We have gotten quite accustomed in the US of looking past our state and local government to federal agencies for answers to all sorts of problems. In the present circumstances, the focus has been on Washington to address the COVID-19 outbreak. It isn't entirely unreasonable. The State Department, the CDC and the FDA all have enormous powers to close borders, restrict travel and relax regulations related to drug and device approvals and delivery, among other things. For the most part, however, the federal government's role is to support pandemic/epidemic preparedness with funding and federal stockpiles of drugs and medical devices. When a pandemic or epidemic breaks out, the federal government supports containment and mitigation with personnel such as the Public Health Corps.
When it comes to fighting the outbreak of disease on the ground, it is the state and local government that direct the effort. Unfortunately, the decentralized approach means the record keeping is also dispersed making it difficult to see the breadth and depth of the outbreak with any nuance or context.
Johns Hopkins University has been providing real-time updates on the outbreak at a macro level that has been very valuable. However, if you are like us and trying to evaluate specific impacts to the health care delivery system, it helps to have a little more context. Using the JHU data, forum posts on Flutrackers.com; county and state health department press releases, and the tool you love to hate, Twitter, we assembled a time series of new cases for each of the affected US counties. When we exclude passengers from the two cruise ships that are considered US cases but for which we are unable to assign a geography, there are 350 cumulative cases in the US (7:12PM ET March 7, 2020).
Of those 350 cases, 252 are located in four hotspots:
- Seattle, WA MSA, epecially King and Snohomish Counties
- Northern California, including the Bay Area and Sacremento
- Los Angeles MSA, including San Diego, Los Angeles and Orange Counties
- New York City MSA
The remaining cases are sprinkled around the US as small outbreaks of one or two cases.
Within each of those hotspots, further context is helpful for assessing the implications of the outbreak.
Case Load v Test Data. As has been well reported, the CDC recommended testing criteria for COVID-19 on February 1, 2020. Those criteria turned, for the most part, on travel to China. On February 27, 2020, the CDC expanded that criteria to include travel to any affected geography or symptoms associated with COVID-19.
Initially, testing was limited. With the exception of Illinois, state health labs struggled with the CDC test. By the middle of last week, testing at scale had evolved and, of course, new cases were identified. It is important to know, however, that in most cases, the identified incidences of COVID-19 to date do not necessarily represent incemental burden to the health system as many of the tested individuals were already in the hospitals or healthy enough to self-isolate at home.
We should note however, data collected and reported by the New York City Health Department seems to suggest an uptick in Influenza-like Illness (the likely classification of unconfirmed COVID-19) early last week. The pattern did not hold beyond Monday and Tuesday and we will report what the data tells us this week.
Based on a few jurisdictions reporting over the weekend that there is now sufficient tasting capacity, the case backlog should clear or be cleared by city and state health departments early next week. The addition of test availability from LH and DGX will only accelerate the timeline. When that backlog is cleared, the rate of change in new cases will finally become meaningful to understanding the breadth and depth of the outbreak.
Rate of Change. As expected, the growth in new and cumulative cases is more a measure of the rate of change in testing rather than caseload right now but serves as a helpful background as testing achieves scale this week. A deceleration of new cases announced in hotspots late last week may indicate the backlog is clearing. If that is the case, we should be able to measure the outbreak more accurately this week.
Northern California
Southern California
Seattle, WA. A good bit of Seattle's case growth can be attributed to the outbreak at the LifeCare Center, a Long Term Care Facility in suburban Seattle. About 25% of cases are former residents of the facility and account for all but one of the 15 deaths in the state.
New York. New York City MSA's caseload springs largely from a Manahattan lawyer and his family and contacts.
What Happens Next. With the outbreak undeniably spreading - at an ROC yet to be determined - testing will provide valuable insights on who is most vulnerable to an attack. Then, public health measures are likely to move from containment such as contact tracing and quarantine to mitigation measures such as cancellation of large gatherings. In the mitigation scenario, testing is likely to be limited to only serious cases that require hospitalization and our view of the outbreak will once again be clouded. Eventually, COVID-19 data will make its way into the CDC Influenza reporting system and clarity will be restored but that could take a few months.
In the meantime, we will continue to compile data we can get and make all the caveated and qualified conclusions we can.
Reminder: We are hosting a call with Dennis Grimaud founder and former CEO of Diatherix Laboratories on Tuesday at 3:15ET. Hope you can join us.
Call with questions.
Emily Evans
Managing Director – Health Policy
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