3 knowns and unknowns in this 'messy' COVID-19 surge

COVID-19 data has been flawed since day one. But its shortcomings or utter lack of existence have never been more troubling than they are today.

"It's time for a data-driven reset on the basic knowns and unknowns of this pandemic," Alexis Madrigal, co-founder of The COVID Tracking Project, wrote for The Atlantic. Thinking of this surge in terms of knowns and unknowns allows us to see how complex the pandemic has become — "the messiest phase of the pandemic yet," in his words. 

Mr. Madrigal has had a front-row seat to deficiencies in state and federal government data collection and reporting on COVID-19 since the beginning of the pandemic. The Atlantic launched The COVID Tracking Project on March 7, 2020. The coalition of volunteers collected and published daily data on COVID-19 testing and patient outcomes for all 50 states, five U.S. territories and Washington, D.C. More than 400 volunteers contributed to the effort, which aimed to increase scrutiny of federal sources and encourage public health agencies to publish more comprehensive data. 

The project ended its daily updates in March 2021, with Mr. Madrigal noting that volunteers spent thousands of hours on a data-reporting effort that was first meant to last a few weeks and it was "time to release these brilliant people back to their lives." The project's data is archived. 

Mr. Madrigal proposes five knowns and six unknowns as of Aug. 15, noting how quickly the virus keeps changing. Three of each are excerpted below. Read his analysis in full here


1. Vaccines effectively reduce the likelihood of hospitalization or death from COVID-19. Fewer than 5 percent of the people being hospitalized and dying are fully vaccinated at this moment in the pandemic. The CDC recorded 35,937 deaths from COVID-19 over a three-month period this summer, with 1,191 of those deaths among the fully vaccinated. In other words, 96.7 percent of deaths this summer have been in the unvaccinated. 

2. Even high levels of vaccination in local regions are not enough to prevent delta's spread. Before variants emerged in this pandemic, 70 percent vaccination was seen as a rough threshold to reach herd immunity. Yet San Francisco, which has 70 percent of its population vaccinated, has nonetheless seen a similar case surge to the one in Maricopa County, Ariz., where 43 percent of residents are vaccinated, Mr. Madrigal points out. 

3. There is still a lot of randomness to the location of the worst outbreaks. The variant of concern in the spring was alpha, which "absolutely torched" Michigan and nearly Michigan alone, matching the state's peak for hospitalizations from the winter. "This didn't happen anywhere else, though some epidemiologists expected it to, based on the experience of European countries. Alpha just kind of went away, and it seemed like the U.S. might be in the clear," writes Mr. Madrigal. "Enter Delta. In this surge, a piece of Missouri began to take off before the rest of the country. Would it be like Michigan? As we all now know, the answer was no." 



1. How many people have had COVID-19? The answer informs how many naive immune systems are susceptible for the virus to touch. "It's such a basic question that it seems absurd to ask, and yet we simply don't know how many Americans have had COVID-19," Mr. Madrigal writes. Although the CDC has done some testing of the levels of antibodies in the U.S. population, the data are incomplete and imprecise. Adding up all COVID-19 cases seems like one promising approach, but varying testing availability and usage and a large pool of asymptomatic infections for each wave of the pandemic results in different and still-unknown case-detection rates through time. 

2. What percentage of infections are confirmed as "cases"? Higher positivity rates have suggested that public health surveillance was missing a greater share of the infections in a community. Now there is more evidence that this is what's happening, according to Mr. Madrigal. "Relative to previous waves, the ratio of cases to hospitalizations is lower. Last winter, we confirmed 12 million cases in December and January. This wave, we've confirmed fewer than 3 million cases since July 1. Last winter, we peaked at more than 120,000 COVID-19 patients in the hospital at one time. Right now, we're already over 64,000. So we are showing 25 percent of the cases and 50 percent of the hospitalizations." He posits that delta is either making people sicker, or the case-detection rate has fallen. "Or, just to muddy things, maybe both."

3. How many people will die? "For people in countries with access to vaccines, the good news is that it seems almost certain that fewer people will die in this wave of COVID-19 than in the winter surge," Mr. Madrigal writes. For the millions of unvaccinated people still getting infected, the old mathematics of COVID-19 will hold. There is also hope that better therapeutics and improved care practices will push the death rate down, but hospitals in hard-hit areas are less likely to be able to provide the highest standard of care. "Florida is already reporting a seven-day average of more than 150 deaths a day, a number that seems likely to rise as the statistics work their way through the system. Florida's peak over the winter was about 180 deaths a day," Mr. Madigral points out. 

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