Independence Day Pandemic Update from Maine

Not-So-Brief COVID-19 Update. Saturday, July 4, 2020.

INDEPENDENCE DAY COVID UPDATE

It has been a while since I’ve posted. Working on the reopening (of MaineHealth and to some degree, Maine generically) as well as returning to unfinished work that I left on the back burner in March has been more complex and time-consuming than I had anticipated. I continue to closely monitor COVID-19 data on a daily basis, which has also become more complex as we see different strategies related to re-openings, re-closures, and control of the pandemic and with varied viral activity across the globe, with many lessons to be gleaned.

I monitor U.S. and Maine CDC’s data, but also watch a plethora of MaineHealth data (de-identified) that we monitor daily, including syndromic surveillance, outpatient and ED visits, positive tests, test positivity rates, and hospitalizations - all by each of our hospitals’ service areas and system-wide. I also monitor nearby states, other states’ and national data, and global data. Especially as the country and world open up, learning lessons from other places is important. And knowing where the hotspots are is also critical, since this virus likes to hitchhike with travelers.

For monitoring pandemic activity in other states and countries, one challenge is the over-reliance on the number of new cases as the metric to compare and contrast geographical regions and populations. Because this metric is very dependent on test availability (and can be a barometer of good testing), I prefer data such as test positivity rates and hospitalizations to compare, and ideally the R naught, but that is rarely available except ones based on case numbers. However, these metrics are difficult if not impossible to obtain for other countries, and even within the U.S., these data sources can be challenging to obtain, since some states do not report new hospitalizations on a daily basis nor test positivity rates, and especially on sub-populations such as people in different age brackets or minorities.

Regardless of the challenges of the data, I’ll share a few gleanings from my observations. First, from a global perspective, reported cases and deaths are the most common metrics available. They indicate the U.S., Brazil, India, Mexico, and South Africa as the countries with the highest numbers of reported cases and/or deaths, with the U.S. leading the way in both numbers and rates.

However, one of the most important lessons from other countries I believe is coming from China. After what were considered extraordinary measures China took to control the pandemic this winter, followed by 55 days without any reported cases, an outbreak emerged in part of Beijing in mid-June. Within two weeks, nearly 8 million people were tested, including all residents of that part of the city, regardless of symptoms. Parts of the city were locked down with strict curfews, and aggressive contact tracing was implemented. After identifying about 300 cases (including asymptomatic ones found through mass testing), the outbreak seems to have subsided, with thankfully no reported deaths. Two likely related outbreaks in nearby cities have also recently occurred, and again are getting under control with wartime like measures. The lesson from China: COVID-19 will not be disappearing, even after nearly two months of no new cases and with very little international travel. Continued vigilance for the foreseeable future is certainly in our forecast.

As has been widely reported, across the U.S. South and West, the numbers of cases are surging. However, as mentioned, I rely on other data. They also show the pandemic activity is surging. For instance, test positivity rates and hospitalizations in these regions have increased dramatically. Interestingly, deaths are only increasing slightly or remaining steady, and in some cases are declining slightly in these states. With median ages of cases <50, it may be that the younger who are becoming infected and who are hospitalized, may not be dying at the same rates as their older counterparts.

Some examples: Arizona’s 7-day test positivity rate has risen to a striking 26%, and across the South, states’ positivity rates are primarily between 10 and 20%. By contrast, the Northeast states’ are 1 – 2%. The numbers of people hospitalized on any given day in Arizona, Arkansas, and Texas tripled during the month of June and doubled during the last two weeks in Georgia, Nevada, and Oklahoma. By contrast, hospitalizations have declined throughout the Northeast, and have remained at fairly low rates the last month. The cautionary tale seems to be that the massive and abrupt re-openings across much of the South and West have resulted in surges that are now threatening their economies, as in many areas, they have had to again close businesses and ask people to stay home.

What about Maine? Maine is seeing a slight uptick in activity. While it may not be a cause for alarm at this point, I do see it as a warning sign of the need for maintaining vigilance and surge capacity. Some signs:

? Maine CDC and MaineHealth’s NorDx laboratories have seen slight increases in test positivity rates, though they are both staying below 3%;

? All counties are seeing some cases among Maine residents the last two weeks. Although the numbers in rural counties are often not large, a case or two most often indicates there is disease in the area, and some rural counties have seen hospitalizations;

? MaineHealth’s syndromic surveillance (the percent of people presenting with symptoms consistent with COVID-19) has seen slight increases;

? The number of cases reported daily in Maine has risen over the last week, in the absence of major outbreaks, from ~10 - 30 range to 25 - 50; and

? The number of hospitalizations has stayed fairly flat with a trend of increasing slightly (from early-mid 20s to late 20s).

New US CDC compilation of forecasts show Maine experiencing possible increases in hospitalizations over the next 4 weeks to 10 – 20 new hospitalizations per day from current rate of less than 5.

