“You’re Gonna Need a Bigger Boat”

Its crunch time for the United States and COVID-19

The title above references a quote famously uttered by police chief Brody in the movie Jaws, following his first look at the size of the shark they were hunting. The chief spent a good portion of the movie trying to keep everyone from going in the water, but the townspeople wouldn’t listen because their entire economy was tied to the beaches in the summer months. Talk about life imitating art, huh? As we enter our 8th month of dealing with COVID-19 (can you believe it’s only been eight months?), we’re still trying to figure out how big this shark really is… and how safe it is to go in the water. As always, we’ll let the data do the talking.

World Class

We’ll begin with a world view to provide context. Globally, there have been over 41 million reported cases of the COVID-19 virus, and it has killed over 1,100,000 people in 200+ countries. Unfortunately, the global new cases per day number continues to trend upward — over 378,000 per day as of October 20, which is an increase of more than 40% since our last blog two months ago. Below are the top ten countries in terms of case count. On the left is mid-August when our last blog was published, and on the right is the count as of October 20. Countries are color-coded by continent to illustrate geographic differences, and key points follow.

Eight of the top ten are the same, with South Africa and Chile being replaced by Argentina and France.
South America has four of the top ten countries (plus Chile at #14), which continues to be a disproportionate presence. This is potentially troubling because the continent has been going through its winter months. Viruses of the past have spread more rapidly in cold weather as people move inside and opportunities for spread increase. Something to watch as winter approaches above the equator.
The United States, India, and Brazil currently account for a combined 52% of the global cases. While that is a large number, population has to be factored into the evaluation of response success – these are 3 of the 6 most populous countries.
The current global death rate (not shown) is just over 5,500 per day, which is down 8% since mid-August. This is of course good news – the rate has taxied in the 5K-6K range since mid-July. Deaths trail case increases by about a month, so it remains to be seen if the recent global increase will show up in November.
The death-related statistics for the United States are not positive compared to the rest of the world. A few rankings are shown below, which provides a natural transition into the discussion of US trends over time.

On the National Level

There are two United States’ case count charts below. The top graph plots the actual daily figures. Note the repetitive pattern over time, like a dolphin jumping as it swims through the water. This is due to inconsistent reporting on the weekends. The bottom graph smooths out the inconsistencies by taking a 7-day moving average. In other words, the July 8 number is the average of the week leading up to July 8. This makes it easier to follow the trend over time.

The bottom graph shows the good news and the bad news. The good news is that after peaking at just under 70,000 cases per day toward the end of July, we dropped to just over 35,000 cases per day around the second week of September- almost 50% lower. The bad news is that we’ve been on a sustained increase in the last month, going back up almost 40% from the lowest point.

The obvious question is why? The ominous possibility is that it could be due to winter coming. Below left is a state-by-state view of case count increases since September 1.

The orange states have all experienced at least a 40% increase in daily case counts, yellow from 0-40% increase, and green states have a decrease in counts. The table on the right lists the states in which the case count has more than doubled since September 1 – total of 19 states. The pattern on the map supports the hypothesis that northern / colder states are indeed increasing faster than southern / warmer states. There are other factors involved of course; will continue to monitor as winter arrives.

What about trending in virus-related deaths? It’s an interesting question. The graph below begins in July to enable comparison to the cases graph above.

Note the lag in peak time between the cases chart in July and the death chart in August, which is expected. There is good news, however. The early-COVID death graphs in the US went as high as 2,250 per day in April. The fact that the graph above peaks at 1,177 despite very high case counts in the summer speaks to the possibility that we have advanced in our ability to treat the virus. Hopefully, the increase in the coming winter will not result in another corresponding surge in deaths.

Are the Rumors True?

There are several narratives being fostered these days about where the country is headed from a virus perspective, and things tend to get sensationalized in today’s environment. A friend told me recently he’s lost interest and faith in the “mixed bag of facts” that is floating around, which is easy to do. Here are some data-based clarifications of recent statements.

There have been many comparisons of COVID-19 to the flu. There are key differences. First, flu survivors don’t have lingering longer-term side effects that some COVID survivors appear to have. Second, COVID-19 is far more deadly. It was recently stated that the flu sometimes kills over 100,000 Americans in a year. The average number of flu deaths in the United States over the last ten years is about 36,000, and the maximum was “only” 61,000. Conversely, COVID-19 has resulted in over 225,000 deaths in about 8 months. If the COVID number is annualized that makes it about 9 times more lethal than the flu, which is bad. Sadly, the situation is probably even worse than that. To wit…
Because COVID-19 hit the US in March, the country has not yet experienced a COVID winter. About two-thirds of the deaths in the United States (and a big majority of flu-related deaths) occur in the winter months. According to the CDC, the highest months in terms of average deaths per day are December, January, and February- note the bar heights in the CDC graph below.

US Average Deaths Per Day (by Month)- 1999-2017

Source: QuickStats: MMWR Morb Mortal Wkly Rep 2019;68:593.

The graph covers 1999-2017. I was able to find the 2019 numbers and they follow a similar pattern. The highest months were December and January, and the lowest months were June-July-August-September. Why is this information in the “clarification” section? Because I was recently forwarded the data below from a friend. The subject was the annual death rate in the United States for the last three years.

The conclusion below the numbers was “2020’s overall death rate is on pace to be LESS than 2018 and 2019.” The author had prorated the data through the end of the year, which would have resulted in about 2.7 million deaths. But that is only the case if we make the (incorrect) assumption that every month has the same death rate.

A more useful way to look at year-over-year comparisons is by what the CDC calls “excess deaths,” defined as “the number of deaths overall during a particular period of time compared to how many people die during the stretch in a normal year.” The current projection of excess deaths in 2020 is 300,000. Additional information and analysis can be found at:

https://www.statnews.com/2020/10/20/cdc-data-excess-deaths-covid-19/

If you’ve heard any other COVID-related numbers and you’d be interested in exploring whether they are fact or fiction, feel free to forward to me and I’ll take a look.

What Happens Next?

I’ve always found it oddly appropriate that COVID-19 is labelled a novel coronavirus, since everything about it has indeed seemed novel. As such, there’s no absolute way to know what the future holds. Given that, I’d like to close with a personal story and a plea.

I was working at a large hospital in Dallas in the winter of 2017-2018. The local hospitals had transport protocols in place to route patients to each other if an individual hospital ran out of space, particularly in the ICU. I’d worked there for six years and never heard about any significant problems. But the 2017-2018 winter was extremely difficult- that was the year that the flu deaths hit their maximum of 61,000. There was no bed space throughout the entire city, and we regularly had crisis-focused meetings about where to route patients. That’s the kind of thing a person doesn’t forget.

A concern of mine as we move into flu season is that the combination of the two diseases could be problematic for the health care system. If this turns out to be a bad flu season and COVID-19 is laid on top of it… yikes. I’d encourage everyone to be vigilant, which includes getting a flu shot and observing safety protocols. If we’re not careful… we’re gonna need a bigger boat.

—Ralph Smith