The latest COVID-19 data may show the first signs of improvement since the surge of summer cases in Arizona, although public health analysts say more time is needed to point to a firm trend.
After weeks of case spikes, it’s possible daily case counts may be flattening, but it will take time to see if this trend continues given test results reporting lags.
Emergency room visits by people with COVID-like-symptoms dropped over the past week, with the exception of a jump back up on Tuesday, according to hospital-reported data posted by the Arizona Department of Health Services.
Other hospital metrics like beds in use are still increasing most days, but may be doing so less quickly. It appears inpatient beds are starting to level off.
And the percentage of tests that have come back positive, which has hovered at the highest level nationwide, may be gradually plateauing or decreasing — but still, at a very high level.
All these metrics remain near the highest that have been reported since the pandemic began, but they may be starting to trend downwards. Another week or two will provide more certainty.
“There are some encouraging signs that the pace of this outbreak is moderating,” said Joe Gerald, an associate professor at University of Arizona’s Mel and Enid Zuckerman College of Public Health.
“I do see some encouraging signs in some of the data. Not all of the data, but some of the data, and it is cause for some very cautious optimism,” said Gerald, who has been modeling Arizona’s outbreak for several months.
Dr. Murtaza Akhter, a UA College of Medicine-Phoenix assistant professor and ER physician at Valleywise and other local emergency rooms, said ER visits may be starting to level off, but patient volume is still high. And the situation could worsen again if people who became ill in recent surges of positive cases get sicker and check into hospitals in the days and weeks ahead, he said.
“We may be sort of plateauing, but that doesn’t necessarily mean we’ve hit the peak,” he said.
Akhter cited Arizona’s high cases per capita — third in the country on Wednesday, trailing only New York City and New Jersey — and high percentage of positive tests, which Johns Hopkins University ranks as the highest in the country.
Case counts: Possibly moderating
Here’s the data the public health experts are looking at:
Over the past week, the daily number of new cases reported by the state health department has started to flatten, one of the first potentially promising signs in Arizona’s COVID-19 battle.
Maricopa County is seeing a “slight flattening of the curve,” according to Dr. Rebecca Sunenshine, medical director of disease control for the Maricopa County Department of Public Health. “What we don’t know for sure is how prolonged that flattening will be. We hope that it will continue to decrease, although it’s much more clear that it is a flattening right now.”
Statewide trends look similar.
“It does look like we have flattened a little bit,” said Joshua LaBaer, director of the Arizona State University Biodesign Institute and leader of the university’s COVID-19 research efforts. “Day over day, the case numbers seem to be kind of consistent, so that’s a sign that it’s not accelerating the way it was a few weeks ago.”
But experts say Arizona is still adding far too many new cases. Even if it’s plateauing, it’s plateauing at a number that’s too high, with around 3,500 new cases added each day.
It’s too soon to tell if the case numbers will continue to decrease.
“We shouldn’t be cheering, and we certainly shouldn’t back off,” LaBaer said.
Gerald cautioned about reading too much into the daily case numbers. He said it does seem like they’re slowing, but the appearance of improvement could be because of delayed test results, as lag times have risen in recent weeks.
Another week or two will show whether there’s actual improvement, he said.
“Things could be getting worse a lot faster than they are. The fact that case counts are moderating; that’s a good thing, but it doesn’t mean we’re out of the woods,” Gerald said.
“This is a really long battle. While I’m optimistic and hopeful these are good signs, we still have a long way to go, so we can’t relax or get overly complacent because we think things are getting somewhat better.”
Death rates: Too soon to tell
In general, it’s too soon to tell what effect moderating cases are having on deaths. Deaths are a lagging indicator, because they won’t be known until several weeks after positive cases emerge.
LaBaer said Arizona’s death rate has been much lower than places like New York. Arizona had the advantage of watching the virus and learning from other places before it got hard hit. He said death rates have continued to rise in Arizona, though, and will continue to do so until case numbers lessen.
Sunenshine of Maricopa County said flattening cases will likely in a week or two lead to a “flattening or decrease” in hospitalization data, and hopefully a week or two after that, a decline in the death rate.
ER visits, inpatient hospitalizations: Signs of slowing
Doctors and nurses say local hospitals are still overwhelmed, but state health department data shows stress on hospitals may be starting to ease slightly.
Emergency department visits for positive and suspected COVID-19 patients had been decreasing for six days straight until they shot up again Tuesday, according to hospital data reported to the state.
A record 2,008 patients visited emergency departments on July 7, but each day since then has seen fewer visits than the day before, until Tuesday’s 1,810 reported visits.
This doesn’t mean visits are low; they just might be decreasing slightly. Emergency department visits in the past week have still been higher than pretty much any time earlier in the pandemic.
Akhter said even if ER volume is potentially plateauing, patients are still staying for hours in the emergency department and it’s hard to find them beds. Hospitals are still overwhelmed and bumping up against capacity, he said.
