POST 33. June 23, 2002. CORONAVIRUS….. Smashing (lowering the daily number of cases) v. flattening the curve (maintaining a plateau)

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“You may think you look silly to wear a mask on your face on a fine late spring day, but you look even sillier in a hospital gown,” -Governor Murphy of New Jersey

“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” -Winston Churchill

APPENDIX. Metrics to Guide Reopening New York

“Epidemiologists define the herd immunity threshold for a given virus as the percentage of the population that must be immune to ensure that its introduction will not cause an outbreak. If enough people are immune, an infected person will likely come into contact only with people who are already immune rather than spreading the virus to someone who is susceptible.

Herd immunity is usually discussed in the context of vaccination. For example, if 90% of the population (the herd) has received a chickenpox vaccine, the remaining 10% (often including people who cannot become vaccinated, like babies and the immunocompromised) will be protected from the introduction of a single person with chickenpox.

But herd immunity from SARS-CoV-2 is different in several ways:

1) We do not have a vaccine. As biologist Carl Bergstrom and biostatistician Natalie Dean pointed out in a New York Times op-ed in May, without a widely available vaccine, most of the population – 60%-85% by some estimates – must become infected to reach herd immunity, and the virus’s high mortality rate means millions would die.

2) The virus is not currently contained. If herd immunity is reached during an ongoing pandemic, the high number of infected people will continue to spread the virus and ultimately many more people than the herd immunity threshold will become infected – likely over 90% of the population.

3) The people most vulnerable are not evenly spread across the population. Groups that have not been mixing with the “herd” will remain vulnerable even after the herd immunity threshold is reached.

For a given virus, any person is either susceptible to being infected, currently infected or immune from being infected. If a vaccine is available, a susceptible person can become immune without ever becoming infected.

Without a vaccine, the only route to immunity is through infection. And unlike with chickenpox, many people infected with SARS-CoV-2 die from it…

An ongoing pandemic doesn’t stop as soon as the herd immunity threshold is reached. In contrast to the scenario of a single person with chickenpox entering a largely immune population, many people are infected at any given time during an ongoing pandemic.

When the herd immunity threshold is reached during a pandemic, the number of new infections per day will decline, but the substantial infectious population at that point will continue to spread the virus. As Bergstrom and Dean noted, “A runaway train doesn’t stop the instant the track begins to slope uphill, and a rapidly spreading virus doesn’t stop right when herd immunity is attained.”

If the virus is unchecked, the final percentage of people infected will far overshoot the herd immunity threshold, affecting as many as 90% of the population in the case of SARS-CoV-2.” (A)

“But for things to return to normal, the only real strategy is to bring down the number of susceptible people. This is the reason why vaccination can wipe a disease out. It effectively reduces the susceptible population. Without a vaccine, though, the only other way to derive immunity is to have the disease. For COVID-19, rough estimates suggest that we need up to 60% of the population to have had the disease to achieve herd immunity.

So although we are slowly descending from the peak of the first small ridge of the epidemic, without the large number of people gaining immunity through having the disease, the mountain metaphor is unhelpful. The laws of epidemic gravity won’t help to pull us down on this descent…

A better analogy would be to the decelerating influence of a parachute. Social distancing and other measures have slowed the spread to a point at which the impact of the disease is currently manageable. But cut the parachute too early, before the danger is averted, and the outbreak will accelerate again.” (B)

“In epidemiology, the idea of slowing a virus’ spread so that fewer people need to seek treatment at any given time is known as “flattening the curve.” It explains why so many countries are implementing “social distancing” guidelines — including a “shelter in place” order that affects 6.7 million people in Northern California, even though COVID-19 outbreaks there might not yet seem severe…

The curve takes on different shapes, depending on the virus’s infection rate. It could be a steep curve, in which the virus spreads exponentially (that is, case counts keep doubling at a consistent rate), and the total number of cases skyrockets to its peak within a few weeks. Infection curves with a steep rise also have a steep fall; after the virus infects pretty much everyone who can be infected, case numbers begin to drop exponentially, too.

The faster the infection curve rises, the quicker the local health care system gets overloaded beyond its capacity to treat people…

A flatter curve, on the other hand, assumes the same number of people ultimately get infected, but over a longer period of time. A slower infection rate means a less stressed health care system, fewer hospital visits on any given day and fewer sick people being turned away…

…in 1918, …a strain of influenza known as the Spanish flu caused a global pandemic. To see how it played out, we can look at two U.S. cities — Philadelphia and St. Louis…

In Philadelphia, city officials ignored warnings from infectious disease experts that the flu was already spreading in the community. The city instead moved forward with a massive parade that gathered hundreds of thousands of people together, Harris said.

