Covid-19 Cases are Rising, But Deaths are Falling. What’s Going on?

VOX

There is something confounding about the US’s new coronavirus spikes: Cases are rising, but the country is seeing its lowest death counts since the pandemic first exploded. The numbers are genuinely strange to the naked eye: On July 3, the US reported 56,567 new Covid-19 cases, a record high. On the same day, 589 new deaths were reported, continuing a long and gradual decline. We haven’t seen numbers that low since the end of March. When laypeople observe those contradictory trends, they might naturally have a follow-up question: If deaths are not increasing along with cases, then why can’t we keep reopening? The lockdowns took an extraordinary toll of their own, after all, in money and mental health and some lives. If we could reopen the economy without the loss of life we saw in April and May, then why shouldn’t we? I posed that very question to more than a dozen public health experts. All of them cautioned against complacency: This many cases mean many more deaths are probably in our future. And even if deaths don’t increase to the same levels seen in April and May, there are still some very serious possible health consequences if you contract Covid-19. The novel coronavirus, SARS-Cov-2, is a maddeningly slow-moving pathogen — until it’s not. The sinking death rates reflect the state of the pandemic a month or more ago, experts say, when the original hot spots had been contained and other states had only just begun to open up restaurants and other businesses. That means it could still be another few weeks before we really start to see the consequences, in lives lost, of the recent spikes in cases. And in the meantime, the virus is continuing to spread. By the time the death numbers show the crisis is here, it will already be too late. Difficult weeks will lie ahead. Even if death rates stay low in the near term, that doesn’t mean the risk of Covid-19 has evaporated. Thousands of Americans being hospitalized in the past few weeks with a disease that makes it hard to breathe is not a time to declare victory. Young people, who account for a bigger share of the recent cases, aren’t at nearly as high a risk of dying from the virus, but some small number of them will still die and a larger number will end up in the hospital. Early research also suggests that people infected with the coronavirus experience lung damage and other long-term complications that could lead to health problems down the road, even if they don’t experience particularly bad symptoms during their illness. And as long as the virus is spreading in the community, there is an increased risk that it will find its way to the more vulnerable populations. “More infected people means faster spread throughout society,” Kumi Smith, who studies infectious diseases at the University of Minnesota, told me. “And the more this virus spreads the more likely it is to eventually reach and infect someone who may die or be severely harmed by it.” This presents a communications challenge. Sadly, as Smith put it, “please abstain from things you like to benefit others in ways that you may not be able to see or feel” is not an easy message for people to accept after three-plus months in relative isolation. But perhaps the bigger problem is the reluctance of our government to take the steps necessary to control the disease. Experts warned months ago that if states were too quick to relax their social distancing policies, without the necessary capacity for more testing or contact tracing, new outbreaks would flare up and be difficult to contain. That’s exactly what happened — and now states are scrambling to reimpose some restrictions. Unless the US gets smarter about its coronavirus response, the country seems to doomed repeat this cycle over and over again. Why Covid-19 deaths aren’t rising along with cases — yet The contradiction between these two curves — case numbers sloping upward, death counts downward — is the primary reason some people are agitating to accelerate, not slow down, reopening in the face of these new coronavirus spikes. The most important thing to understand is that this is actually to be expected. There is a long lag — as long as six weeks, experts told me — between when a person gets infected and when their death would be reported in the official tally. “Why aren’t today’s deaths trending in the same way today’s cases are trending? That’s completely not the way to think about it,” Eleanor Murray, an epidemiologist at Boston University, told me. “Today’s cases represent infections that probably happened a week or two ago. Today’s deaths represent cases that were diagnosed possibly up to a month ago, so infections that were up to six weeks ago or more.” “Some people do get infected and die quickly, but the majority of people who die, it takes a while,” Murray continued. “It’s not a matter of a one-week lag between cases and deaths. We expect something more on the order of a four-, five-, six-week lag.” As Whet Moser wrote for the Covid Tracking Project last week, the recent spikes in case counts really took off around June 18 and 19. So we would not expect them to show up in the death data yet. The national numbers can also obscure local trends. According to the Covid Tracking Project, hospitalizations are spiking in the South and West, but, at the same time, they are dropping precipitously in the Northeast, the initial epicenter of the US outbreak.

