Health officials discuss US virus trends
Health officials discuss coronavirus data, trends and a rise in cases across the U.S.
and his folks Aer joining in, we're gonna be using the Q and A functionality. So if you have questions, feel free to drop them in that way. Feel free to also raise your hand as well, too. So Kristen Crystal can calling you when we go to switch to Q and A or hope is toe. Take up 30 minutes of the time, sharing all the different updates and then having a good 30 minutes of time to be able to answer any and all questions that folks have. So with that, let's let's get started. I would love to welcome everyone to today's press call that's being hosted by a wonderful group of collaborators from code exit strategy Resolved to Save Lives. Duke's Margolis Health Policy Center Covert act Now and, of course, United States of Care, which is helping us hostess Webinar today. My name is Ryan Ponchaud Sermon. One of the co founders of Covert exit Strategy as well as the U S digital response, were a group of technologists that have been helping out towards the covert response. This site, in particular, is a nonpartisan effort to help track states they've been tackling Cove. It and trying to help you focus in on the measures that matter the most. But I'm joined here by my colleagues as well, too. And so they're going to share their names where they're from and what they're gonna be touching on today. And so with that, Marta love for you to introduce yourself, them and, uh, Brian Martin Machine Ska. I'm a consulting professor and deputy director for policy at the Duke Margolis Center for Policy at the university. And I will be giving an overview off how the States are doing Debbie. Hi, I'm Debbie, and I am a researcher out of University College, London and also the chief operating officer of Kodak, now based out of Los Angeles Stars. Hi, Cyrus Shape our I'm, director of the Prevent Epidemics team and chief science officer of Covert 19 Response at resolved to save lives. I'll be talking about covert 19 indicators. Pixar slips. I am Liz Hagen, director state of of policy for state engagements at United States of Care. And I'll be talking about how the flu and covert will be intersecting and what states could do to plan for that. And I'm Christina Wilcox. I'm the managing associate at the Big Markkula Center. And I'll be talking about two new reports that are here in this prison and released on testing. Awesome. Thank you. Martha. Do you want to kick us off with the state of the United States? Absolutely. Thank you, Ryan. So, to start on a national level, this is a graph from the Kobe tracking project. We, um this is actually our main source for the data that we use at the covert exit strategy. Dashboard, as you can see, You know, the July peak has, um the number of cases has have really dropped since July on, but But what? What? This is actually masking some of their regional trends. So, Ryan, if you could switch to the next slide, This is also from the covert tracking project. Um, you know, very well known that the Northeast had a peak early on in the epidemic. I will show you some of the states and how they're doing. But a lot of the Northeast states are maintaining sort of this low level of spread. Um, you know, jumping on sort of historically what was happening in the south and the West. So basically the Sun Belt states were hit really hard. And then this spread has really shifted towards the Midwest. And they're the cases air still really on the rise in some states, much more than in others. If you could switch to the next Ryan. So just let's talk a little bit about what is happening in some of the states. So again, in the West, cases have dropped in California and in you can see sort of the decline in the number just last 14 days. But the decline has been study. The positivity rate has been dropping. Azaz. Well, um, the same thing in Washington state which last time we had this press call was negative. Let's change in the last 14 days, but a big decrease from what was happening earlier. And Washington State now has fixed its reporting so we no longer see 100% positivity rate, which is what is something that we have been I'm seeing for a while on our website. If you go to the Northeast a Z I mentioned, you know, not too long ago all of these states were pretty much green. We have s o you know, New York continues to do really well main as well. A tous point despite that outbreak that they had surrounding this particular super spreader event. Um, Vermont, Vermont is doing extremely well in terms of positivity, right? In the number of cases, the reason we are flagging them as yellow is because the they do actually very little testing. Overall, the testing is showing very few cases. But if they are in testing in the right places, they might actually be missing cases. So we we are actually recommending, um, to to have potentially higher level off testing in that state s O. But the states are continuing to dio pretty well. Rhode Island stands out because they do have a higher level of cases per million. If you look, for example, at Arizona, if you could just swap to Arizona Arizona is that 62 eso Rhode Island has a higher number of cases. Rhode Island also has a T least on the HHS protect data set. Um, they actually have a really high. I see you. Capacity utilization. Frankly, the data actually suggests over 100% which is not possible. So there might be some data issues, but that's why Rhode Island has been, um, coming up like that. If you look at some of the Southern states, uh, you know, Florida does continue to be so dark red, but the number of cases per million are significantly lower. Nonetheless, there positivity, right still continues to be high. And if you sort of hover across these states in the in the south, these air lower numbers than what we were seeing, um, even several weeks ago, the with many of them still a really high positivity rate of over 10% and then it's you sort of move up. This is where really the spread has kind of gone north through the center of the country. Thes were sort of newer cases. I think the rial stand out is if you could scroll up to North Dakota. This is a really high number of cases. It is not a zbig of a peak. This is more than Texas ever had. This is somewhat less than where Arizona was at its peak and Florida. But this is really one of the highest rates that we have seen in the country, and it's still on their rise. If you could switch to the next slide, Actually, um, Ryan. So this is something that hopefully will be forthcoming on the covert tracking project website. This is, at this point and mock up, but what you can see is sort of the number of cases per million for different states. So the one on the left, this is New York. Andi. Then you see some of the states that we were talking about Texas, Um and, uh, and Florida and Arizona, Those air sort of the cases