“Within 48, 72 hours, thousands of people around the Philadelphia region started to die,” Harris said. Ultimately, about 16,000 people from the city died in six months.

In St. Louis, meanwhile, city officials quickly implemented social isolation strategies. The government closed schools, limited travel and encouraged personal hygiene and social distancing. As a result, the city saw just 2,000 deaths — one-eighth of the casualties in Philadelphia.

The city, now known for its towering Gateway Arch, had successfully flattened the curve.” (C)

“The national picture is highly instructive. While the country as a whole has successfully flattened the curve, it has yet to show the extended period of decline necessary to declare ourselves out of the woods — a “squashing” of the curve. The same applies to most states. While a small number have sustained a long squashing period, most are still rising and falling day by day…

Your garden-variety epidemic has four acts. First, it grows very slowly (the first yellow block), resembling a low, linear curve, even though exponential growth is marshaling its forces.

After that, cases spike dramatically (red), infecting more and more individuals every day and registering wide public attention. There are two scenes in this second act. In the beginning, more people test positive every day than the day before. This is the hallmark of exponential growth, when the number of cases is not only growing but accelerating. At some point—in this case, around April 1 nationally, though the data is too noisy to pin down a precise date—that acceleration slows, at what’s known as an “inflection point.” The number of daily cases continue to grow compared to the previous day, but not as rapidly as before. The sooner policy interventions like school closings and stay-at-home orders are put in place, the sooner one reaches this critical midpoint.

Then, in Act Three, the curve flattens (yellow again), with approximately the same number of new infections reported every day. This is the phase that, early on, all of us were hoping for: the celebrated “flattening of the curve.” But it is not the end of the play. A flattened curve suggests some measure of control over the situation, but no one should be too happy with a large number of new infections every day, even if that number is constant. Furthermore, if a given country or state relaxes social distancing measures while still in the yellow phase, it could easily re-enter red territory.

Ideally, a flattened curve leads to a squashed one in Act Four (green). This is the moment when there are fewer new positive cases today than there were yesterday. The longer the fourth act can be drawn out, the closer we come to the final exeunt.

In tidy, computer simulations of an epidemic, the drama ends here after a very, very long fourth act. This is not the case with COVID-19. Across the country, states are seeing what might have been the final descent reverse as cases begin to climb again. What we now face is what will happen in Act Five.

Nationally, the U.S. has returned to a flattened curve (yellow again), where cases are neither spiking nor declining. This opening scene in Act Five is not ideal, but worse would be to return to a spike, as has occurred in several states. Take, for example, Tennessee:

Rather than progressing from flattening to a decline, Tennessee has returned to Act Two, with cases growing, despite intermittent good days…

Tennessee is one of the states that has seen a backlash to isolation measures in recent weeks, and it’s tempting to blame the regression on the protests. However, the latency time of infections from the COVID-19 virus is too long for such a neat correlation.

Again, it might be tempting to blame an apparent mid-April regression on local protests against social distancing orders. But in actuality, what appears to be an organic spike is more likely to be a rise in known cases due to an influx of test kits in Ohio. After reporting that Ohio’s curve had flattened two weeks ago, Cleveland’s ABC News affiliate now suggests that an increase in testing, with a particular focus on state prisons, is responsible for the return to rising cases.

In Georgia, meanwhile, where an abrupt easing of some public restrictions on businesses garnered both celebration and contempt, there is no sign of an extended decline that, from a public health standpoint, warrants such a liberation—or, as of yet, a sufficient lapse of time to know how damaging the reopenings may be.

It remains to be seen how Act Five plays out for the country at large. One can be cautiously optimistic that, should a supermajority of states endure the unpleasantness of every available intervention even as the curve flattens and declines, this will eventually conclude as a tragicomedy, not as Hamlet.” (D)

“The United States, meanwhile, is moving to open up on the basis of a vaguely articulated assumption that settling for mitigation is good enough.

One reason for the pressure to open up is that while widespread orders to shelter in place have clearly succeeded in slowing the spread of infection, they’re not bringing case volumes down quickly. Authorities fear the economic pain of prolonged shutdowns, and it seems like the mass public is growing impatient and starting to bend the rules.

