I do not believe we are in any position in Kentucky to let go of the alligator we are wrestling. I am still waiting for better clarity of what we are actually facing.
Both new cases and deaths from Covid-19 infection continue to rise sharply in Kentucky. Observed mortality of confirmed cases remains above 5%. Simple daily plots of the numbers of cases by themselves cannot indicate whether we are turning a corner or flattening a curve. Comparison with other states and the nation as a whole does suggest our efforts to mitigate the disease are having an effect. Plotting the data on a logarithmic scale makes visualizing small and large numbers together on the same scale more accessible to analysis. More to the point here, such semi-log plots of the numbers enable us to observe whether the rate of increase in cases or deaths is actually slowing down. Over the past few days, there have been tantalizing suggestions that in fact that both cases and deaths are in fact doing so. Additional reported numbers over the next few days will clarify this hoped-for shift. Nonetheless, we have not achieved plateaus of either daily reported cases or deaths. In fact, semi-log plots of the number of new cases over the 30 days since the 100th new case show continued exponential growth with doubling times of every 5 days. Unless the very recent possible dip in new cases is real, at the current rate of increase, Kentucky will reach 10,000 total cases as early as May 4th. It seems to me that now is not the time to throw in the towel. It is appropriate to begin planning for an eventual data-driven, gradual, and stepwise reversal of our current non-medicinal efforts to deal with this stunningly infectious new disease, but otherwise it’s not very smart to do so precipitously. We have much more to learn about what is happening behind the scenes and our testing capability is still on its baby legs.
A higher than expected observed mortality rate does not accurately reflect overall case mortality. There are other things to worry about at this point- like some folks selfishly ignoring the prohibition of large group meetings!
[Addendum April 10, 2020: Governor Beshear announced this evening 90 new deaths, the largest in a single day by far.]
Since my article of April 3, the number of tallies of daily cases and deaths has increased. The figure below reflects the numbers released last evening on April 6 by Governor Andy Beshear. Click on the graphic to enlarge it. [An interactive graphic with updated data and alternate visualizations can be accessed here.]
The data underlying this figure can be viewed on my Tableau Public Website using the interactive link above. The data I present are the unchanged numbers as announced at the end of each day at the Governor’s public briefings. It should be noted that these announced counts have been continuously subject to adjustment by the Commonwealth to correct for duplications, late entries due to weekends, or other minor edits, but remain reasonably accurate as we go day to day.
It would be nice to believe that the slight downturn in the green “Positive Tests/Cases” line reflects the “flattening of the curve” that we are all working for. Things should become more apparent over the next few days. Recognize however, that Kentucky is testing many more people for viral infection. Yesterdays announcement noted that some 18,000 people had tests, compared to 2,556 just one week ago! The lesson here is “Seek and ye shall find.” There has always been– and still are– many more infected people in the community than we knew of. Many if not most of these have no or minimal symptoms. We should expect to see the number of new cases go up, especially if the new testing contract with Gravity Diagnostics works as hoped. A continuing increase in new cases should not be used to justify backing off from our efforts to protect each other from ourselves!
The Observed Mortality Rate depicted in the red line above represents the known number of deaths up to that day as a percent of the total number of known positive tests for virus at that time. The fact that this calculated mortality rate is still rising– indeed higher than the mortality rate in places whose epidemics have been running longer– is actually expected and should not cause disproportionate alarm at this point. Because of the lack of earlier testing, the true number of community infections was much underestimated. Only the most severe cases were identified and we expect a higher mortality in this subset of patients.
Recall too that the symptom-free incubation period between exposure and symptoms can range from 2 to 14 days. Similarly, infected people who eventually die do not generally do so on the first day of their symptoms. In a sense then, the Observed Mortality Rate curve is catching up with the number of unrecognized infections that occurred at a time of low testing. This observed mortality rate is surely higher than the actual case mortality rate which is a measure of how many infected people eventually die of their Coronavirus infection. What I expect to occur is that the Observed Mortality Rate will in near weeks begin to decline and level off at a considerably lower level. Epidemiologists all over the world are waiting to see what that level will be and who is most vulnerable.