that where you see that big peak? North Dakota is quite a stand out right now, and they're really reaching for new heights, and everything is sort of going up north. So this is definitely a state toe watch. One thing that I will say about North Dakota is they do seem to be doing, um ah, lot of testing when you look at their positivity rate, it is, I think, just over 5% which is significantly higher than what other states had the ones that had really tremendous outbreaks earlier. And I guess the one last thing I would like to point out is to talk a little bit about the new cases per million versus currently hospitalized. Um, if you could scrawl if you could sort Ryan by the currently hospitalized and you can see that this case, the states that have really high rates of hospitalization are actually not the states that necessarily our having the highest outbreaks right now, Um, this is because of the lag between hospitalizations and outbreaks. If you sort by new cases per million, you can see that North Dakota actually is not at all among the ones with the high hospitalization rates. But we probably are expecting that this number might go up given the level of outbreak that they have currently. So, at this point, I would like to actually pass it on to Debbie from Kobe back now. And she can take a deeper dive. Beyond that goes beyond states. Thank you. Thanks, Marta. Just gonna pull it. My slides and I do have slides today just s so we can get through everything as quickly as possible. But all this you can also find on the Kodak now website. And so what I want to do today is talk a little bit about the trends. And when I talk about trends, I'm talking about not just what's happening right now, but also really, what's happening over time and what you can see from this animation. And I know there's going to be a slight lag for some of you, but we'll be sending this out afterward. Eso no worries about that. Are a lot of people kind of regional trends that you've really seen. Want to talk about your, uh, the slide notes? I think they're just covering. Can you see the slide notes? Yeah, I think, actually, we re just re shares scream over time and tagged the Sure because this is a good animation. Yeah. There we go. Okay. All right. So can you still see the slide notes? Yes. Why are Okay, does this work? Um, stop sharing, caring woman share over time because this is a really good graphic to see. Just what Debbie is gonna pull up is just the increase of cases that you see per county and yeah, if you keep it like this, Debbie works, It looks great. Okay. Um all right. Can you see my entire screen or just the entire thing? Eso if there's any notifications or emails coming in e think we're all. Yeah, you've all been there. We've all been here. Uh huh. Okay. Can you know this is perfect. Okay, that's a relief. Yeah, So, as you can see, here, thistles The trend of how new cases have emerged in the US since March until today. So you know really how it started the Northeast, But now has become you see the red kind of spread, especially in states in the South on. But what I want to show next is actually, if we look at the top counties now by infection growth rate, one thing you'll notice is that, you know, out of these top 512344 of the county's air, actually, college towns. Um but more than that, what's interesting is, if you look at death, they don't necessarily line up with cases. And so, with cases you'll see and we're looking at Ingham County in Michigan right now. There's a huge spike right now seeing cases right around this time when students are going back to school. But if you look at death, you do see, you know that's going up a little bit, but it's nowhere near the shape that you're seeing really four cases. So that's one thing that we know that it's quite interesting. What are some other trends? So here I'm showing two counties. One is Glacier County, and the other one is part County. And you'll see that Glacier County obviously has a lot more incidents than we're seeing. Um, really, in Port county and what we also noticed here. One moment. Okay. Excuse my technical difficulties. Uh huh. So I ran a tap on you, but can you see my screen now? It's loading. And there we go. Yes. Great. So what we'll see is that and you're looking at Glacier? Hopefully. Okay, So what? You'll see that in Glacier? There's actually just 56% of the population that is covered by health care and that contrast with 88% of the population in Park County. Right? And so there's something very interesting going on there, and these two counties that are both the mission Another example, which I'm not visualizing here, but again, you can see this on the site are the Grange County and then also Dearborn County andan those counties. You likewise, we'll see similar trends where 60% population in grange County has health care coverage, while 93% population Airport County has healthcare coverage and illustrates like you see here, the counties where there's a greater proportion of insured individuals often have lower risk when you look at the data. Another trend we're seeing here. So right now, if you look at all these counties, what you'll see is that a lot of the worst performing counties are also the counties with the highest poverty rates in their states. So, for example, if you look specifically at Florida, you'll see that six out of 10 counties the highest case incidents Hamilton gets, um, Dixie Liberty, Franklin Jackson are also among the 10 counties of the highest poverty rates in the state. Um, and same in California. If you look at 500 counties with the highest case of citizens, so Madeira, Tulare, Imperial Fresno, Merced said. Those were also among the ones with the highest poverty rates. So there's a very interesting correlation there. Yeah, so what are we looking at here? We're looking at Union County and Murray County in Georgia, and what you'll see here is that we're looking at death and obviously Union County, you know, the death. The deaths are much higher again, this is normalized. But what's really interesting to me then extrapolated, Or if you move back from that and you'll see that Union County is 34% over the age of 65 Murray County is about 15% over 65. And so there were also seeing a trend where counties with older populations are typically seeing, um, poor response to co bit, then counties with younger populations. Last thing we're seeing, um, it looks like certain industries. Institutions seem to be correlated with high incidence of co bed. Um, and what you see here is one of this to county, which happens to be home Thio meatpacking plant. And in general, we're seeing that a lot of the places with outbreaks are associate with prisons with meat packing plants and also with reservations. So, for example, Trousdale, Tennessee um Hardeman County, Pima County in Arizona, lost by in Florida. All those have major correctional