But the reality is that the United States has not really tried the strategies that have made suppression successful. To accomplish that, America would need to invest in expanding the volume of tests, invest in more contact tracers, and create centralized quarantine facilities so that infected people aren’t simply sent home to infect the rest of their household.

Since the US didn’t spend April doing that, trying to achieve suppression — along the lines of Taiwan, Hong Kong, Korea, and New Zealand — would necessarily involve more delay and more economic pain. But doing so would save potentially tens or hundreds of thousands of lives and almost certainly lead to a better economic outcome by allowing activity to truly restart.” (E)

More people will die if states that reopened their economies too quickly and are reporting spikes in cases don’t take actions to prevent further spread, New York Gov. Andrew Cuomo said during his final daily press briefing on Friday.

The number of new deaths over the next four weeks is expected to accelerate in nine states compared to last month, according to forecasts published by the U.S. Centers for Disease Control and Prevention.

The coronavirus has killed more than 30,900 people in New York, the most of any state in the nation, according to data from Johns Hopkins University.

Cuomo issues dire warning about states reopening too quickly from Covid-19 lockdowns

More people will die if states that reopened their economies too quickly and are reporting spikes in cases don’t take actions to prevent further spread of Covid-19, New York Gov. Andrew Cuomo said during his final daily press briefing on Friday.

“More people will die and it doesn’t have to be that way. Forget the politics, be smart, open the economy intelligently and save lives at the same time. That’s what we showed works in New York,” Cuomo said during his final briefing.

Cuomo’s final daily coronvirus press briefing comes over 100 days after the beginning of the state’s response to the outbreak. New York confirmed its first coronavirus death, an 82-year old New York woman with pre-existing health issues, on March 14.

Since then, the coronavirus has killed more than 30,900 people in New York, the most of any state in the nation, according to data from Johns Hopkins University. The coronavirus has killed more than 118,400 people in the U.S., according to Hopkins data…

In the days leading up to his final press briefing on Friday, New York had reported record-low hospitalizations from Covid-19 and consistently recorded less than 50 daily deaths.

“Over the past three months we have done the impossible,” Cuomo said. “We’ve reopened the economy and we’ve saved lives because it was never a choice between one or the other. It was always right to do both.” “ (F)

“Gov. Phil Murphy on Tuesday spelled out the reasons for why New Jersey isn’t ready to fully reopen just yet, even as the state’s case and hospitalization numbers have declined sharply. He also announced during a news conference that New Jersey has 470 additional coronavirus cases and 51 more deaths…

But Murphy said he’s worried about a resurgence of the virus, especially if more indoor facilities reopen and as the region moves closer to fall, when COVID-19 is expected to return in the colder weather and if no vaccine is developed. The rate of transmission outdoors is 1/19 of what it is inside, Murphy said.

“This virus, by its very nature, is going to come back,” Murphy said…

Murphy also noted that hospitals and the state’s health care system are still too taxed to deal with a complete reopening…

“Our health care system is regaining capacity to meet the challenges ahead. We know there will be more COVID-19 hospitalizations,” he said. “Our hospitals are in a better, stronger position to care.”

Murphy, however, said New Jersey still has “too many people in our hospitals,” especially since the state’s numbers are among the highest in the nation.

“The only thing that will push these numbers down is slowing the spread of COVID-19,” Murphy said “That is why social distancing must remain our top priority.”

Murphy said he dined on Monday as New Jersey reopened outdoor dining and indoor retail, but he said he saw too many people not wearing masks. Read more: NJ’s Big Reopen Day: Here’s What You Can Do In Coronavirus Crisis

“You may think you look silly to wear a mask on your face on a fine late spring day, but you look even sillier in a hospital gown,” Murphy said.” (N)

“Arizona, Florida, California, South Carolina and Texas all reported record-high single-day increases in coronavirus cases on Thursday as states continue to ramp up testing and the virus reaches new communities.

Arizona health officials reported 2,519 confirmed cases on Thursday, surpassing the previous single-day high of 2,392 reported on Tuesday. Florida officials announced 3,207 new cases Thursday morning, shattering the state’s previous single-day high of 2,783 new cases also reported on Tuesday. California officials reported Thursday 4,084 new cases that were confirmed on Wednesday…

The record-setting numbers come amid an ongoing tide of new infections and increasing hospitalizations reported among a slew of states across the American South and West. Some states now seeing a rise in infections were among the first and most aggressive to reopen.

