The Orange Death: COVID-19 Resurgance in the United States

By Foss Tighe

In mid April the Trump administration shifted policy away from their limited efforts at controlling COVID-19 to re-opening the U.S. Economy. Daily detected cases in the US had plateaued at around 30,000 cases per day. Deaths in the United States had also plateaued at around 2000 per day. Perhaps more importantly, daily new cases and deaths in the New York State, the US epi-center of the pandemic in April, had peaked and gone into decline. There was reason for cautious optimism that the darkest days of the pandemic for the US were over.

But there was no reason to believe that the basic dynamic of the highly infectious coronavirus had fundamentally changed in anyway. It had now been detected in all 50 states. Though there was hope that the coming warmer weather might lesson the infectiousness of the virus there was little evidence in that direction. In April Brazil and Columbia were just beginning to report infections, Ecuador and Panama were seeing climbing number of infections, Egypt was already experiencing a steep rise in infections, cases were being detected all over Africa during that time. In the Southern Hemisphere, only Australia and New Zealand had seen a declines in cases. These declines were attributed to aggressive efforts in those nations to slow the virus.

In the realm of theraputics, there had been no big breakthroughs, despite President Trump’s touting of Hydroxychloroquine, evidence was already accumulating that it was not effective. Remdesivir, which would not be approved by the FDA until May 1st, was then shown to reduce time to recovery in a randomized trial. It’s power was still very limited with an estimated “Needed to Treat” value of over 20. Which means that for every 20+ people treated with the medication, only one will experience the improved outcome sought in the study. Remdesivir is also very expensive. In July there was some better news when a British study reported improved hospital outcomes from an inexpensive 60 year-old medication dexamethasone.

Though there remains much uncertainty around the strength and duration of the immunity of infection survivors, the number of people who had been infected and recovered from COVID-19 was very small in April. Based on the number of detected cases in mid April (665,000), only 0.2% of the US population had been infected, leaving 99.8 % of the population still susceptible to infection. Recognizing that detected cases in mid-April likely vastly underestimated the number of actual infections, we might estimate the total number infected as 10 times higher than the detected number which would still only bring the infected population to 2%, leaving 98% of the United States still susceptible to infection.

Flattening the curve in April had been achieved at a tremendous cost. In addition to the 30,000 deaths by mid-April, the Federal government had approved close to 3 trillion dollars of deficit spending to mitigate the economic damage done by the economic shut down that was needed to slow the virus. Millions were unemployed, looming evictions and foreclosures were postponed by federal and state rules. But the rate of new infections was declining. Some states had very low rates providing an opportunity for tight infection control through testing, isolation and contact tracing, which would have pushed new infections even lower. There was a short window of opportunity to gain control over the pandemic had non-essential economic activity remained shut down for a few more weeks. But we never really saw the “other side of the curve“.

Figure 1: Daily Cases in the United States declined between late April and early June.
https://www.worldometers.info/coronavirus/country/us/

The President’s abandonment of any responsibility for controlling the pandemic combined with his rush to re-open the economy ensured the decline in new infections was modest and short lived.

Public health officials and large sections of the public understood that the virus would not miraculously disappear. In fact, the virus had not changed at all and remained the same dangerous threat it was in February, March and April. Thanks to the efforts of people like Dr. Fauci, Trump’s own Opening Up America Again plan even included some of the requirements that would have ensured the virus was under control prior to opening up the economy. But Trump was not interested in the details of declining cases, increased testing, improved positivity rates, and adequate contact tracing programs. Instead he worked to bully governors to open quickly, even encouraging armed thugs to descend on state capitals where re-opening programs were too slow for Trump’s liking.

Many of the states that opened up early did exhibit some of the required data patterns outlined in the Opening Up America, plan, but no single state achieved all of the requirements outlined in the plan. Not surprising, Trump threatened states that were opening too slowing, but made no such treats against states opening without meeting his own Aministration’s requirements for opening. Some states even made changes to their reporting systems that made the data look more favorable for opening up. In Florida a public health scientist was fired over a dispute regarding changes to that state’s portal.

Despite meeting some re-opening criteria, nationally few states have met the contract tracing guidelines. The website covidactnow.org provides data on a state and county basis on a number of coronavirus metrics. In particular it estimates what percent of the cases the state can trace based on the number of contact tracing staff they have hired, and the number of daily cases the state is experiencing. Figure 2 shows recent data from Texas, showing that given their contact tracing capabilities, the state can only track an estimated 7% of new infections. According to covidactnow.org, only a handful of states have adequate contact tracing capabilities to track new cases in their state.

Figure 2: Key infection control metrics for the state of Texas
https://covidactnow.org/

Contact tracing is a key part of most strategies that hope of actually containing the virus. Taiwan was particularly effective at use testing, contact tracing and quarantine to protect its citizens from the ravages of COVID-19. Because the number of cases greatly impact the cost and effectiveness of starting a contact tracing system, it is most effectively done when infections are at their nadir. The time to launch such programs in the US would have been in May.

Resurgence of COVID-19

Since the aggressive push to re-open, the death total in the United States has passed the grim milestones of 50,000, 100,000 and most recently 150,000 dead.

Given the Trump administration’s priorities it was inevitable that the number of infections began to rise. This rise began, in some of the eager to open states just a few weeks after memorial day weekend, and nationally by mid June. Trump’s response was just more mendacity. In response to increased in infections he blamed increased testing. When the positivity rate was also increasing, the Trump administration made a big deal out of the lower age of those being infected, as if somehow younger people being infected did not indicate a potential problem. In June and July data made public through the CDC indicated there was an increase in number of COVID-19 hospitalizations in the very same states where there were increased cases. The administration suddenly and mysteriously decided that all hospitalization data should stop being reported to the CDC, but should instead be routed to a new service a the Department of Health and Human Services. Not surprisingly, the transparency and reliability of the data made available by HHS has been far lower than when it was routed to CDC.

But all of that was too late, by early July, deaths rates in states like Texas (figure 3), Florida (figure 4) and Arizona (figure 5) were beginning a clear increase.

Figure 3: Daily Deaths Texas
Figure 4: Daily Deaths Florida
Figure 5: Daily Deaths Arizona

Figure 1 shows that by mid June, daily new cases surpassed the previous peak from mid April. Current daily new cases are more than double the mid-April peak. The disease has not changed, the treatment options have changed very little, the percent of the population with possible immunity has not changed significantly. Added to those facts consider that the pre-existing conditions known to increase risk of bad outcomes with COVID-19 are more prevalent in the South. There is no reason not to believe in the coming weeks the daily deaths from COVID-19 will also exceed that of the mid-April height. How will the Trump administration try to dismiss it when the 3-5 thousand Americans are dying each day?

Foreseeing this resurgence in the COVID-19 in the United States did not require a crystal ball, nor an intense deep understanding of infectious disease. It merely required listening to our public health experts. Under Trump’s leadership, the United States has squandered the progress made through mid April and the trillions of dollars that small progress cost. Now we face a renewed outbreak larger and wider than the first, for which we are not significantly better prepared than the first. President Trump’s role in this resurgence is criminal on so many levels. That is why I dub this resurgence the Orange Death.

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