing we do in medicine, public health, or living together is absolutely risk free. It is only a matter of justice and social cohesion that we share that unavoidable risk of being alive.

I updated KHPI’s tracking data on the Tableau Public website as of April 15 for your inspection.

Peter Hasselbacher, MD
Kentucky Health Policy Institute
April 16, 2021