New cases have risen rapidly in Arizona and some hospitals are nearing capacity. The state reported a record-number of patients in ICU beds on Thursday, accounting for 84% of the state’s capacity.

On Wednesday, Arizona Gov. Doug Ducey addressed the recent surge and announced new policies that allow local officials to require that residents wear masks in public and in businesses after a slew of health specialists wrote a public letter asking the Republican governor to do so.

In making the announcement, the governor also acknowledged that the virus is spreading more quickly than is acceptable. He had previously said that officials expected cases to rise after the state eased restrictions and reopened businesses on May 15.

“I said two weeks ago that there is not a trend here,” Ducey said Wednesday evening while presenting a chart of daily new cases across the state. “Looking at the last two weeks of data, there is a trend. And the trend is headed in the wrong direction and the actions we’re going to take are intended to change that direction and reverse this trend.”

Ducey asked Arizonans to practice social distancing and recommended they wear a mask. He also announced plans to continue to ramp up testing as well as contact tracing, a process whereby health officials contact infected people and try to identify the source of infection as well as other people who might have been infected…

“We want to slow and contain the spread,” he said Wednesday. “We have successfully slowed the spread of Covid-19 in the past. We’re going to successfully slow Covid-19 again.”..

Earlier Thursday, former Food and Drug Administration Commissioner Dr. Scott Gottlieb told CNBC that some states now seeing a resurgence in cases are “on the cusp of losing control.”

“These are outbreaks. We’re seeing doubling times now falling under 10 days,” Gottlieb said on CNBC’s “Squawk Box.” “These are on the cusp of getting out of control. I think these states still have a week or two to take actions to try to get these under control.”

He added that he’s concerned about “the lack of political will” for officials to continue to implement proven interventions like social distancing and mask wearing.

“I’m more concerned than I was three weeks ago heading into the fall,” he said. “Unless we get comfortable taking some common sense measures, where we can, some limited measures, we’re going to be stuck with a lot more spread.” (G)

“As Florida reported another record day of new confirmed COVID-19 cases on Friday, with 3,822, Gov. Ron DeSantis pushed back against suggestions that the state may become the next epicenter of the nation’s coronavirus pandemic and that it’s quickly running out of hospital beds to care for patients.

At a news conference in Miami with local hospital executives and state and local leaders, DeSantis said that most of the state’s new cases have been found among younger people with milder symptoms and insisted that Florida has plenty of hospital beds available.

“A lot of the people who are testing positive now are not symptomatic,” he said.

DeSantis said the state has also ramped up testing of residents and staff at Florida nursing homes and assisted living facilities, requiring testing every two weeks for every staff member of a long-term care facility in the state.

“That will help us prevent the introduction of this virus into those facilities,” he said.

When it comes to hospital beds, the governor said the state has “twice as much capacity in the hospitals throughout the state of Florida today than before the pandemic began and that’s with having elective surgeries, which have been going on since the beginning of March [actually May].”

Mary Mayhew, secretary of Florida’s Agency for Health Care Administration, which regulates hospitals, accused the news media of overlooking the ability for hospitals to boost the number of staffed beds to handle a surge of patients.

“Our hospitals have an incredible ability to rapidly increase their capacity,” she said. “That is often overlooked by the media as they focus on current capacity.”

But the agency’s statewide hospital bed dashboard provides the data that national media have cited when reporting that Florida’s hospitals are running out of room at the same time that the state is reporting record numbers of new COVID-19 cases. The dashboard does not reflect hospitals’ ability to boost capacity.

Mayhew said there are more than 15,000 hospital beds currently unfilled statewide, which equals 25% below capacity — the same number reported by the agency’s dashboard.

“The trends are absolutely favorable,” Mayhew said. “The acuity is down.”…

The Florida Medical Association, the state’s largest and most politically influential physicians group, wants local governments to do more than crack down on social distancing, though.

On Friday, the group’s president issued a statement urging Floridians to use face masks to reduce spread of COVID-19, and calling on local officials to adopt regulations requiring face masks in public places.

“The science is clear,” said Ronald F. Giffler, the FMA president and Pompano Beach physician. “Asymptomatic infected individuals can release infectious aerosol particles while breathing and speaking. Not wearing a mask or face covering increases exposure.””  (H)

“As Florida health officials report another record single-day increase in cases of the novel coronavirus, new data shows hospitals across the state have filled most or all available beds in their respective intensive care units.

