Monthly Archives: April 2020

Covid-2019 epidemic trends: U.S. and Massachusetts

The following U.S. map, prepared by John Hopkins University researchers Holm and Forster, also distributed by Associated Press, shows prevalence of death from Covid-2019 by county, as reported to state and federal public health agencies through April 16, 2020.

U.S. county death rates from Covid-2019, through April 16, 2020


Source: Holm and Forster, John Hopkins University

The New York Times publishes its own estimates of cases and deaths attributed to Covid-2019 by states. The following table shows the ten most severely affected states, ranked by cases of illness per thousand state residents, as estimated for the about the same date as the foregoing U.S. map reflected.

Covid-2019 illnesses and deaths by states, April 17, 2020

State Illness count per 1,000 residents Death count per 1,000 residents
New York 229,642 11.8 12,822 0.66
New Jersey 78,467 8.8 4,840 0.43
Massachusetts 34,402 5.0 1,404 0.20
Louisiana 23,118 5.0 1,213 0.26
Michigan 29,952 3.0 2,226 0.22
Pennsylvania 30,121 2.4 1,027 0.08
Illinois 27,575 2.2 1,142 0.09
Florida 24,745 1.2 726 0.03
California 29,398 0.7 1,050 0.03
Texas 18,191 0.6 461 0.02

Source: New York Times, April 17, 2020

As the map shows and the table reflects, Massachusetts has developed one of the worst Covid-2019 epidemics of any state, just short of New Jersey and New York. Gov. Baker has taken criticism for issuing orders as public advisories rather than in forms enforceable by State Police. However, data for the spread of the state’s epidemic tend to show that Baker’s approach is working to some degree, although the state remains at high rates of cases and deaths, as reported daily.

Covid-2019 trends, Massachusetts, through April 16, 2020


Source: analysis of Massachusetts daily Covid-2019 data

The blue trend curve shows the slope of a semilograrithmic plot of cumulative cases versus epidemic days. The steep initial portion shows a rapidly growing epidemic, in which doubling time of the case load is shrinking. Day one is chosen to be the first day with a cumulative total of 20 or more reported deaths: March 26, 2020. Two days earlier, Gov. Baker issued his first restrictive order: that “non-essential” businesses close. On Day 7, Baker issued a second restrictive order, expanding the list of business that should close. On Day 14, Baker issued a “grocery guidance,” describing how retail stores that continue to operate should install and conduct protective measures. The blue trend above is using five days spanning each point to calculate the slope of the logarithm of case counts, so it stops two days short. The red trend above shows that the cumulative mortality has been climbing, as victims of the disease die: from about one percent initially to near four percent.

Each advisory order from Gov. Baker was followed in five to seven days by a sustained reduction in the epidemic’s spread, shown by a drop in the slope of a plot of the logarithm of cumulative case count. While Massachusetts has made progress, a goal of ending the state’s epidemic is far from attainment. Over the past week, ending April 17, the state has been reporting averages of about 1,900 new Covid-2019 cases and 115 deaths from Covid-2019 per day. Many governors of states with severe epidemics are taking cautious approaches to relaxing restrictions. California has been notably cautious. Gov. Newsom issued a declaration of emergency March 4, 2020, well before Gov. Baker’s declaration of emergency on March 10. Collaborating with governors of Washington and Oregon, Gov. Newsom said they would use “science to guide our decision-making and not political pressure”–rejecting hasty actions being promoted by the Trump administration.

– Craig Bolon, Brookline, MA, April 18, 2020

Geoff Mulvihill, Lacking U.S. coordination, states team up on when to reopen, Associated Press, April 18, 2020

Coronavirus in the U.S.: latest map and case count, New York Times, April 17, 2020 (as found April 18, 2020)

Zeke Miller, Alan Suderman and Kevin Freking, Trump proposes plan to reopen economy, Associated Press, April 16, 2020 (includes U.S. map of Covid-2019 prevalence by county from Holm and Forster at John Hopkins University)

COVID-19 cases, Massachusetts Department of Public Health, for April 16, 2020

Patricia Wen, Massachusetts confirmed coronavirus cases by city and town, Boston Globe, April 15, 2020

Mark Arsenault, Massachusetts experts push back on university’s bleaker Covid-2019 forecast, Boston Globe, April 15, 2020

Liz Kreutz and Alix Martichoux, Newsom unveils plan to ease California stay-at-home restrictions amid coronavirus pandemic, ABC News, April 14, 2020

Press releases related to COVID-19, Massachusetts Office of the Governor, March and April, 2020

Declaration of a state of emergency to respond to COVID-19, Massachusetts Office of the Governor, March 10, 2020

Governor Newsom declares state of emergency to help state prepare for broader spread of COVID-19, California Office of the Governor, March 4, 2020

Hong Kong flu of 1968: patterns of an epidemic

The Hong Kong flu of 1968 and later years was the last major virus epidemic in the United States before the ongoing Wuhan virus epidemic, caused by the Covid-2019 virus first described in Wuhan, Hubei, China during late 2019, also known as SARS-CoV-2. The Hong Kong flu caused at least 100,000 fatal illnesses in the United States, among more than one million worldwide.