I would like to have seen a more dramatic decline in numbers nationally, but we were as a country late to the game and it shows. My hometown of New York City, where I learned to be a physician and know its hospitals, is taking a terrible beating. In Kentucky we learned from the experiences of other nations, cities, and institutions and made the hard decisions early. I give our Public Health Department and the Governor’s offices much credit. I am following their advice and you should too.
Peter Hasselbacher, MD Emeritus Professor of Medicine, UofL April 7, 2020
If I have made an error in math or terminology or understanding, please help me correct it.
We have not yet reached the peak of either cases or deaths!
It has been my tenant, that as a society “We are no more healthy than the sickest among us.” In recent months, I restate as a corollary that, “We are no more healthy than the person standing right next to us!”
When I started this, I was actually surprised to see that I have not written for these pages for a full year. Ironically, the last article I wrote dealt with Kentucky’s major epidemic of Hepatitis-A. Fortunately, after more than 5000 cases, 2400 hospitalizations, and 62 deaths, that viral epidemic has simmered back down into its always-threatening background rate. Sadly, the non-medical societal determinants and public health support that permitted and accelerated that outbreak are still with us. It was just a matter of time that another life-threatening epidemic would come calling in the United States and to our Kentucky Home. This global pandemic, Coronavirus (Covid-19), is a particularly nasty one for which the world was ill-prepared. Reams of paper and terabytes of postings have been published attempting to explain why and how things got so bad so quickly, or whether we are overreacting. I expect to add something to those discussions, but not in this first effort. For now: it is what it is– bad! We will have to deal with it.
My readers know I like to play with numbers. I have been trying to assemble data about the number of cases of Coronavirus in the Commonwealth of Kentucky. It has not been easy, and I cast no blame. Despite the fact that the virus has been ping-ponging around the world causing death and devastation along the way, we in the United States were not prepared to test for the illness, to trace contacts, or even to take care of large numbers of very sick people. For now, I have been scraping numbers from Governor Andy Beshear’s daily reports to the state about the status of the epidemic and the state’s plans to deal with it. Governor Beshear has drawn national praise for the way he and his administration are managing with this maximally challenging problem and for communicating with the public. I echo that praise. I do not believe we are over-reacting.
The drama surrounding Kentucky’s epidemic of Hepatitis-A continues. Chris Kenning reported today for the Courier-Journal that Dr. John Bennett, current infectious disease branch manager, was dismissed last Friday. No specific reason was offered, but this is the second dismissal from that position in less than a year. His predecessor, Dr. Robert Brawley, was similarly dismissed less than a year ago after he lobbied for a more aggressive approach for what became the worst the Hep-A epidemic in the country. No doubt Governor Bevin’s administration will continue to deny that there was any connection between Dr. Brawley’s recommendation and his dismissal.
Dr. Bennett inherited a mess. A reasonable person might speculate that he is taking the fall for criticism that has been directed toward higher-ups in the administration. We may never know. However, turmoil as we deal with a new outbreak of serious, food-born E. Coli infection is not what we need now. Hep-A and E. coli pathogens are both transmitted by feces of infected individuals– basic sanitation stuff. There are other threats of serious infections on the horizon that we may need to deal with including a drug-resistant fungus, Candida auris.
Above is an updated graph from Frankfort showing new cases of Hep-A up to the week through March 23. It appears to show a sharp drop for the most recent week, but I assert that it is premature to conclude that the epidemic is ending. The report from which the figure is extracted warns that all cases in the current period have not yet been incorporated into the totals. Indeed, charts from earlier weeks that initially showed apparent trends downward before all the cases were counted ended up hovering around 40 new Non-Jefferson County cases per week. Over the last 4 reporting weeks, the number of counties having new cases decreased only from 21 to 19. The number of counties having at least one case during the epidemic continues to increase, now up to 105 counties. We are not yet home-free. I do not have access to updated data for Kentucky’s ongoing Hepatitis-B, Hepatitis-C, and HIV epidemics which remain endemic threats. We deserve some stability and are owed more confidence than we now enjoy.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
April 8, 2019