Numerous Florida medical facilities reported dwindling ICU bed availability on Thursday, with several reporting no availability at all, according to the latest report published by Florida’s Agency for Health Care Administration (AHCA). Palm Beach County was among those statewide regions where the availability of beds was most scarce. An accompanying report from AHCA shows about 75 percent of available hospital beds statewide are currently occupied.

The AHCA’s data showed two of Palm Beach County’s 17 hospitals have already filled all ICU beds, while several other medical centers reported limited availability. One hospital in Miami-Dade County has also reached its ICU bed capacity as of Thursday, and the majority of hospitals have filled more than half of beds in intensive care units. Palm Beach and Miami-Dade counties have reported two of Florida’s most severe local virus outbreaks.

More than 12,500 people have been hospitalized with virus infections in Florida since the start of the pandemic, according to the state’s Department of Health (DOH). The number accounts for all patients admitted to medical facilities, so Thursday’s daily total is unclear.

AHCA released its most recent data regarding Florida’s hospital and ICU beds as the state sees a substantial spike in virus cases. Florida confirmed its highest daily increase in positive diagnoses on Thursday, surpassing four single-day records set throughout the past week. The DOH’s latest update confirms 3,207 new cases identified since Wednesday, bringing Florida’s total to 85,926 diagnoses overall. Almost 17,000 people have tested positive for the coronavirus in Florida over the last seven days…

The latest figures reported by Florida’s DOH on Thursday showed the state’s total virus case count had more than tripled since reopening procedures were first initiated on May 4. Governor Ron DeSantis permitted all state regions to enter Phase 2 of Florida’s reopening plan on June 5, allowing bars, movie theaters and other entertainment venues to begin operating. Most other establishments, including personal care services, gyms, restaurants and retailers, reopened with some limitations in place when DeSantis effected Phase 1.”  (I)

“Crystal Stickle, interim president of the Florida Hospital Association, said some Florida hospitals are better equipped than others to keep their positive patients in one area. “All hospitals handle it differently. As long as they have dedicated staff and keep the door closed and properly identify a room with a coronavirus patient, I would not consider that an alarming practice” she said.

Holy Cross has an entire floor for patients with COVID-19 with an adjacent dedicated ICU. “We are trying to keep patients as safe as possible,” Gorensek said. A patient may need to wait in isolation within the emergency room until a test result returns before getting X-rays or scans. In an emergency, a nurse will whisk them from the ER to surgery and return them to the COVID-designated floor.

“We have had patients come in with a heart attack or stroke in the mildly early stages, and we have picked up the virus and have been able to avoid exposure,” she said.

With the presence of the virus more difficult to detect, South Florida hospitals have become more wary of incoming patients. In mid-May, Gov. Ron DeSantis allowed hospitals to reopen for elective services after prohibiting them for eight weeks during the peak of the coronavirus crisis. Now that patients are returning for hip replacements and colonoscopies, hospitals tout their efforts to keep a separation between the well and the sick.

At the five Tenet Health hospitals in Palm Beach County, anyone who comes in for elective surgery must be tested in advance, said Maggie Gill, CEO of Tenet’s Palm Beach Health Network. A positive result means the hospital will postpone the procedure for 14 days, and test again.

Of course, emergency procedures can’t wait. “We have patients in the hospital who are symptomatic, some who are asymptomatic, and some awaiting discharge. It’s a mix,” Gill said during a news briefing with DeSantis Friday. ”We have the capacity, PPE (Personal Protective Equipment), trained staff, and we are smarter in terms of how we manage patients today than we were in March.”

Dr. Larry Bush, an infectious disease specialist at Wellington Medical Center, said he, too, has learned how to better treat and identify the virus. “We are testing everyone admitted, putting them in one area, and observing anyone who comes in for something else but develops respiratory issues,” he said, adding that the screening has paid off. “We found three people with COVID who were not admitted for that.” (J)

“At least three hospitals in Palm Beach County, Florida, are out of intensive care beds as the number of coronavirus cases in the state spikes dramatically, according to a report Thursday.

Hospitals in the county — including Palms West Hospital, Palm Beach Gardens Medical Center and Wellington Regional Medical Center — had zero adult ICU beds left on Thursday, as nearby areas reported few open, according to NBC affiliate WPTV, which cited state health data.

In total, 18 percent of critical-care beds were open in the county while fewer were available in other parts of Florida, according to the state Agency for Health Care Administration, which tracks hospital bed availability.

