VoxCare: The truth about the new Covid-19 spikes

Today's coronavirus snapshot, as of 12 pm ET Wednesday: 2,141,276 confirmed US cases (8,210,642 worldwide) 117,033 confirmed US deaths (444,853 worldwide) 24,449,307 tests conducted in the US (74,314 tests per million people) —Dylan  . The White House is pushing a narrative that renewed concerns over the coronavirus's spread are merely a media concoction — a worrying strategy in light of the recent spike in cases in some parts of the United States. What's actually happening in the United States is much more complicated, and new research on the recent spike in Tennessee reveals some subtle ways in which the pandemic may be evolving. Why the White House's coronavirus narrative is wrong The White House's view is best represented by Vice President Mike Pence's Wall Street Journal op-ed from Tuesday: "There Isn't a Coronavirus 'Second Wave'". The vice president ticks through various data points — increased testing numbers, low positive test rates in many states, a steady plateau in new cases nationally, and a decline in deaths — to make his case. For starters, Pence's choice of frame is a misnomer. The experts I've spoken with aren't talking about a second wave at all. "We are still in the first wave; we're not yet seeing the second wave," David Celentano, who chairs the epidemiology department at Johns Hopkins, told me last week. Pence's preference for focusing on the national numbers obscures the very basic fact that America is not experiencing one Covid-19 outbreak but many. The virus is hitting different places at different times and spreads differently depending on a variety of local factors. Part of the reason for the national plateau in cases is a decline in New York City and the surrounding area, which were hit hardest by the coronavirus at first. But other places, spared in the early weeks of the pandemic, have now seen their first significant surge. The states with new Covid-19 spikes — Arizona, Arkansas, Florida, Texas, etc. — were able to lock down and stave off the coronavirus for a while because it hadn't saturated their communities in the way it had New York and other early epicenters where the virus first landed in the United States. Social distancing prevented their outbreak from growing exponentially. But now those states are seeing problematic trends, trends that Pence conveniently ignores in his op-ed: Hospitalizations are increasing and the rate at which Covid-19 tests are coming back positive is on the rise. Both suggest that the increase in cases is not simply the result of more testing, as Pence would clearly prefer Americans to believe, but also more spread within the community. I should also point out that, in other venues, Pence has outright falsely claimed a decline in cases when the opposite is true. As CNN documented, Pence said at a White House event that Oklahoma's cases are falling but that's wrong; new cases are up 123 percent over the last two weeks and the positive test rate has more than doubled over the same period. Local health officials say they wish the Trump campaign would postpone a planned rally in Tulsa because of the new spike. Pence is right that, mercifully, daily coronavirus deaths have declined nationwide (to date, at least 117,000 Americans have died from Covid-19, though that is likely an undercount). But deaths lag behind all of the other pandemic indicators; they are the last place where any new spread would show up in the numbers. First, people test positive and get counted as a new case. Next, those who develop severe symptoms are hospitalized and added to those figures. Last, some of the people who end up in hospital will die. It's only at the end of the disease's course, which can take several weeks to reach, when new trends in the pandemic are reflected in death data. There is one other way in which Pence's spin is troublingly Pollyanna-ish. He portrays the plateau in national cases as reason for celebration. But as Max Roser with the University of Oxford pointed out on Twitter, the US has not supressed the virus to nearly the degree that Europe collectively has. (And don't blame more testing; the US continues to see a higher positive test rate than many European countries.) Our World In Data We can't be complacent. The coronavirus is a sneaky pathogen, with symptoms not revealing themselves for days after an infection, even though infected people can spread it to others before they realize they have the virus. Because of that time lag, it is already too late by the time a local health system nears or reaches its capacity. Preemptive action is necessary. We have to protect each other through social distancing and other safety precautions, even if our government leaders are wrongly assuring us there is nothing to worry about. That doesn't mean staying in lockdown forever. But it does mean wearing masks, washing hands, and minimizing our contact with other people to keep the coronavirus in check. What is actually happening in some of the states seeing Covid-19 spikes Just because the White House is advancing a coronavirus narrative disconnected from the facts doesn't mean we aren't learning more about the pandemic and how it might be evolving. New research out of Tennessee, one of the states with an increase in cases and hospitalizations, provides