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No End in Sight as U.S. Cases Pass 5 Million

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August 9, 2020 --- The U.S. logged 5 million confirmed COVID-19 cases, hitting another grim milestone in the nearly 6-month long pandemic that has devastated the country.

The U.S. tally is substantially larger than the next closest country, Brazil, which has logged roughly 3 million cases. It is roughly 2.5 times the size of the outbreak in India, though the total population in that country is more than 4 times as large.  

Experts say the number of cases underscores the failure of our national response.

In July, newly reported cases in the U.S. topped 70,000 a day. "Seventy thousand was the number of cases that they had in Wuhan, China where this started, in total. So we were having a Wuhan a day in this country,” says Carlos Del Rio, MD, an infectious disease specialist and a professor of Global Health and Epidemiology at Emory University in Atlanta. “We’re doing a crappy job."

While cases have slowed slightly in recent days, they have been rapidly accelerating in the U.S. Since the introduction of the virus, it took the U.S. more than 12 weeks to reach its first 1 million cases, 7 weeks to amass 2 million cases, 3.5 weeks to reach 3 million, and 2.5 weeks to hit 4 million, and another 2.5 weeks to reach 5 million.

For comparison, the states of Alabama and South Carolina each have roughly 5 million residents.

Five million is only the visible portion of a much larger outbreak. A recent study by the CDC estimated that the actual number of U.S. infections is about 10 times higher than that number.

“We're still under-counting but I do think it signifies an important marker because we didn't have to have that many cases,” says Amesh Adalja, MD, an infectious disease and critical care specialist who is also a senior scholar at the Johns Hopkins Center for Health Security in Baltimore.

The U.S. also leads the world in deaths with more than 162,00, and has a 7-day average of more than 1,000 deaths a day. 

The nation's response to the pandemic has stumbled for months. Here’s where we stand on some key measures.

Positivity Rate

One of the measures experts are using to track the outbreak is the percentage of COVID-19 tests that come back positive, which is also called the test positivity rate.  The positivity rate is important because it helps public health officials know whether an uptick in cases in a community is due to greater numbers of tests being conducted there or if there are truly more infections.

If that number is increasing in an area, it means the outbreak is growing. 

The average of positive tests in the country for the past 7 days is 7.5%, although in some hot spot states it’s much higher. In Arizona, Florida, Texas, Alabama, Nevada and Idaho, for example, test positivity is over 15%. Mississippi is currently over 20%. In Puerto Rico, positivity is 100% meaning everyone who is tested has the virus, an indication that only very sick, hospitalized patients are being tested. When the rate is high, it suggests a location is catching mostly the sickest people and missing mild cases or people with no symptoms.

The World Health Organization suggest that an area is safe to relax social distancing requirements once the rate remains at 5% or lower for 14 days. Currently, 28 states are over that threshold.

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Testing and Tracing

The U.S. has conducted more than 60 million tests – more than any other nation worldwide. According to the COVID Tracking Project, states report results for about 700,000 to 800,000 tests daily.

Still, public health experts say the U.S. is still running far fewer tests than it should to effectively track the virus.  Based on the current number of infections in the U.S., the team behind covidexitstrategy.org says that overall, the country is only running about 40% of the tests we need to control the spread of the disease. States and territories on the low end include Puerto Rico, which is doing only about 3% of needed tests, and Mississippi, which is at 15% of its projected requirement. States that are doing better include New York, Connecticut and New Jersey, which are currently testing about twice as much as advised for the size of their outbreaks.

Part of the reason for the shortage of tests is that labs have been overwhelmed as they struggle to keep up with the demand.  Many patients report waiting a week or more for results. The wait for results in some hard-hit areas is currently so long it renders testing completely ineffective.  Long delays prevent people from being isolated while they are infectious, allowing the virus to continue to spread.

Testing in the U.S. has been hampered from the beginning.

Contaminated test kits sent by the CDC to state public health labs delayed detection of the virus for weeks, preventing cities and states from understanding the rapid spread of the infection.

As testing has lagged, a shortage of public health workers continues to prevent effective contact tracing and isolation of people who were known to be infected and the people they exposed.

Personal Protective Equipment

Months into the pandemic, health care workers in many areas must still ration essential protective gear such as n95 respirators, gowns, gloves, and face shields.

A vast majority of hospital nurses – 87% -- reported having to reuse at least one piece of PPE at work, according to a July survey from National Nurses United.

The Trump administration did not centralize purchasing for gear. That has forced hospitals to find supplies on their own, sometimes bidding against each other.

FEMA Administrator Peter Gaynor told Congress in late July that the country was doing better with its PPE supplies but was “not out of the woods completely.” Most PPE is made in Asia, he said, but the U.S. is ramping up its production.

Masks and Face Coverings

Masks for personal use are no longer in short supply. But wearing them has become a political statement. 

Wary of worsening the shortages of protective gear for frontline workers, public health officials initially discouraged people from wearing masks, leaving them confused about the value of face coverings.