But Wellington Regional Medical Center disputed the state data, saying there were in fact eight available ICU beds at the hospital, according to WPTV.

“Our critical care bed availability is greater than the Palm Beach County average reported by the Agency for Healthcare Administration,” a spokesman said. “In the event we see a surge of cases that need to be hospitalized, our hospitals have plans in place to continue providing care safely, and include the ability to increase our critical care capacity.”

Only 9 percent of the beds were left in nearby St. Lucie County, 12 percent were open in Okeechobee County, and 63 percent were up for grabs in Martin County, according to the report.

In total, more than 75 percent of adult ICU beds were occupied in Florida Thursday, according to the local station WCTV.

The alarming uptick in cases comes after Florida was hit by a record number of new infections — 2,783 new cases in a single day — earlier this week, and as scientists predict the state could become a new epicenter for the pandemic.

Earlier this week, Palm Beach County Emergency Management Director Bill Johnson said the area is “not in a crisis mode” but that a “surge plan” will go into effect.” (K)

“The White House coronavirus task force has been out of public view as President Donald Trump has shown an urgency to move past the pandemic, downplay recent surges in Covid cases in some states, and get Americans back to work.

But the nation’s top infectious disease expert, Dr. Anthony Fauci, has been warning Americans about the risk of further spread of the virus.

On Wednesday, Fauci, the director of the National Institute of Allergy and Infectious Diseases, joined the US Department of Health and Human Services’ podcast “Learning Curve” and gave his expertise on the pandemic and the vaccine development process.

He also defended the stay-at-home orders as having saved “millions of lives,” and drew attention to anti-science bias and the disproportionate impact the virus is having on the black community.

“One of the problems we face in the United States is that unfortunately, there is a combination of an anti-science bias that people are — for reasons that sometimes are, you know, inconceivable and not understandable — they just don’t believe science and they don’t believe authority,” Fauci said.

“So when they see someone up in the White House, which has an air of authority to it, who’s talking about science, that there are some people who just don’t believe that — and that’s unfortunate because, you know, science is truth,” Fauci said.

“It’s amazing sometimes the denial there is. It’s the same thing that gets people who are anti-vaxxers, who don’t want people to get vaccinated, even though the data clearly indicate the safety of vaccines,” Fauci added. “That’s really a problem.”

Trump has frequently disregarded expert advice — and often the guidance of his own administration — during the pandemic. He long touted the use of the anti-malarial drug hydroxychloroquine as a treatment for Covid-19 despite a lack of medical evidence, and the Food and Drug Administration revoked its emergency use authorization for the drug earlier this week. His suggestion that ingesting disinfectant in April was a potential treatment — he later said he was joking — was quickly denounced by medical experts. And he has refused to wear face masks in public despite widespread beliefs that doing so slows the spread of the virus.” (L)

“Just when many cities around the world were reopening after closing down due to COVID-19, their citizens going into a bright summer weekend, the grim headlines brought a hard reality: “The World Health Organization issued a dire warning on Friday that the coronavirus pandemic is accelerating, and noted that Thursday was a record for new daily cases—more than 150,000 globally,” reports the New York Times. “The world is in a new and dangerous phase,” said Dr. Tedros Adhanom Ghebreyesus, the Director-General of the W.H.O. “Many people are understandably fed up with being at home. Countries are understandably eager to open up their societies and their economies. But the virus is still spreading fast. It is still deadly and most people are still susceptible.”

According to the paper’s database, “81 nations have seen a growth in new cases over the past two weeks, while only 36 have seen declines.”

“The pandemic is accelerating,” said Dr. Tedros. “More than 150,000 new cases of COVID-19 were reported to WHO yesterday—the most in a single day so far,” he said.

In the United States, California, Arizona, South Carolina, Texas and Florida had record-high single-day increases in cases yesterday. Florida, for one, has “all the markings of the next large epicenter of coronavirus transmission,” and risks being the “worst it has ever been,” according to a model by scientists at Children’s Hospital of Philadelphia and the University of Pennsylvania…

Governor Ron DeSantis pointed to “overwhelmingly Hispanic” people to blame for the rise in cases. “Some of these guys go to work in a school bus, and they are all just packed there like sardines, going across Palm Beach County or some of these other places, and there’s all these opportunities to have transmission,” DeSantis said during a press conference in Tallahassee.