Covid Tracking Project

And a similar regional shift in deaths may be underway, though it will take longer to reveal itself because the death numbers lag behind both cases and hospitalizations. But even now, Alabama, Arizona, Florida, Nevada, South Carolina, Tennessee, Texas, and Virginia have seen an uptick in their average daily deaths, according to Covid Exit Strategy, while Connecticut, Massachusetts, and New York have experienced a notable decline. There are some reasons to be optimistic we will not see deaths accelerate to the same extent that cases are. For one, clinicians have identified treatments like remdesivir and dexamethasone that, respectively, appear to reduce people’s time in the hospital and their risk of dying if they are put on a ventilator. The new infections are also for now skewing more toward younger people, who are at a much lower risk of dying of Covid-19 compared to older people. But that is not the case for complacency that it might superficially appear to be.   Younger people are less at risk from Covid-19 — but their risk isn’t zero For starters, younger people can die of Covid-19. About 3,000 people under the age of 45 have died from the coronavirus, according to the CDC’s statistics (which notably have a lower overall death count than other independent sources that rely on state data). That is a small percentage of the 130,000 and counting overall Covid-19 deaths in the US. But it does happen. Moreover, younger people can also develop serious enough symptoms that they end up having to be hospitalized with the disease. Again, their risk is meaningfully lower than that of older people, but that doesn’t mean it’s zero.