facilities. Likewise, Dakota County, Buena Vista County, Louisa County, um, Somerset County in California. Those all have major meatpacking meatpacking plants that have seen outbreaks. Um, and we're also seeing reservations in Bighorn County Minnesota in Yellowstone County. Um, those have also seen outbreaks. So, you know, let's take away here. I think there's really a trend that we're seeing in co bed spread over time, and that's that Kobe continues to disproportionately affect our county's most vulnerable groups. So those who are older, those who are poor, those who have less access to health care and those who have less mobility eso that's just something to keep in mind. That's been happening for a while. We expect that to continue and thank you for bearing with the technical issues. Thanks, Debbie. And if folks go to covert act now, you can dig into counties and they've got a neat little tag. The county has a college in it. It, uh, highlights that as well, too. But there's really good data if you scroll all the way to the bottom of their county pages that show you cases and so forth. Um, tossing the baton, desirous who's gonna dig into indicators and how they've been changing a bit over time. So Paris to you? Yeah, I just want to share Oh, definitely release the screen share. Great. Thank you. All right. Can you see my slides. Yes. Okay. I'm gonna talk for five minutes about indicators under fire. And again, I'm with resolve to save lives. Of course, this group, like many others, believes information and data is essential in terms of covert 19. We need the information and data to understand the risk of disease to inform our personal behaviors. When I go outside my house, how risky is it? And also public health and social measures in a community to target interventions, uh, to avoid blanket measures. So in terms of what we did before, in terms of everybody stay home but perhaps have more refined, precise measures so that it doesn't impact the whole population, Um and then monitor how effective our interventions have been. For all those reasons, the state is essential. I think with Cove in 19 we're starting to see and have seen indicator issues. So there's big buckets of indicators that I'm sure you're familiar with. I'll just go through some of them and some of the issues and and how that might impact the coming weeks. So in terms of syndrome X surveillance, we use things like people presenting to emergency departments with a certain constellation of symptoms and categorize them into Covad like illness or influenza like illness. Uh, but as we and in in the past few months, that's been in a season where there hasn't been flu. But now, as we answer flu season, um, we'll start to see influenza like activity rise. And so right now, when we have in the past few months, we've had little flu activity in any bump could be covert. I think it'll be harder to discern some of the changes and understand whether it's covert or flu a zone Early indicator Using syndrome, Big data In terms of cases, many states and jurisdictions still don't report probable cases of CDC advises. Um, and really, case levels fluctuate with the type of test that's done, and I'll go into that a little bit more and the level of testing. And so the case numbers really depend on how a different area, whether it's a state of jurisdiction, approach the data around cases. In terms of testing. We have a rise of an urgent testing, which I'll cover that isn't being captured everywhere, especially in nursing homes. And so as testing methodologies are rolled out and they're not captured by data systems. We have less comprehensive look at testing and subsequently case numbers in terms of hospitalizations. We all know about issues with transitioning hospital data from CBC to HHS, kind of a hiccup there. Maybe not the best rollout in terms of transition. And so the hospital data, really, on a national level really will depend on the timeliness and completeness and consistency of that data being reported by HHS and in terms of deaths. We've also seen issues around categorization of deaths, changes in how deaths are counted. I saw a recent article over the weekend in Texas about that, and it's important for trust to make sure that we're transparent about how we're counting things, Um, and that there's some consistency in how we categorize deaths. Uh, and it could make things like excess deaths total deaths more important as an indicator. But even that information is lagging, so it's not useful for what's going on right now. So these are just some of the indicator issues that we face. So I'm gonna talk a bit about androgen testing. Um, and this is a graphic from the FDA. Just an overview of different types of tests, molecular tests, PCR, an agent tests and then antibody tests and an agent. Tests are useful because they're faster, you know. How long does it take to get a result? One hour or less? Right. But they also have. They have lower sensitivity, which means have a higher chance of missing an active infection than a PCR test. And they do require confirmatory testing in certain scenarios. Where, essentially, if, UM, it's not matching up with your suspicion of of cove it in a patient, you might need to confirm it with the PCR test. So there's advantages and disadvantages to manage and testing. There's, uh, an urgent tests. There's a a few an urgent tests authorized by the FDA. Here's a list. Sure, you're familiar with B. D. Abbott that was recently in the news for getting an emergency use authorization. Um, and we have performance based on what the manufacturers air saying, but we don't have great data on real world performance for these tests. Why am I talking about an agent tested because an agent tests are rolling out across the country? As you can see here, here's some Cem fax related to that in terms of the federal government pushing out an urgent tests. Million's of an urgent tests to nursing homes. We know which nursing homes we don't know. How many to each of these nursing homes, um, Health and Human Services, procuring 150 million rapid antigen tests from Abbott and planning to send a proportion of that to nursing homes. A consortium of six states earlier in the year announcing a compact to procure three million antigen tests. And Abbott planning to ramp up to 50 million an urgent tests a month in October and just to give you a size, a sense of the scale of that. We're only doing about 25 to 30 million PCR tests in the US uh, every month. And so we're talking about ah, factor greater than one when it comes to the number of an urgent tests that are being rolled out. So an agent tests are going to be used more and more in the coming weeks, and we need to know what the situation is when it comes to those tests and the results. Yeah, there was an article actually posted this morning, um, by Kaiser that they did a survey of 50 states looking at an urgent tests and how