Experts, including Florida Agriculture Commissioner Nikki Fried, disagreed, saying the farmworkers left weeks ago.”  (M)

“Peter Navarro, the White House director of trade and manufacturing policy, said in an interview on Sunday that the White House was working to prepare for the possibility of a second wave of the coronavirus in the fall, though he said it wouldn’t necessarily come.

“We are filling the stockpile in anticipation of a possible problem in the fall,” Mr. Navarro told Jake Tapper on the CNN program “State of the Union.” “We’re doing everything we can.”

The comments come in contrast to President Trump’s repeated assertions that the virus will “go away” and his questioning of its ability to last into the fall and winter.

But if anything, the virus is gaining ground. Nationwide, cases have risen 15 percent over the last two weeks. Cases are rising in 18 states across the South, West and Midwest. Seven states hit single-day case records yesterday, and five others hit a record earlier in the week.

Florida and South Carolina had their third straight day breaking single-day records, and Missouri and Nevada both hit their records on Saturday — increases that came as the United States reported more than 30,000 new infections on both Friday and Saturday, its highest totals since May 1.

Florida reported 4,049 new cases on Saturday, bringing the state’s total to about 94,000 cases and more than 3,000 deaths; South Carolina reported 1,155 new cases; Missouri 375; and Nevada 452. Arizona, Utah and Montana also hit records.

California, Texas, Alabama, Oklahoma and Oregon hit records last week as well.

At the same time, overall deaths have dropped dramatically. The 14-day average was down 42 percent as of Saturday.” (O)

APPENDIX

Metrics to Guide Reopening New York

Governor Cuomo outlined guidelines that will help regions create individual plans based on facts and data to reopen New York.

Map of the 10 regions of the state and a list of counties within each region.

The state will monitor core factors to determine if a region can reopen.

The loosening of restrictions in New York will be considered on a regional basis, based on the following criteria. These criteria are designed to allow phased reopenings to begin in each region only if:

The infection rate is sufficiently low;

The health care system has the capacity to absorb a potential resurgence in new cases;

Diagnostic testing capacity is sufficiently high to detect and isolate new cases; and

Robust contact-tracing capacity is in place to help prevent the spread of the virus.

Regional Control Rooms

The regional control room will monitor regional metrics during the reopening process. These regional control rooms will monitor the hospitalization rate, death rate, number of new hospitalizations, hospital bed capacity, ICU bed capacity, testing and contact tracing within its region during reopening and alert the state if the region’s metrics no longer meet the reopening guidelines and adjust the reopening plan for that region accordingly.

Monitoring New Infections

The first key to reopening is continuing to control the rate of transmission of COVID-19, which limits infections and ensures that healthcare facilities are not overwhelmed.

Metric #1: Decline in Total Hospitalizations

The Centers for Disease Control and Prevention (CDC) recommends that reopening be dependent on a downward trajectory of hospitalizations and infections over a 14-day period. Before a phased re-opening begins, a region must experience a sustained decline in total net hospitalizations – the total number of people in the hospital each day, calculated on a three-day rolling average – over the course of a 14-day period. Alternatively, regions that have seen few COVID cases overall will satisfy this metric if the daily net increase in total hospitalizations (measured on a three-day rolling average) has never exceeded 15.

Metric #2: Decline in Deaths

Before reopening, a region must experience a sustained decline in the three-day rolling average of daily hospital deaths over the course of a 14-day period. Alternatively, regions that have seen few COVID cases overall will satisfy this metric if the three-day rolling average of daily new hospital deaths has never exceeded 5.

Metric #3: New Hospitalizations

In addition to monitoring the decline in disease trajectory, it’s important to monitor the absolute level of infection in each region. This is because it’s possible for a region that has seen a high level of infections – for example, New York City – to see a sustained decline in hospitalizations and deaths over a 14-day period, while still having an underlying infection rate that is too high to allow for a safe phased re-opening.

A phased re-opening for each region will be conditioned on the occurrence of fewer than two new hospitalizations per 100,000 residents (measured on a three-day rolling average).

Health Care Capacity

This pandemic has made clear that having enough hospital capacity is critical. Upon the recommendations of public health experts, every region must have the healthcare capacity to handle a potential second surge in cases – regions must have at least 30 percent of their total hospital and ICU beds available at all times.

Metric #4: Hospital Bed Capacity

In addition to ensuring that disease progression is contained, guidance from both the CDC and World Health Organization (WHO) require that regional health system capacity remain sufficient to absorb a potential resurgence of new cases. Phased re-openings will therefore be conditioned on the hospital bed capacity in each region. Regions must have at least 30 percent of their total hospital beds available before a phased re-open can begin.