But as more evidence emerged that they could be a powerful way to prevent the virus’ spread, public health officials encouraged people to use them. But not everyone was on board, including Trump.

 “This is voluntary. I don’t think I’m going to be doing it,” he said in April, according to the Los Angeles Times.

Amid arguments about protecting public health vs. personal freedoms, many states and businesses settled the question on their own. At least 34 states and the District of Columbia have some type of mask mandate. Many businesses including Target, Walmart, CVS, and Walgreens require face coverings for people to enter.  

As cases have surged, Trump appeared in public for the first time in a mask in mid-July, encouraging all Americans to wear them.

“If action was taken swiftly in January, February, and March we would not have had this type of an experience with this virus. So I do think when we see that number -- 5 million -- it's important for the American public and people to realize that it could have been much lower. It could have been much better,” Adalja says.

Health Inequities

The pandemic has also laid bare the grave societal ills in this country.  People of color have disproportionately been affected by every facet of the pandemic.

“The greatest tragedy is that the impact from both the health and social and economic crises are not impacting all communities equally,” says Harry Heiman, MD, clinical associate professor of Health Policy and Behavioral Sciences at Georgia State University.

Native Americans and African Americans have been hospitalized with COVID-19 at rates that are 5 times higher than whites.  Hispanics and Latinos have a rate of hospitalization that is 4 times higher than whites, according to CDC data.  Black Americans make up 12.5% of the U.S. population but account for 22.4% of deaths from COVID-19.

Black workers have faced higher unemployment than whites. They’re also more likely to work in essential “front-line” jobs where they may be more exposed to the virus.

“It has been said that the measure of a civilization is in how it treats and protects its most vulnerable members. By every measure we have failed. I only hope that these grim statistics serve as a wakeup call,” Heiman says.

Black and Hispanic children are being hit harder by COVID, too.  A new study of 1,000 children testesd for COVID found that while about 7% of non-Hispanic white children were positive for COVID-19, about 30% of non-Hispanic Black and 46% of Hispanic children were positive.

Vaccines

Top public health officials say they’re optimistic a COVID vaccine is in reach by next year. Nearly 200 are under development worldwide. In the U.S., large-scale phase 3 testing of three vaccines is underway. In early testing, the vaccines have developed an immune response to the virus that causes COVID-19 and have caused only mild side effects.

Through “Operation Warp Speed,” the U.S. hopes to have 300 million doses of a safe and effective vaccine ready by January 2021. Of the 6 vaccines that the federal government is backing through its “Operation Warp Speed” program, all but one are being tested in humans.

If a vaccine is ready, it’s not clear how many people will get one. Several polls have shown people are reluctant to do so. A recent poll by WebMD found fewer than half would get a COVID vaccine the first year it’s available.  A recent poll by CBS news suggested the number of Americans reluctant to get vaccinated right away might be as high as 70%.

Super Spreader Events

Modeling studies indicate that the COVID-19 pandemic is largely being driven by super-spreading events, where one person infects at least 5 others at a time.

The CDC has documented a number of such events in the U.S., where dozens of people became infected after a shared exposure.  These danger zones have included church choir practices, summer camps, and family events like birthday parties and funerals.  These events revealed that the virus could be expelled into the air from the back of the throat by singing, loud talking, and cheering, even when people were not showing any signs of being sick.  They also suggest that the virus is airborne.

Ending the Pandemic

As grim as the situation is in the U.S., public health experts stress that it is not hopeless.  COVID-19 spread can be stopped if we all work together.

“We have a long way to go, but can stop the virus with a comprehensive strategy: The 3W's (Wash your hands, Wear a mask, Watch your distance),” says Tom Frieden, MD, former director of the CDC who is now president and CEO of the nonprofit Resolve to Save Lives initiative.

Frieden recommends a strategy he calls “boxing the virus in” with expanded testing, contact tracing, and effective isolation and quarantine as well as “using a levels system for reopening, reporting data consistently and transparently, and finding and closing spots where the virus can spread."

WebMD Health News Reviewed by Brunilda Nazario, MD on August 09, 2020

Sources

Carlos Del Rio, MD, professor of Global Health and Epidemiology, Emory University, Atlanta

Amesh Adalja, MD, senior scholar, The Johns Hopkins Center for Health Security in Baltimore

Harry Heiman, MD, clinical associate professor of Health Policy and Behavioral Sciences at Georgia State University, Atlanta

Tom Frieden, MD, president and CEO, Resolve to Save Lives, New York

Johns Hopkins Coronavirus Resource Center, Accessed July 24, 2020

JAMA Internal Medicine, July 2020

Pediatrics: “Racial/Ethnic and Socioeconomic Disparities of SARS-COV-2 Infection Among Children.”

Milken Institute, Faster Cures Covid-19 Treatment and Vaccine Tracker.

U.S. Health & Human Services Fact Sheet: "Explaining Operation Warp Speed," June 16, 2020.

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