With Maine’s economy opening up, with traveling increasing substantially (tourism, snowbirds returning home, family visits, etc.), and with surges in much of the rest of the country, this uptick in activity and national forecasts for Maine to see possible increases in hospitalizations these next several weeks are not a surprise. Given the likely low levels of immunity among Maine people and continued evidence that a significant proportion of transmission (some studies indicating >50%) is from people who do not have symptoms, it is important for all of us to remain vigilant.

Maine continues to see a number of cases among racial/ethnic minorities, with about 30-50% of new daily cases being in this group, especially among Blacks, and increasingly among Hispanics and Asians. Again, I hesitate to use the number of cases as a barometer, since it can indicate the availability and/or use of testing. One major question is: what is the health impact of COVID-19 infections? Although COVID-19 can impact people in many ways that are hard to measure, such as displacement from home or work and loss of pay, two direct health metrics that are readily available are hospitalization and death rates. Racial minorities account for 5% of Maine’s population, yet they account for 14% of cumulative hospitalizations. Nationally, their hospitalization rate is 5x that of the white population. My guess is many of Maine’s racial minority population contracting COVID-19 are younger, so they are not getting hospitalized at the higher rates as seen across the country. We see evidence of that in the recent large increases in younger populations testing positive in Maine, with now over 60% of cases being younger than 50 years old. Racial minorities comprise 3% of cumulative deaths with COVID-19 in Maine, which is slightly lower than the 5% of the population they represent, so again, this is perhaps an indicator of a younger age. Regardless, with disproportionate socioeconomic, cultural, and linguistic barriers faced by many among our racial minorities, there are looming needs for organizations and people to work together to:

? Engage minority communities in authentic ways that include building the necessary ingredients of mutual trust and respect;

? Through this engagement, develop data-driven comprehensive strategies;

? Deliver culturally and linguistically appropriate services by staff who reflect the culture of those being served, and in settings where people are most comfortable;

? Build upon cultural assets and strengths of communities (e.g. existing relationships in faith communities) and continue to build sustainable capacities for addressing a myriad of health and other issues; and

? Report on outcomes.

I hope in the long run more of a systemic approach can be developed, such as strengthening the public health infrastructure to be more fully responsive to our minority communities. Portland Public Health’s Minority Health Program, Wabanaki Public Health serving Maine’s Tribes, and Maine CDC’s former Minority Health Office are perhaps models to learn from.

Visitation to hospitals and some congregate living facilities is starting to open up in some places. This is a critical strategy in this chapter of learning how to co-exist with COVID, but leaves many questions that are not fully answered. For instance, how do providers and facilities re-engage with loved ones as members of the care team and still maintain physical distancing, masking, hand hygiene, and avoid crowding in order to reduce the chances of disease spread? With so many older people and others in congregate living settings having lived through an especially lonely period of isolation, how do we address those challenges? Building trust, engaging with each other, reflecting the culture of the setting and people being served, building upon the strengths of the facility, and monitoring outcomes are important strategies for any setting, including congregate living settings.

Although China seems to be successfully controlling a new outbreak, I think most would agree that the strategies used there would not be well received or tolerated in most of the U.S. Within our great country, we have many communities, many cultures, and as a result, need a variety of tools that combine what science is teaching us with what communities are telling us. Building trust, engaging with each other, reflecting the culture of the setting and people being served, building upon the strengths of a community, and monitoring outcomes are important strategies for any setting, any community.

On this Independence Day, we are reminded that our country was created based on the principles of equality. With this pandemic preying on those who are older, who have chronic diseases, who are essential workers, who live in overcrowded conditions or in congregate settings, we have daily data that remind us of the critical responsibility all of us shoulder to ensure all living in America enjoy the rights to life, liberty, and the pursuit of happiness. For me, that means today did not include the usual large gathering celebrations, and means I’ll continue to wear my mask, keep physically distanced, and practice vigilant hand hygiene - for my sake as well as for others.

A podcast of these posts, read by my daughter is here:

https://www.podbean.com/media/share/pb-ch5zi-d66fd3

State and U.S. 7-day Test Positivity Rates

https://coronavirus.jhu.edu/testing/individual-states

Hospitalization Data by State

https://covidtracking.com/data

CDC Weekly COVID Data Report

https://www.cdc.gov/…/covid-da…/pdf/covidview-07-03-2020.pdf

US CDC 4-Week Forecasts for Hospitalizations: https://www.cdc.gov/…/cases…/hospitalizations-forecasts.html

US CDC 4-Week Forecasts for Deaths: https://www.cdc.gov/…/2019-n…/covid-data/forecasting-us.html

Wabanaki Public Health

https://wabanakipublichealth.org/

Portland (Maine) Minority Health Program

https://www.portlandmaine.gov/467/Minority-Health-Program

Declaration of Independence

https://www.archives.gov/founding-do…/declaration-transcript