30 October Blog Post: COVID-19 and the San Francisco “Miracle”

30 October Blog Post: COVID-19 and the San Francisco “Miracle”

Returning to a topic I have covered in previous blog posts – the San Francisco COVID-19 response has generally been laudable. But a strange this is happening in the press such that it is now being presented as the paragon of public health response. This week the @latimes published an article entitled “How San Francisco became a COVID-19 success story as other cities stumbled” (link: https://www.latimes.com/california/story/2020-10-25/san-francisco-slow-coronavirus-reopening).

In the article, UCSF Chief of Medicine Dr. Robert Wachter (who writes weekly “COVID Chronicles on his Twitter feed @Bob_Wachter and is an encyclopedia of knowledge – well worth a follow) is quoted saying “We have, at least so far, done everything right.” Dr. Larry Brilliant (@larrybrilliant – also worth a follow), an epidemiologist who was a significant contributing force to the @WHO smallpox eradication effort chimed in saying “San Francisco continues to lead the nations [sic] large cities in effective COVID-19 response. Proof that SF is not just another pretty face!”

Seriously?

While the first bumping and self-congratulation of these two esteemed Bay Area residents seems to be a light in a dark time in our country, their fervor isn’t matched by the data. In addition, they serve only to divide the country further into those who “get” COVID and those who don’t. Mask wearing, hand washing cities of science get to dance after the hammer (analogy is in the LA Times article) while other municipalities do not. Comparing Los Angeles’ pandemic experience with San Francisco’s, Wachter evens wonders aloud whether the difference in Los Angeles’ response as compared to San Francisco stemmed from “leadership or the people.” 

Ouch.

The problem I have is that San Francisco has had the exact same difficulties which have faced every other municipality in the world. They benefit only by comparison to the United States as a whole, which is worst in class. Sort of like saying my Buick Skylark is superior to your Ford Pinto, simply because the Skylark didn’t suffer from an exploding gas tank (apologies to those of you born after 1980 for the reference).

The figure below shows that San Francisco suffered the exact same mid July surge that plagued much of the United States. Case rates, having hovered in the 3-5 new daily cases per 100,000 jumped sharply to over 15. Recovery to baseline rates below 5 was slow. Whereas the acceleration in cases occurred from 6/19/2020 to 7/17/2020 (one month), the recovery extended until 10/9/2020 (three months). Note that since early October, cases are again rising (a pattern we are also seeing in Los Angeles).

Additionally concerning is the recent spike in mortality rates (Figure below).

Unlike many large municipalities, San Francisco has actually had weeks in which the mortality rate was zero. However, since late September, mortality rates have spiked – which is a very different pattern than we have seen in Los Angeles or nationally. Granted, San Francisco is a relatively small population (883,000) so rates can whipsaw in a way not seen in a larger denominator such as Los Angeles.

The Los Angeles Times article further quotes Dr. Wachter explaining that if the entire country had followed San Francisco’s approach, Wachter said, there would be 50,000 dead from the pandemic instead of more than 220,000. Here San Francisco benefits by comparison.

To date, there have been 145 deaths in San Francisco – population under a million. In Seoul, South Korea there have been 57 deaths – population 9.9 million.

So, no San Francisco, you haven’t done “everything” right. And the tough part of the pandemic – the dance – has yet to come.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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27 October 2020 Blog Post: COVID-19 Update in Los Angeles County – Cases Increasing 48% since Labor Day

27 October 2020 Blog Post: COVID-19 Update in Los Angeles County – Cases Increasing 48% since Labor Day

The Los Angeles Department of Public Health yesterday tweeted “Effective October 23rd, outside operations for go-carts, batting cages and mini golf at family entertainment centers in LA County may resume. There have also been updates to the school reopening protocols (TK-12 schools that are open for high-needs, specialized services can increase student capacity from 10% to 25%).”

Once again, the County’s messaging is decoupled from reality – continuing to open sectors while cases rise. As Figure 1 below shows, cases have risen 48% since the week ending 9/8/2020. We have gone from 7.79 new daily cases per 100,000 population to 11.54 new daily cases per 100,000 population.

The Health Department blames Lakers and Dodgers fans for the uptick (Link: https://www.si.com/nba/2020/10/27/lakers-dodgers-fans-drive-uptick-los-angeles-coronavirus-cases). But, in the same statement, they return to the same excuses that we have become accustomed to hearing: testing delays, data processing errors and late recognition of case increases. Or, as Dr. Barbara Ferrer stated:

“We’ve been seeing, first, very low case numbers a couple weeks ago and then in the last few days very high case numbers,” she said. “Now that we’ve processed the backlog of cases from the state, and analyzed the numbers by episode date, it is clear that our cases increased. This increase is not as steep as what we saw in July, but this is a cause of concern.”

In the national press, California is busy patting itself on the back about its underwhelming COVID-19 response. A recent Los Angeles Times article has suggested that if the county mirrored San Francisco’s response, that 170,000 lives would have been saved. It went further saying “San Francisco did everything right” (Link: https://www.latimes.com/california/story/2020-10-25/san-francisco-slow-coronavirus-reopening). This is clearly not the case as there have been a total of 140 deaths in San Francisco, a population of about 880,000. In South Korea, a population in excess of 51 million, there have been 460 deaths. Comparing oneself to worst in class response is disingenuous and promotes a false sense of satisfaction.