There are major problems characterizing an epidemic caused by a new virus, even using technology of molecular biology that had not yet been invented when the Hong Kong flu of 1968 struck.
• How reliably do laboratory tests identify and classify infections?
• How large a fraction of the population has been tested for infection?
• What fraction of infections have been missed or misclassified?
How often or seldom do infected people transmit infection?
• How often is death resulting from infection missed or misclassified?
• How long do virus deposits remain infectious in typical environments?
• How much viral dose is needed to cause an infection?
How much individual variation occurs in resistance to infection?
• Can infection and contagion occur without clinical symptoms?
• How much individual variation appears in severity of infection?
• Are infections or severe illness resulting from them seasonal?
• How reliable are antibodies as indicators of prior infections?
• Do infection and recovery confer immunity, or can disease reoccur?

Accurate answers to such questions often take years of research. Without answers, social measures to control an epidemic may misfire: costly but ineffective steps taken or simple and effective steps missed. Medical measures often take years of research as well. Vaccines against virus diseases can be highly effective, but they are usually difficult to develop. The first successful, strategically developed vaccine–against yellow fever–took more than 35 years after the classificatiobn of yellow fever as a viral disease in 1901. About 35 years after identification of HIV as the virus causing AIDS in 1985, there is still no safe and effective vaccine licensed by the U.S. government.

Contemporary news: Although the Hong Kong flu turned out to be about as deadly in the United States as the Wuhan virus is often predicted to become, in 1968 the Hong Kong flu did not draw a comparable public response. Writing in the New York Times, Jane E. Brody–then and now a featured writer on personal health–reported in 1968 that “Hong Kong flu gained a foothold…last week. To date, 28 states have reported attacks….” She did not cite case counts or express alarm. Currently Mrs. Brody, now a mother of two and a grandmother, is counseling readers about “managing coronavirus fears” although competing for today’s readers with thousands of other news writers who are stimulating fears. In 2020, she writes, “…it’s the bad news that gets the most attention….”

As Times reporter Brody noted in late 1968, U.S. labs produced about 5 million doses of a late-season vaccine for seasonal flu incorporating activity against the Hong Kong flu. Such a vaccine was possible because of more than 30 years of U.S. experience producing, testing and using flu vaccines. Around 1970, the United States typically produced about 30 million doses of flu vaccine per year, versus about 150 million doses per year recently. There is no comparable experience producing vaccines against a coronavirus, so that recent efforts toward such a vaccine start with a largely blank slate.

Following the patterns of other influenza strains, Hong Kong flu epidemics starting in 1968 and 1969 were seasonal: beginning in late fall and ending before the start of spring. The chart shows deaths in thousands per month from Hong Kong flu during its first two seasons in the United States.

Hong Kong flu deaths, U.S. 1968 and 1969 seasons


Source: Viboud et al., 2005

So far, disease caused by the Covid-2019 virus does not clearly appear seasonal, although the less than four months experience is too limited to be sure of that. In the United States, counts of cases were still rising in most places though the middle of April, 2020, when all records of the Hong Kong flu in the northern hemisphere show cases beginning to fall no later than February.

Contrasts: While the Wuhan virus epidemic seems to be following a similar pattern of surges and responses to controls worldwide, the Hong Kong flu did not. As Viboud and colleagues documented in 2005, Hong Kong flu epidemics followed different patterns in North America and in Europe and the Far East. In North America the first season was the stronger, while elsewhere the second season dominated. A factor these authors did not consider was U.S. vaccines targeting Hong Kong flu. It looks highly unlikely that vaccines targeting the Covid-2019 virus will be produced in time to arrest the first epidemics outside China, still accelerating as of mid-April, 2020. More likely, these epidemics will be controlled by social measures and by intensive testing to identify contagious carriers.

– Craig Bolon, Brookline, MA, April 15, 2020

Marc Lipsitch, Who is immune to the Covid-2019 virus?, New York Times, April 13, 2020

Jane E. Brody, Managing coronavirus fears, New York Times,April 13, 2020

Gina Kolata, Why are some people so much more infectious than others?, New York Times, April 12, 2020

Matthew Perrone, Fears of ‘Wild West’ as Covid-2019 blood tests hit the market, Associated Press, April 12, 2020

Christopher Murray, Forecasting Covid-2019 impact on hospital bed-days, ICU-days, ventilator days and deaths by U.S. state in the next four months, Medrxiv (Cold Spring Harbor Laboratory), submitted March 26, 2020

Xinguang Chen and Bin Yu, Coronavirus disease epidemic in China: real-time surveillance and evaluation with a second derivative model, Global Health Research and Policy 5(7), March 7, 2020

Seasonal influenza vaccine supply for the U.S. 2019-2020 influenza season, U.S. Centers for Disease Control and Prevention, September 24, 2019

Douglas Jordan, Terrence Tumpey and Barbara Jester, Discovery and reconstruction of the 1918 pandemic virus, U.S. Centers for Disease Control and Prevention, December 17, 2019

Timeline of HIV and AIDS, U.S. Department of Health and Human Services, 2019

I. Barberis, P. Myles, S.K. Ault, N.L. Bragazzi and M. Martini, History and evolution of influenza control through vaccination: from the first monovalent vaccine to universal vaccines, Journal of Preventative Medicine and Hygeine 57(3):E115-E120, 2016

Errling Norby, Yellow fever and Max Theiler: the only Nobel Prize for a virus vaccine, Journal of Experimental Medicine 204(12):2779-2784, 2007

Cecile Viboud, Rebecca F. Grais, Bernard A. P. Lafont, Mark A. Miller and Lone Simonsen, Multinational impact of the 1968 Hong Kong influenza pandemic: evidence for a smoldering pandemic, Journal of Infectious Diseases 192(2):233-248, 2005

Jane E. Brody, Hong Kong flu attacks thousands here swiftly, New York Times, December 11, 1968