they approach the data and it shows what we suspected and that there's huge variability so you can see here. Some states don't report any androgen test results. And just for your reference, an agent test results. If in an urgent test is positive, C S T E, which is a group the organization around epidemiologist and CDC consider that a probable case and not all states report probable cases. Eso you see here, some states don't report any an urgent test. Some, um, don't require reporting. Um, some require Onley positive tests to be reported so you see essentially different states will add to the number tested. Different states will add to both the number tested and and whose positive and it's it's not the same everywhere. And and there's nearly widespread acknowledgement that this is being under reported. And this is a table from the article I thought was interesting. They have obviously all the 50 states, if you want to see. But they asked the state how they deal with an urgent tests. Are they included in positive negative and total testing numbers? Are they requiring reporting and you see the variability just in this subset of states. So when you want to get a national picture of how it's going, this is not helpful. Um, And how does this impact really? How did the issues around testing data impact? Um, Cove in 19 in the US? Well, certainly there's gonna be more uncertainty. And how Cove in 19 is spreading in the U. S. Are declines. We see in case counts. Riel, Are they an artifact of the changes in type of testing? And how big is that artifact? Are we double counting positives? If a person test positive and on an engine test as a probable case, are they going to receive a confirmatory test? Are they Are those counted independently or can we track that person? Do we know if it's the same person? Um, there's gonna be increasing limitations on any decisions based on testing in case data, right? So if we don't know about the tests, we don't know about the true number of cases that can affect things like case incidents and positivity rates. And some people are using positivity rates to do things like open schools. So what goes into that calculation are in urgent tests considered. How is that different? You know, most of those thresholds were designed in the absence of widespread androgen testing. So certainly some considerations there and in terms of disease control. If somebody test positive on on an urgent test and doesn't receive confirmatory testing and it's not reported to the health Department, how are we following up on context? How is the Health Department even knowing about it? So that'll certainly limit disease control efforts. And overall, I think, to summarize, we have ongoing issues with Cove in 19 data. It's getting worse, not getting better. And that will continue to hamper our response nationally. And now I'll turn it over the list. Thanks. I have somebody take over the screen shares Well, so I can pull up loses. Thanks so much. Can everyone hear me? Okay, awesome. Well, good afternoon and mourning. For those of you on the West Coast, everyone, I'm with Hagen, director of policy for State engagements at United States of Care And happy to be joining you all Today s o this week on up on the screen, you'll see that we at United States of Care put out suggestions to states about how the best deal with the seasonal flu while continuing to combat Covitz. I'll briefly go over those recommendations. Um, you know, we know that states have a long history of dealing with the annual flu, encouraging vaccines and stopping what widespread flu outbreaks. But as has been mentioned are already text healthcare System is now confronted with this sort of unprecedented double whammy of the upcoming flew in the fall, converging with what we're already experiencing with Covic. So at United States of care, we've been engaging on a lot in one on one conversations with people, policymakers and leaders to really understand and have, ah, unique view into what people want to see out of their health care system, what they want to see out of their leaders and what they need to see out of their leaders, as well as ways that states can combat covert 19. Well, um, fighting the flu. So we've broken this down into four key areas. The first is to communicate Clearly, state leaders need to be clear in their communication about why protective measures such as mask wearing enclosures are necessary to keep people safe from flu and cove in states can play a vital role in providing that clarity toe to people about whether they're infected with either the flu or co vid because they do have similar symptoms. Second is preparing for increased health care demand. States need to have contingency plans in place so that the health care system resource is can be efficiently allocated and third is addressing the needs of high risk people. States will need to continue to rely on the latest data on the flu trajectory as well as the coveted Koven. Metrics and data like has been mentioned on this call to drive towards action. And that's especially important for high risk populations. And last is that states need to develop plans for increasing the vaccination rate for the flu in a typical flu season. Unfortunately, only 50% of people get vaccinated and the rates even lower among communities of color. So increasing this rates is essential to both minimizing the street on our health care system and then making sure that people can actually stay safe, clear communication about this is vital because people do have a lot of concerns about continuing to receive medical care during the pandemic. Um, eventually, states can leverage the experiences using the flu vaccine. Thio eventually provide covert vaccinations toe large numbers of people to. So this can sort of be seen as a sort of test run for that eso those air the high level recommendations on and we'd be happy to take questions at the end. Awesome. Thank you, Liz. We've got two more little pieces. Christina, do you wanna let me pull this up for you? Take the time. Next. Right. So just a reminder. I'm Christina. Sell Cox on a managing associate with the Duke Margolis center, and I wanted to talk about quickly Talk about two new reports from the Duke Margolis Center. The first report which you can see the title page there was released in mid August, and it's really meant to act as a primer on these different types of tests and basic explanations of how they work biologically and how the samples air. Um, take in and process a swell as, uh, different terms used around test performance, including explanations of how likely positive test result being through our false varies with local president prevalence of active infections. A some of those kind of nuanced type issues that are really important to understand. We also talked about the regulatory and payment structures around Cove in 19 testing and then finished