Metric #5: ICU Bed Capacity

Nearly 30% of hospitalizations for COVID-19 ultimately require critical care. It is therefore critical that regional health care systems not only maintain sufficient bed capacity for a potential resurgence in cases, but also achieve sufficient capacity for ICU beds specifically. Accordingly, regions must have at least 30 percent of their ICU beds available before a phased re-opening can begin.

In addition, to ensure nurses and doctors have the personal protective equipment (PPE) they need, every hospital must also have at least 90 days of PPE stockpiled. The State is working with the hospitals, nursing homes, and other facilities to develop a timeline to build a robust stockpile. We can’t afford to risk another scramble for PPE while medical personnel are left under-protected.

Diagnostic Testing and Contact Tracing Capacity

The key to controlling the virus is aggressive testing and tracing, so that hotspots can quickly and effectively be isolated.

New York has worked hard to scale up testing at rates higher than any state or country in the world. Hospitalization rates are important, but testing identifies the full rate of spread. Regions can watch that rate move, and adjust their reopening strategies as needed.

Widespread testing is also key to effective contact tracing. This allows health officials to identify asymptomatic carriers, who are spreading the virus undetected, and isolate them before they infect others.

Metric #6: Diagnostic Testing Capacity

Widespread diagnostic testing is a key lynchpin on which our ability to contain the spread of the virus depends. Testing is critical to identifying new infections, isolating them, and tracing their contacts. Phased re-openings will depend on the ability of each region to achieve 30 tests per 1,000 people per month, consistent with the recommendation of Dr. Deborah Birx of the White House Coronavirus Task Force. New York scaled up testing at rates higher than any state or country in the world. The State is committed to continuing to rapidly expand our capacity statewide to help all regions meet this threshold.

Metric #7: Contact Tracing Capacity

The CDC and WHO also recommend that robust contact tracing programs be in place before local governments consider easing restrictions. Contact tracing helps prevent the spread of COVID-19 by rapidly interviewing positive patients; identifying their close contacts; interviewing and alerting those contacts to the risk of infection; and instructing those contacts to quarantine or isolate for 14 days, to be sure they don’t spread COVID-19 to others. The New York State Department of Health (DOH) has partnered with former New York City Mayor Michael Bloomberg, the Johns Hopkins University School of Public Health, and Vital Strategies to recruit and train an army of contact tracers to meet the needs of each region statewide, including from State, City and County Health Departments. In collaboration with these partners, DOH has established region-specific thresholds for the number of contact tracers required, based on the characteristics within each region.

Contact tracing helps prevent the spread of COVID-19 through four key steps:

First, labs report positive cases of COVID-19 to contact tracers on a daily basis via a state reporting system.

Contact tracers then interview positive patients to identify people they may have been in contact with over the past 14 days. Based on the results of the interview, tracers will advise the positive individual to get tested, and either isolate or quarantine themselves for the following 14 days to prevent further spread of the virus.

The contact tracer then notifies and interviews each contact of the original positive individual to alert them to their risk of infection, and instructs those contacts to quarantine or isolate for 14 days to prevent further spread.

Finally, the contact tracer monitors those contacts by text throughout the duration of their quarantine or isolation to see if the contacts are showing any symptoms.

Members of the tracing team will also work with any individual being traced who needs social services assistance, such as housing, food, or medicine, while they are quarantined or isolated.

Ongoing Monitoring

Once a phased reopening begins, it is essential that the rate of transmission be carefully monitored and remain under control. Each region must appoint an oversight institution as its “control room” to monitor the regional infection rate during the phased reopening. This team of local elected officials, as well as hospital and state representatives, will monitor the above metrics and other key indicators, and can slow or shut off reopening if indicators are problematic. This team will also monitor business’ compliance with reopening guidelines and ensure that local officials are enforcing these rules when necessary.

Phased Reopening of Business

Each region will reopen businesses in phases, with at least two weeks in between each phase. This allows state and local leaders to monitor the effects of the reopening and ensure hospitalization and infection rates are not increasing before moving to the next phase and permitting more economic activity.

The phase-in plan prioritizes businesses considered to have a greater economic impact and inherently low risks of infection for the workers and customers, followed by other businesses considered to have less economic impact, and those that present a higher risk of infection spread.

Additionally, when phasing-in reopenings, regions must not open attractions or businesses that would draw a large number of visitors from outside the local area.

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