No two coronavirus outbreaks are the same. While the country waits to see what effect the combination of economic reopenings, anti-police violence protests, and warmer weather will have, different places are facing different kinds of danger as the pandemic progresses.
In some places, new cases might have started to level off, but because those areas have already been hit hard by Covid-19, infections are still widespread. Their health systems could still be at risk of exceeding their capacity, even if cases are plateauing or starting to decline.
In other places, they are starting from a lower baseline in case numbers, but worryingly, their rate of positive coronavirus tests has increased in parallel to their increase in testing capacity. That suggests the outbreak is still growing.
Either situation should be a warning against reopening too fast, too soon, experts told me.
“Reopening with an already increasing epidemic (estimated by new positives, new hospital admissions, % positive, all imperfect) means that the trend will only accelerate,” Marc Lipsitch, a Harvard epidemiologist, told me over email. “Reopening with high case numbers means that even if we plateau and don’t have increasing cases per day, the amount of damage is proportional to the number of cases per day, as is the difficulty of controlling transmission by test and trace.”
Some examples would be illustrative, right? The best example of the first scenario — a high baseline, with hospital capacity threatened even though new cases are relatively flat — would be Maryland.
Maryland (where I live) has endured a rough coronavirus outbreak. Among the 50 states plus Washington, DC, it ranks ninth in Covid-19 cases per 100,000 people and 11th in deaths. If you look at raw numbers, its outbreak does appear to be plateauing: Cases have dropped by 17 percent over the past 14 days.
But such a small decline in new cases still means there are a lot of new cases happening in Maryland every day, because the coronavirus was already widespread. If you look at the number of new Covid-19 cases per million people, Maryland ranks second among states, behind only Massachusetts, according to the folks running the Covid Exit Strategy dashboard.
And those new cases are popping up in a state where hospitals are already stretched. About 20 percent of Maryland’s ICU beds are currently available and just 14 percent of all hospital beds are free.
The goal has been to lower the reproductive rate of Covid-19, to get it below 1 (meaning one person only infects one other person or preferably less, on average). But it will take a long time for the outbreak to peter out if so many people have already been infected and are still spreading the virus, just more slowly.
“A reproductive number slightly above 1 isn’t going to translate to an immediate surge because of the doubling time. But if the number you are doubling is quite large, that will only help you so much,” William Hanage, who studies communicable diseases at Harvard, told me.
And now new risks have been introduced as social distancing starts to relax and people gather both informally and for the protests happening in Maryland and elsewhere across the country. Public health experts like Hanage continue to worry about “superspreader events.”
Other states face the same set of problems as Maryland. Rhode Island and Massachusetts, for example, have high rates of new cases per million people (112 and 147, respectively), and their health system capacity is not particularly strong (their ICU and general hospital bed availability rank as low or extremely low).
So that is one type of Covid-19 danger: persistent if plateauing spread and low health system capacity. The other is best represented by Alabama: a parallel increase in both testing capacity and positive test rate, which would indicate an outbreak that is continuing to grow.
To date, Alabama has experienced a relatively mild coronavirus outbreak. It ranks 23rd among states in cases per 100,000 residents and 26th in deaths. But Alabama has its own set of problematic trends, which might be different from Maryland’s but still give experts cause for concern.
Over the past two weeks, Alabama’s testing rate has increased, from an average of 4,100 tests per day to 5,000. That’s good; everybody agrees on the need for more testing to better track the disease. But what’s worrying is the percentage of those tests that are coming back positive has also started to increase.
The hope would be that as testing increases, the positive rate goes down; that would suggest that public health officials have a fuller picture of what the outbreak looks like in their state. But if the positive test rate is going up, that indicates that testing still has not been ramped up sufficiently to totally capture the pandemic’s spread but also that the virus is continuing to spread undetected.
“If the more you test, the more you find, you’re incubating yourself a problem,” Hanage said.
Much like the Maryland scenario, other places have the same problems as Alabama. Arizona, for example, increased its testing from 5,300 per day to 6,700 per day over the past 14 days, but the positive test rate has also jumped from 7.2 percent to 10.7 percent. Mississippi, North Carolina, and Pennsylvania are experiencing the same trends, even if they are not quite as stark.
What are we to do with all this information? First, it is simply a reminder that just because two places are experiencing very different kinds of coronavirus outbreaks does not mean one is necessarily doing “better” than the other.
But maybe most fundamentally, it is a reminder that the coronavirus is going to be with us for a long time. Whether your state has already peaked and now must contend with a long, slow decline or your state is seeing its Covid-19 cases increase, the end to the pandemic is still a long way off — especially as social distancing relaxes, whatever the reason.
“My big thing is that we should accept we are in a pandemic which isn’t going away,” Hanage said. “And it would be a good idea to decide what we are going to do, if and when it gets bad again, now (as if it’s not already bad enough).”
Update: The Maryland Hospital Association reached out after this story was published and said the ICU capacity figures from the Covid Exit Strategy, based on data from the CDC and the state, were wrong. About 20 percent of Maryland’s ICU beds are available, not 4 percent. The hospital association said it was in communication with government agencies to update the statistics. The story has been updated to reflect the hospital association’s data.
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