CDC

There can also be adverse outcomes that are not hospitalization or death. Illness is not a zero-sum game. A recent study published in Nature found that even asymptomatic Covid-19 patients showed abnormal lung scans. As Lois Parshley has documented for Vox, some people who recover from Covid-19 still report health problems for weeks after their initial sickness. Potential long-term issues include lung scarring, blood clotting and stroke, heart damage, and cognitive challenges. In short, surviving Covid-19, even with relatively mild symptoms, does not mean a person simply reverts to normal. This is a new disease, and we are still learning the full extent of its effects on the human body. But even if we recognize that young people face less of a threat directly from the coronavirus, there is still a big reason to worry if the virus is spreading in that population: It could very easily make the leap from less vulnerable people to those who are much more at risk of serious complications or death. The coronavirus could easily jump from younger people to the more vulnerable One response to the above set of facts might be: “Well, we should just isolate the old and the sick, while the rest of us go on with our lives.” That might sound good in theory (if you’re not older or immunocompromised yourself), but it is much more difficult in practice. “The fact is that we live in communities that are all mixed up with each other. That’s the concern,” Natalie Dean, a biostatistics professor at the University of Florida, says. “It’s not like there’s some nice neat demarcation: you’re at high risk, you’re at low risk.” The numbers in Florida are telling. At first, in late May and into early June, new infections accelerated among the under-45 cohort. But after a lag of a week or so, new cases also started to pick up among the over-45 (i.e., more at-risk) population. “The rise in older adults is trailing behind, but it is starting to go up,” Dean said. Anecdotally, nursing homes in Arizona and Texas — the two states with the most worrisome coronavirus trends right now — have seen outbreaks in recent weeks as community spread increases. The people who work in nursing homes, after all, are living out in the community where Covid-19 is spreading. And, because they are younger, they may not show symptoms while they are going to work and potentially exposing those patients. As one expert pointed out to me, both Massachusetts and Norway have seen about 60 percent of their deaths come in long-term care facilities, even though the former has a much higher total fatality count than the latter. That would suggest we have yet to find a good strategy for keeping the coronavirus away from those specific populations. “There is so far not much evidence that we know how to shield the most vulnerable when there is widespread community transmission,” Marc Lipsitch, a Harvard epidemiologist, told me. That means the best recourse is trying to contain community spread, which keeps the overall case and death counts lower (as in Norway) and prevents the health care system from being overwhelmed. Health systems haven’t been overwhelmed — but some hospitals in new hot spots are getting close Arizona, Florida, and Texas still have 20 to 30 percent of their ICU and hospital beds available statewide, according to Covid Exit Strategy, even as case counts continue to rise. While some people use those numbers to argue that the health systems can handle an influx of covid patients, the experts I spoke to warned that capacity can quickly evaporate. “Let’s keep it that way, shall we?” William Hanage at Harvard said. “Hospitals are getting close to overwhelmed in some places, and that will be more places in future if action isn’t taken now. Also ‘not overwhelmed’ is a pretty low bar.” Hospital capacity is another example of how the lags created by Covid-19 can lull us into a false sense of security until a crisis presents itself and suddenly it’s too late. Because it can take up to two weeks between infection and hospitalization, we are only now beginning to see the impact of these recent spikes. And, to be clear, hospitalizations are on the rise across the new hot spots. The number of people currently hospitalized with Covid-19 in Texas is up from less than 1,800 on June 1 to nearly 8,000 on July 4. Hospitalizations in Arizona have nearly tripled since the beginning of June, up to more than 3,100 today. And the state-level data doesn't show local trends, which are what really matter when it comes to hospital capacity. Some of the hardest-hit cities in these states are feeling the strain, as Hanage pointed out. Hospitals in Houston have started transferring their Covid-19 patients to other cities, and they are implementing their surge capacity plans, anticipating a growing need because of the trendlines in the state. Once a hospital’s capacity is reached, it’s already too late. They will have to endure several rough weeks after that breach, because the virus has continued to infect more people in the interim, some of whom will get very sick and require hospitalization when there isn’t any room available for them. “We’re seeing some drastic measures being implemented right now in Texas and Arizona along those lines: using children’s hospitals for adults, going into crisis mode, etc.,” Tara Smith, who studies infectious diseases at Kent State University, told me. “So it shows how quickly all of that can turn around.” And, on top of Covid-19, these health systems will continue to have the usual flow of emergencies from heart attacks, strokes, accidents, etc. That’s when experts start to worry people will die who wouldn’t otherwise have. That is what social distancing, by slowing the spread of the coronavirus, is supposed to prevent.   We don’t have to lock down forever — but we have to be smart and vigilant Lockdowns are extraordinarily burdensome. Tens of millions of Americans have lost their jobs. Drug overdoses have spiked. There has been a worrying increase in heart-related deaths, which indicates people who otherwise would have sought medical treatment did not do so during the worst of the outbreak this spring. But we cannot will the coronavirus out of existence. Experts warned months ago that if states reopened too early, cases would spike, which would strain health systems and put us at risk of losing more people to this virus. That appears to be what’s starting to happen. And it may get worse; if the summer heat has suppressed the virus to any degree, we could see another rebound in the fall and winter. So we must strike a balance, between the needs of a human society and the reality that most of us are still susceptible to an entirely novel pathogen that is much deadlier and more contagious than the flu. That means, for starters, being smarter about how we reopen than we have been so far. There is strong evidence that states were too cavalier about ending stay-at-home orders and reopening businesses, with just a handful meeting the metrics for reopening laid out by experts, as Vox’s German Lopez explained.   “What I’ve seen is that reopening is getting interpreted by many as reverting back to a Covid-free time where we could attend larger group gatherings, socialize regularly with many different people, or congregate without masks,” Kumi Smith in Minnesota said. “The virus hasn’t changed since March, so there’s no reasons why our precautions should either.” To date, most states have opened up bars again and kept schools closed. Lopez made a persuasive case last week that we’ve got that backward. One of the most thorough studies so far on how lockdowns affected Covid-19’s spread found that closing restaurants and bars had a meaningful effect on the virus but closing schools did not. That study also found that shelter-in-place orders had a sizable impact. While those measures may not be politically feasible anymore, individuals can still be cautious about going out — and when they do, they can stick to outdoor activities with a small number of people. Masks are not a panacea either, but the evidence is convincingly piling up that they also help reduce the coronavirus’s spread. Whether a given state has a mandate to wear one or not, that is one small inconvenience to accept in order to get this outbreak back under control. And, really, that is the point. While the current divergence between case and death counts can be confusing, the experts agree that Covid-19 still poses a significant risk to Americans — and it is a risk that goes beyond literal life and death. We know some of the steps that we, as individuals, can take to help slow the spread. And we need our governments, from Washington to the state capitals, to get smarter about reopening. It will require collective action to stave off the coronavirus for good. Other countries have done it. But we have to act now, before we find out it’s already too late.