by summarizing the key challenges that the nation still faces around testing, many of which we talked about on this call. Increasing meeting, meeting more supplies, the right test for the right purposes. Funding, particularly for for routine screening on data reporting, including the an urgent tests thing issues that that Cyrus mentioned. The second report was released last week, and, um, here's the Here's the cover for that one on this report. Really, talks really goes into the differences between diagnostic testing, which is really for individual decision making, UM, and routine screening, which is more to protect high risk settings by breaking train chains of transmission, using frequent testing and isolation of infected individuals in combination with other mitigation measures. Um, and then also surveillance testing, which is really meant to understand the changing number of active infections within a community for that public health decision making that was discussed earlier as well. On one of the things that actually, if you could go back one, uh, to this 11 of the things that we talked about this report. We don't need to do the same level of screening and surveillance everywhere. It really should be based on risk. It should be targeted. Should be targeted. Intervention. Um And so this figure shows how the report estimates the number of screening and surveillance tests that difference that two settings schools and nursing homes might need as prevalence changes over time. Like we saw with deputy presentation, however you can see at the bottom that that's that all these scenarios still require a large number of tests. Be able to do that sort of routine screening and surveillance. Luckily, if you go to the next table, we can see that the number of tests a point of care tests, which are the tests are probably gonna be most useful for the screening and surveillance are gonna be ramping up fairly quickly until until we get to fairly large numbers in April on dso uh, we do think that that that that capacity will be there. However, we do need toe encourage that we need to have a more clearly understood funding stream for this type of screening tests we need to build and test with based protocols for using these type of tests to build the evidence, including real world performance, like science pliers mentioned on from these tests and creating best practices on drily clarified, clarifying demand required for this sort of testing to create that that that that supply demand eso that manufacturers see that this this type of testing will be valuable on and used over time. So that's everything I have. I hope you guys check out the reports, right. Thanks, Christina. One other thing that I wanted to mention coming out of Duke Margolis recently is a webinar that we held last Thursday That might be off interest to a number of you. This was actually on vaccines? Yes. So here you can see from the agenda. We had a number off officials from the Center for Biologics at the FDA. In particular, there was a long discussion with Peter Marks, who is the director of the Center for Biologics and also a number of former FDA commissioners discussing, uh, basically where we are on vaccines. Um, there was an interesting discussion about the, you know, what are what is FDA looking for in clinical trials. At what point will they know that they can actually act on it? What is going to be the process on? But what does the EU a The emergency use authorization. How does that play into it? So I really recommend, um this is the next slide you can see. You can watch a video of it. So again, it's on the Duke Margolis website. Ah, lot of really useful information and and context setting for how a d. A. Is thinking about it and how others who know about the regulatory process think how, how they should perceive, given the situation that we're in. So that's it. Thank you, Ryan. Thanks, Marta. Were about to open up for questions in two minutes. So if you have a question, please drop it in the Q and A. Or raise your hand, and so Crystal will be able to call you. Uh, the topic to close on is taken extension of Cyrus's point, which he ended on, which is that the state of data is still really bad and really hard. I think when you're doing when we're doing our research and you're doing your reporting, you'll likely find yourself, probably citing sources that aren't the federal government right for us. Our main primary sources have been the Cove It tracking Project, which goes to state websites and crawls informations, takes the screenshots and aggregates them in a nice, usable way for us. And so we owe a debt of gratitude to the covert tracking team and just making it really easy to interact, use and analyze their data on a two calls ago or three calls ago. Now, you know, we sort of raise the flag on some of the CDC HHS data issues. Right When the data started flowing from CD CTO HHS, the data from the CDC website went away, and as the weeks went by the site, the data appeared again on the public protect website. And so we've actually been going to the HHS Protect website to get are I See you and inpatient bed estimates, and the state of this data here is it's getting better and better as every week goes by. But it has been a hard and rocky road these past few weeks because every week there's an inconsistency. Still, somewhere in the case here, there's still inconsistencies with Rhode Island data. But the good part is that this data on the reported side is being updated daily on the estimated side. It's only happening once a week and the CDC world that used to happen three times a week, but it's only once here, but they're still inconsistencies. We still pull that data in, but folks to raising flags when they come to covert exit because they'll say, Well, hey, you know, how can River Island 118%? Ah, utilization or even 80%? When you talk to the teams over in Rhode Island, they'll say No, our hospital systems are doing quite fine. And so this is one of those measures that needs to be tackled and fixed quite soon because it's a really strong measure of how our health system is doing. It's worth most so saying that while HHS protect has, you know, quote 200 data sets in it, this is still the only data set that's being made available to the public, uh, in a meaningful way. There are, you know, glimpses of the data within this system being released on different parts of of HHS or CMS websites, right? They released a bunch of nursing home data. And if you scroll down and look and go, okay, wait, wait a second. You're actually releasing county level positivity data? It's not being done in a thoughtful way yet. There's so much good data behind it, and we know that there's good data behind it because there are relationships between institutions. The wonderful institution of chop, which is the Children's Hospital of Philadelphia, where HHS is sharing some of these