a critical glimpse under the hood of these new trends. The study, from a team of Vanderbilt professors, is direct on the question of whether Covid-19 is spreading: "the virus continues to entrench itself in new communities." Still, the outbreak in Tennessee may be changing in important ways. The researchers found that while cases and hospitalizations are increasing at the same time, fewer people are ending up in the hospital than we would expect based on earlier trends. They explain: While hospitalization rates have risen statewide, hospitalizations have not risen proportionately with case numbers over the course of the pandemic. Why is this? One reason is that the risk profile of positive cases has varied over time and across regions. For example, some areas have at times seen large numbers of new cases among younger people who, absent any other underlying health conditions, have a much lower risk of hospitalization. In other areas there have been outbreaks among high-risk populations in congregate settings such as nursing homes. Outbreaks among higher-risk patients are generally followed by a rise in hospitalizations—but are hard to detect using raw case counts that include much larger numbers of low-risk individuals infected by the virus. In other words, it would appear that the coronavirus is currently infecting a younger and less vulnerable population, one less at risk of hospitalization, than it was in March and April. There are some differences in the case mix in different regions across Tennessee, but that is the statewide trend. The Vanderbilt study helpfully illustrates this change in chart form: Vanderbilt University In my conversations, some public health experts were anticipating this kind of shift. As states begin to reopen — Tennessee relaxed its stay-at-home order on May 1, businesses like restaurants and movie theaters are open again — it may be younger and healthier people who take advantage while older people who know they are more at risk may decide to exercise more caution. But, to repeat a theme, this is not a justification for complacency. First of all, while fewer young people are hospitalized with Covid-19 compared to older cohorts, a not-insignificant number of them still are. According to the CDC, the hospitalization rate in the US is 52 per 100,000 people for ages 18 to 49, 136 for ages 50 to 64, and 274 for ages 65 and older. So seniors are clearly the most at-risk, but younger people should not think they have no chance of developing a serious case of Covid-19. Second, if the coronavirus is spreading in the broader population, it has a disconcerting habit of finding its way to the most vulnerable people. New outbreaks in nursing homes have surfaced in Arizona, Florida, Texas and Tennessee in recent days — all states with those worrying aggregate trends. "Outbreaks seem to follow community spread," David Grabowski, a Harvard professor who has tracked Covid-19's impact on long-term care facilities, told me. "We are seeing outbreaks in a new set of states." And while hospitalizations in Tennessee are not rising at the same rate as new cases, there is still a risk that local health care systems could be overwhelmed if these trends continue. At some point, the sheer number of people infected could lead to a critical mass of hospitalizations. And many hospitals are now seeing more non-Covid-19 patients again, which reduces their capacity to handle a surge in coronavirus patients. Summarizing their findings on the recent spike, the Vanderbilt researchers wrote: "This has not yet taxed Tennessee's hospital capacity but does not guarantee that another increase in hospitalized cases will occur in areas with capacity to treat them." "Some hospitals across the state have limited ICU and floor beds currently available for potential COVID-19 cases," they concluded. "A surge in cases could stress these facilities." CHART OF THE DAY Amanda Northrop/Vox These diseases may balloon because the world is fixated on Covid-19. If things weren't bad enough, the Covid-19 pandemic is likely to take a toll well beyond the people it infects and kills, as Katherine Harmon Courage covered for Vox: As people under stay-at-home orders forgo routine medical care, including scheduled vaccinations for children, preventable diseases like measles and whooping cough will have more unprotected people to infect. And that puts not only more people at risk, but also more strain on the healthcare system. "Any country is vulnerable when faced with multiple threats," Claire Standley, a faculty member at Georgetown University's Center for Global Health Science and Security, told Vox in an email. "Those most at risk are the ones with limited human, material, and financial resources to support outbreak response." And this is already playing out. The Democratic Republic of Congo is currently fighting Covid-19 alongside Ebola and the world's largest outbreak of measles. And Yemen is battling Covid-19 in the midst of devastating armed conflict as well as a massive cholera outbreak. This is not only an unmitigated disaster for the people who live in these countries. "An outbreak anywhere is a threat everywhere," Standley says. "If disease threats proliferate elsewhere in the world, that poses a risk" of it spreading outside a nation's borders too.