The last time Los Angeles saw community spread rates this high was in early June – and what followed was a massive July surge in cases. Buckle your seatbelts, nobody is at the wheel.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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18 October 2020 Blog Post: Why Testing Matters

18 October 2020 Blog Post: Why Testing Matters

In mid-July, Orange County’s COVID-19 outlook was bleak. Case rates were peaking and more than 700 people were hospitalized at a time because of coronavirus. The Sheriff declared “non-enforcement” of mask ordinances, the School Board voted 4-1 to return to school without restrictions and declared masks “harmful” for good measure. The County’s Health Officer had quit after receiving death threats.
 
But now, their situation is completely different. Newly appointed County health officer Dr. Clayton Chau said the situation is getting better because “residents are overwhelmingly complying with public health orders — like mandatory masks and limiting the number of people indoors at certain businesses.” The County has teamed up to promote testing among disproportionately affected ethnic groups. One non-profit even provides housing for those affected by COVID-19 who are otherwise unable to care for themselves.
 
Orange County has been in the Red Tier on the state’s four-tiered virus monitoring system since Sept. 8, which limits indoor business activity. It is close to moving into the Orange Tier which means that bars can open for outside operations and bowling alleys could resume operations.
 
In Los Angeles County, a totally different picture has emerged. Los Angeles has seen rising daily COVID-19 case numbers and an uptick in the transmission rate, indicating a likely increase in future cases barring “major behavioral changes and stricter adherence to health guidelines such as wearing face coverings.”
 
According to the Los Angeles Daily News “in order to move out of the most restrictive tier of the state’s four-tier coronavirus economic-reopening roadmap, the county needs to get its daily average new case numbers down to about 700. In the past week, however, the number has regularly topped 1,200.”
 
From my perspective, the difference is simple – Orange County has continued to show a commitment to testing and Los Angeles has not. In Figure 1 below, the different in per capita testing rates is clear. Orange County rates (blue line) dipped some from their mid-July peaks but then have maintained a rate typically exceeding 200 daily tests per 100,000 population.
Testing functions not only to identify new case clusters but also serves as a proxy measure of public health efforts. Core public health functions include (adapted from CDC):
 
1. Assess and monitor population health status
2. Investigate, diagnose, and address health problems and hazards affecting the population
3. Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it
4. Strengthen, support, and mobilize communities and partnerships to improve health
 
Without a return to these core functions, Los Angeles County will continue to find itself mired in the highest risk tier, with no end in sight. More worrisome, persistent moderate level community spread of COVID-19 will make the county more susceptible to a subsequent surge in cases.
 
We can learn from our neighbor. While Orange County has redoubled its surveillance efforts – it has gone one further by specifically including communities that have been disproportionately affected by COVID-19. Los Angeles has done nothing approaching these outreach efforts which are a key element of any public health response.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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15 October 2020 Blog Post: COVID-19 Update in Los Angeles County

15 October 2020 Blog Post: COVID-19 Update Los Angeles County

An article in yesterday’s Los Angeles Times article was entitled “Coronavirus transmission rate grows in L.A. County.” This actually is not the case – it is holding steady (not particularly good news either).
 
The Los Angeles County Health Department is now reporting COVID-19 statistics every Tuesday for the purposes of state-wide tier alignment so I have adjusted my analyses accordingly. Below are the County’s latest case numbers, still in the “purple” (widespread) zone.
 
The current case rate stands at 9.58 new daily cases per 100,000 population. This has been flat for the past 4 weeks with prior rates of 9.51, 9.61 and 9.66. Decreasing to the “red” tier (substantial) would require rates to dip below 7. The closest LA has gotten to such was on 9.15 when the rate was 8.14.
 
So what are the implications of continued sideways movement? There is really no silver lining here for as rates stay steady, we remain at risk of yet another epidemic surge. Community transmission of an infectious disease can ‘smolder’ much like a forest fire. Hot spots, if not extinguished, can easily flare and propagate. By not maintaining downwards pressure on case rates, we are simply prolonging the inevitable – another surge.
 
According to the linked article, new infections has been connected largely to worksite outbreaks, defined as a cluster of three or more cases. According to Public Health Director Dr. Barbara Ferrar, “this is a cause for concern, and we’ll continue to be monitoring what’s happening at workplaces.”

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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2 October 2020 Blog Post: Dyssynchrony, Part 2: Los Angeles County COVID-19 Chronicles

2 October 2020 Blog Post: Dysynchrony, Part 2: Los Angeles County COVID-19 Chronicles

It occurred to me that publishing the LA County epidemic curve beginning in March may not be adequately illustrating the disconnect between public health messaging and numeric reality. So I have presented the past 10 weeks of the epidemic curve (from the week ending 7/17 until the week ending 9/25 in Figure 1 below).
Case rates have increased in Los Angeles County each week since 9/11. Increasing from 7.77 new daily cases per 100,000 population to 8.71 and 9.04. The light blue solid line represents the data trend line of which the last two weeks are above.
 
Most galling about the current LA County messaging is simply this – LA County has not attained the metrics (https://covid19.ca.gov/safer-economy/) set forth by the State to even begin discussing reopening. The highest risk tier (widespread, or purple) is set at greater than 7 new daily cases per 100,000 population. The State does some fancy footwork with ‘adjusting’ these rates, ostensibly to penalize counties that are not doing enough testing. Los Angeles County is doing far less testing than it was 10 weeks ago (Figure 2). LA County’s “adjusted” rate is 7.3 new daily cases per 100,000 which by my math is still above 7.
Yet in Los Angeles, we forge ahead reopening:
 
 
The openings come despite what LA County Health Department Director Dr. Barbara Ferrer describes as a “small increase” in daily coronavirus case numbers when compared to the early part of September. She said the increase “may either reflect lower testing numbers at the beginning of the month, or they may reflect the fact that we’re starting to see some small increases in community transmission.”
 
I guess we will see which one it is correct, with the LA County population being subjects of this experiment.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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