data streams. And here is a wonderful map where you can see county level data on positivity and this is coming from the HHS protect system. But in a private relationship. Um, we're also able to see that this data exists in places when you can go when you go look and see the White House task force reports that continually get leaked and you can see that there's really detailed data within these at the county level that really helpful. Remember, our site stops at the state level because that's all Kobe tracking dot com is able to get on the state level, and others were crawling and scraping different state websites to get this information kind of jumping through hurdles just to get it when the HHS protect system in the task force have such detailed level levels of information. And if you've been following this issue, you know, at the end of this June July July timeframe, August the Center for Public Integrity continues to host and put out every report that gets leaked. The house. You know, when when the pressure of these reports get seen by states governors go Well, of course I have these e need to make them public. And in this case here for Oklahoma, the governor there has made them public, which is fantastic, but Onley, maybe a handful of other states. I think it's around 12 when asked, Share them with the Center for Public Integrity. The rest will hold on to them, like states like Alabama say that it's private and confidential information. Um, if you recall on August 31st is well to the House Select Subcommittee on the coronavirus released eight of these reports. But once again, these reports from the past 14th, 19 you know, in stopping in August 9 and so a report of these drops every Sunday and we still can't get access to them. I think from our team here, who runs the site that really relies on data. We'd love to get access to the reports, but the data underlying it is even more powerful just for being able to help navigate this public health response. And with that, we're gonna open up Thio Q and A. And so I will let me. Can I just say one thing? Just that just this. I think it's this morning. The CDC has released indicators related to schools. Um, and and we've gotten some questions around schools, so we haven't really had time to process this or I haven't. But they people who want to know what's the magic number to open schools safely, and you see here it's more of a phased approach. Um, I can't comment on whether or not these are the appropriate levels, but can say the units are a bit different here than what we've said. Greater than 200 cases over 14 days per 100,000 people is the same as 140 per million per day on our website, and many states air above that. And it just speaks to the fact that you know there's a difference between burden the level of disease and trend. And while we might be trending down from the peak, um, we're still rarely high level in terms of the amount of disease. And I don't know if my screen change, but you can see here different countries in the world, and the U. S is still orders of magnitude above other countries. So just to comment Thanks, Cyrus Crystal, do we have any questions from folks raising their hand, or should I go toe some of the ones that have been sent in? You can start with the scent in ones, and then I have a few. Okay, this one's from Joedy. McCreary. Many college campuses have gone virtual with case numbers high in those areas. Is there a point when we should begin to talk about all campuses? Go going virtual. Are we there yet, or how much worse would things have to get for that to become a consideration? And Cyrus, that's kind of a build upon what you just showed. So how would you react? Um, let me just read that. Um, yeah, I mean, I think basically, there's different approaches across the U. S. Everybody is the tolerance for different levels of disease in terms of their decision around schools, there is no standardized approach in many schools. Many places are opening schools in areas with high community transmission, where it's where we would say, You know, it's not advisable to do so and you're seeing thousands of cases at universities, um, and other schools. So, um, there's no there's no the risk level is high So I think I heard that the coach of L S U football say most of the team has cases. You know, these people aren't inclined to have severe outcomes because of their age, and co morbidity is or you know, they're young and don't have many, um, but, uh, you know, the approach is definitely not the same, depending on where you live. And we would say that if you have a high rate of community transmission, you shouldn't you shouldn't be in person. That builds on the question that comes from Paul Newberry from The Associated Press in Atlanta. I would like to get the experts opinion on the way college football is returning to play in the age of covert, especially in light of developments such as L s U Oregon, saying a majority of Zap. That's what you just said of his team contracting the virus and has since recovered. Also, if anyone has an opinion on the Big 10 Conference announcement today, that they will start their season next month with such protocols is the 21 shut they shut down for any player who test positive and shutting down in team that has a positivity test rate of 5% among the players. Um, I would say we've learned, you know, professional sports leagues. We've seen even with the tremendous amount of resource, is that there's been some issues. The MBA certainly has done the best. Major league baseball has had issues then Ba being in a bubble baseball, traveling much like colleges, would having issues where they've had to postpone games and teams have been infected. But they have a lot of resource, is to protect people and do testing on an ongoing basis and have a bubble, and they get paid to do it. You know, colleges or different situation where it's you know, it's an educational institution that the level of resource is is highly variable. While you might have an L s U of Georgia and Alabama, with a tremendous amount of resource. Is other schools in the conference might not have that it might not be able to protect their players as much. And we're still learning Maura about young people in myocarditis. So, um, again, the approach is different, depending on Conference Pac 12 not starting till the spring. Some starting now I think we're you know, we're kind of undergoing a natural experiment to see what happens, but we are going to get a lot of college athletes with covert infections and we don't know the long term impact of that. Thanks, Styris. I've got a few questions from Tennessee, so I'm gonna pull up particular things. We'll get to those in one second. But there's a question from Kevin Stewart. Uh, that's on some of the death data that CDCR here. The CBC's latest Cove in 19 data reveals that 78% of child deaths or minorities How do you interpret this? Marta? Are Liz. Vince Cyrus is well, too. Yeah. I mean, I think it's it's concerning. You know that there's a disproportionate number of Children in that study from vulnerable populations. So many factors that could go into it in terms of, um, severity of illness on presentation, lack of access to healthcare, higher rates of transmission, Um, and hospitalization. Um, I haven't reviewed it, but I think like other things related to cove it in terms of Covic burden, we've seen the disproportionate impact. So it's not surprising to me. Yeah, I wanted toe emphasize what Saira are re emphasize. What, Cyrus? That I would agree with all of that. I think the other piece and that I mentioned in the With Intersection with the Flu is that we know that people from communities of color, as I mentioned, are much, much less likely to get flu shots. And so, um, that's a particularly important pieces. Well, to think about the, you know, the whole family, kids and adults and even get flu shots as well. Thanks, Liz. Here's I'm gonna pull up Tennessee and these are the questions, Um, in Memphis, Tennessee, and Shelby County, the superintendent canceled sports for all high school athletes. Can you talk about? Well, we think we talked about the safe on, and should athletes be paying playing now? But there's a specific question about the impact of covert in Tennessee. And so maybe more tires. I'm just gonna pull up. Tennessee is the whole here. And if you can share some commentary on what you're seeing and then I'll pull up the covert act now stuff, too. But this is Tennessee. Yeah, I think these are probably the two rows toe focusing on the cases per million. And how those things are looking as well as testing is a whole um, yeah, I mean, most, uh, trying to see can you go to case from? So, for instance, in terms of the school guidance, I just looked at from CDC that it's above that threshold for the highest level of risk. So that's a concern, and that's statewide to figure. I'm sure there's a lot of, um, heterogeneity in the data and Tennessee in terms of Memphis versus National. I'm just not up to date on that, um, but but overall, Tennessee seems to have, you know, ah, high level of co vid circulating. Um, we in terms of whether it's a smart move and what's down the road or whether or not a year is appropriate, it's we just don't know. It's hard to say a lot of it depends on how we respond to right now in terms of the co vid situation in the US. So if we can do everything, um, possible to control Cova, then certainly by early next year we should have things under control. We've seen that in other countries in the world. If we continue to have a variable approach by state by county, um, have these data issues and it's gonna people along and it could very well go into next year. And then in that case, it may be more Make more sense in terms of if your goal is to protect, um, students. Thio shut it down for the for the rest of the year. But there's a lot of things that are to be determined. One thing to highlight is well, too is I think this here is is to compliment Tennessee and say that there is, You know, there were two targets we've always been sharing. Sorry, we originally shared 5 to 500 k a day target for the United States, and that's adjusted per capita. But then the results. So another target we added recently about a month and a half ago called test target Incident adjusted right. So if the state has higher positivity, it means you have to test more. And if you have low positivity, then you can start to test last. And so on that baseline target. Tennessee is testing quite a lot, which is fantastic. But because of its high positivity rate, if it really wants to try to get that to being something 3% or lower, or to get a grasp of what's going on, it still has to test a lot Mawr. And so if it's testing, sorry, it is testing 23,000 test the day today. It should be aiming to get to 44,000. Um, to be able to really get a grasp of what's going on on the ground. I've got one more question here, but if there's folks on the line still, if you drop any last final out, here we go. We got one more question coming in as well to in areas of the county sorry country where cases are declining, are there certain policy changes that seemed to have made the biggest impact? This is from Katie Davis Young, so I can take that. I mean, if you go back to the slides that we showed during my presentation, you can see that the case number of cases on the rates the number of cases per million have really declined dramatically. And a lot of the states, um, it's very challenging to say which policies are really resulting in this. There's just so many moving pieces at the same time. But it really is a combination of two things. I mean, obviously, if you close bars, people can go into bars. But they can still go and have parties and and throw big parties and not wear a mask. So, um and have them indoors. So it's really a combination off some of the policies that you put in place, whether you have a mask, mandate or not, whether you have bars open or not, whether you limit the number of people that get together, but it has. It's also combined with how people respond to this. It's one thing to have a mandate, but the question is to what extent people follow the mandate on de so it You really cannot have a successful set of policies unless they are implemented and implemented when people follow them. So really is a combination of things which you see, for example, in Arizona, Arizona still does not have. Um, if you could write, if you could verify, it is. But my understanding is that they don't have a mask mandate, but the governor is promoting, um, uh, mask usage. You know, we would like to see, um uh, you know, increased mask usage. Um, but, uh, you know, ultimately is how people are going to behave. Policies that support the right behavior, Um, that reinforce mask wearing that reinforce social distancing that reinforce hand washing. Um, so all of that makes a difference. Yeah. If for folks who are tracking policy issues there's a great resource that co 19 state policy dot org's, which is a structured data set that, uh, shows you what states are doing and rolling out. This doesn't look pretty, But if you download the c S v of it, it's actually quite quite good. It will show you per state the different policies when they've been act and acted when they haven't, That's how we're able to say Well, Arkansas has a mask mandate. California does, but Arizona doesn't We particularly only show mask mandates on covert exit when it's the Level three category, which is saying, you know, you should also be wearing them outside when you're around people on nearby folks. Um, there are quite a few states that have just level to mandate. So, yeah, here, I can show you exactly where. Um, you can see there's a nice table chart here that shows over time the different states, how they've enacted them and the ones that have been doing it recently. What's kind of interesting to show is that the no statewide mandates you could call them holdouts. They haven't many of them. Haven't, uh, I would say no new state has added a policy in the past few weeks, and so it's it's quite fascinating to see, but if you look at how all these states that have really good, strong statewide mass mandates, you know, they've been able to bend the curb quite quite well. We've got a question from Sara Krueger. Let's see, um, here we owe Debbie mentioned that four out of five counties with the highest growth rates or college towns, what do you think about a return to the classroom for elementary, middle and high school students. How great of a risk will that be? Students in Wake County may return to the classroom in late October. What do you all predict is gonna happen then? Are you concerned about a similar situation to what happened in Georgia, where more than 1000 students and teachers were asked to quarantine so feel free to jump in anyone else's panel? But I think from our perspective, we provide the data, which is that when you reopen schools and this includes not only colleges but also elementary, middle and high schools, you will probably see high infection growth rates. Um, that's that. I know that this is a really complex issue. We know that there are places where Children rely on schools for food. We know that you know, there are places with limited digital, um, access where students don't have the option. Thio. You know they don't have the equipment and they don't have the access to actually dial into remote classes. We also know that there are parents who cannot take time off from work. Thio watch over their Children. So I think it's an incredibly complex situation and So you know, we're not necessarily at the point where we would unilaterally tell anyone in a prescriptive way what to do about, you know, returning to classroom for elementary, middle and high schools. But we can tell what we can tell people are what will probably happen. And then I think there are a lot of other variables, and I think it is all about trade offs, and those trade offs need to be weighed. Um, you know every person for, you know, students, parents, schools. And, you know, frankly, there is no single answer. There's no right answer. There's probably no good answer. And if I can add to this, um, you know, we should not be thinking of schools reopening as a binary decision. Your reopen or not. Um, clearly, if you reopen in a setting where there's tremendous community spread, you will probably be shutting down very quickly. But when the community spread is somewhat lower, you might still need to have to shut down pretty quickly if you allow the virus to spread if it gets into the school setting. So how you reopen really makes a difference? So you know this the program, the schools that have been successful. Um, they limit the number. The number off they require masks. They, uh, limit, uh, interaction with, ah lot of students. So they might set up these mini pods where students Onley interact with a small number of other students. They will have lunch is in the classroom. They will do a hybrid model so that there's fewer kids in the school at the same time, they have a lot of procedures put in place. Thio, you know, emphasized the social distancing. Uh, you know, they're wearing masks, the washing hands and just trying thio if the virus gets in to prevent it from spreading. So it's not just if you open, but if you open, are you gonna be able to stay open the end? What policy do you have to keep the virus in check? And just to say, looking at the CDC guidance, the majority of the South and Midwest are classified as the highest risk of transmission for opening schools. Sarah, I know that. Yeah, I just noticed from a note from Crystal that that do you have a follow up is well to that. You wanna ask, um, over the line or um, no, I think that was a thorough answer, and I appreciate that. Awesome. Thank you, Sarah. Um, we've got one more question here before we wrap Cyrus. Do our Everyone is well to do physician offices. Emergency departments typically have rapid cova test. Now, this is from Depp. Would I think, uh, it's hard. It's highly variable assed faras I've seen, you know, depending on the hospital, having access and being a part of a larger network like, say, h m O versus being a, a county rural hospital might have less access to things like that. From what I've seen, the rationing of those rapid tests is occurring in emergency departments the reserve for, say, if they have a limited number reserved for things like only admitted patients. Whereas other people you know where they're doing. Testing that takes 1 to 2 days, Hopefully not longer to get it back if people are being discharged. So there is some rationing going on, and I think, you know, huge variability in terms of the availability of those rapid tests. Thank Cyrus. We got a question from Tom Corwin in Georgia, the racial disparity and deaths continue up to age 69. Thoughts on what might be influencing that. You know, Liz, I think you and the team at U. S s C year doing a bunch of work right now on the racial disparities of Covic. No, Kobe tracking has been digging up lots of data. I mean, e think we all have that same question that Tom does. Yeah. I don't know that I can shed any light on that on that, particularly at this point. But then we have something that we would be happy to look into and follow up on. Unless other Panelists have any insights there. I guess that is it. Just up to 69 above 69. There are There are no more racial disparities, is it? Sorry. Well, maybe I think for for next for our next call that we're gonna do. I know that the topic of election, uh, you know what? What does Koven mean for going to polls and so well, absolutely. Spend some time on that. And then, Tom, I think we'll make sure Thio try. Thio have a section is well to on the racial component to cove it. And it's what it's unfortunately doing and okay, so with that, we have 60 seconds left. So I want to thank everyone so much for joining and thank you for everything you do as well. On reporting on covert and keeping people informed, you know, we started this off is just a phone call conference call. That's kind of evolved into this, and it's always meant to be here for you and your teams toe help answer the questions that are on top of your mind. And so we likely will do one more of these again in either two or three weeks. If you have suggestions or areas that you're digging into, please send them ahead of time. Thio, um, Chris, or press at Covad exit strategy. Or go to any one of us will start to compile things so we could make this time that we have together meaningful and with that, thank you so much and have a wonderful rest of Wednesday and rest of the week