“In the ER, it is very hard to get a patient a critical care bed when he needs one, regardless of what the numbers say,” Akhter said. “Looking at those numbers is reasonable, but it doesn’t fully account for the fact that on the ground, it’s hard to get a bed.”
Daily emergency department visits statewide surpassed 1,000 on June 16 and have been above that level every day but two since. During April and May, ER daily visits for COVID-19 were typically in the 400s and 500s, rising into the 600s in the last few days of May.
“Hopefully it’s a sign of things improving,” said Will Humble, executive director of the Arizona Public Health Association and former state health director, of the more recent data.
Humble said ER visits are a “leading indicator,” compared with deaths, which are a lagging indicator.
That means spikes in ER visits may be a warning sign of increases in cases and hospital beds occupied in the days and weeks ahead. Decreasing ER visits could be a sign of the opposite — an early indicator that things may be abating.
Dr. Frank LoVecchio, a UA College of Medicine-Phoenix professor and emergency room doctor at several Valley hospitals, said he has not seen a decrease in ER visits.
“When you look at numbers in Arizona and look at our dashboards, they don’t tell the whole picture,” he said. “Universally, it is a mess. We talk about a pandemic; I talk about pandemonium in the ER. It is such insane gridlock, it’s hard to fathom.”
LoVecchio said he is “optimistic” that ER visits really are going down, but said, “I don’t see that.”
He instead sees what seem to be flat or increasing numbers of COVID-19 emergency department visits. He said rooms meant to hold 40 patients are now holding 80, with patients lying two to a room and new patients often seen first in the ER waiting room instead of an exam room.
Ninety percent of the patients LoVecchio sees in the ERs are COVID-19-related, he said. He said he hears from colleagues in New York and New Orleans that things will “all of a sudden” level off and he’ll be seeing very few, instead of nearly all, COVID-19 patients.
“I can’t wait for that to flip,” LoVecchio said.
Gerald said he does not rely much on ER trends in his analyses because they tend to fluctuate more than other hospital metrics like inpatient beds, ICU beds and ventilators in use by COVID-19 patients.
All those trend lines have been largely increasing in recent days, although Gerald said inpatient beds may be “moderating.” That’s “somewhat encouraging,” he said, as changes in inpatient beds typically lead to changes in ICU beds; as inpatients moderate or decrease slightly, it’s hopeful ICU beds might do the same a few days later.
Inpatient hospital beds filled by COVID-19 patients have been steadily increasing since early June, but starting last week, they began flattening for the first time, according to state data.
For the first day in weeks, Tuesday saw no record numbers for inpatient beds, ICU beds and ventilators in use for suspected and confirmed COVID-19 patients.
While that’s a positive, hospitals remain overwhelmed. High numbers of new patients are still admitted to hospitals, and beds are tight for all COVID-19 and non-COVID-19 patients.
LaBaer said he’s heard from many that they have temporarily closed ICUs off to new patients as they’ve run out of beds.
Percent positive: Possible plateau
Another indicator that seems to be moving in the right direction is the percent of tests that are coming back positive.
It’s possible that number might be leveling off or decreasing compared with a few weeks ago. According to Arizona Department of Health Services, the percentage of positive tests out of all tests per week was at 21% two weeks ago, up from 20% three weeks ago, 18% four weeks ago and 14% five weeks ago.
But last week, it’s at 17% so far for tests that have been run, although many test results are still outstanding. When the state decided to reopen on May 16, that percent positive number had been trending down to as low as 5%.
Arizona still has the highest percent positive nationwide, according to a Johns Hopkins analysis, although its seven-day average has decreased slightly from last week. Johns Hopkins calculates Arizona’s current seven-day average at 24.7% positive, down from last week’s 25.3%. Its graph of 7-day moving averages shows a plateau and a decrease in percent positivity from last week.
“It’s still incredibly high,” Gerald said. “It’s a bad number no matter how you look at it, but it’s just not as bad as it might have been.”
Arizona ideally wants to get the percent positivity under 5%, or at least under 10%, meaning there is adequate community testing to catch symptomatic cases, asymptomatic cases and negative cases.
Humble said ramping up testing, and contact tracing and other interventions, will significantly drive down the percent of positive tests. Arizona will reach a lower percent positive when there is less community transmission and when testing is more widespread to test lower-risk people, he said.
Face masks: Likely having an impact
The impact of face coverings, which were mandated by many Arizona cities starting in late June, could be reflected in recent case data.
“If we have any moderation right now, I think the most likely explanation is that face masks may turn out to be a very important component of our public health response,” Gerald said. “The timing fits.”
LaBaer said that increased face mask usage, in addition to other interventions like closing bars and more people staying home, may be responsible for some of the gradual flattening of recent days — suggesting that individual action can go a long way.
Akhter, the emergency room physician, urged strongly that individuals wear face masks whenever around others to slow the spread and protect the hospital system so it can care for COVID-19 and all other patients.
“I’m doing everything I can in the ER to help people, and so are my colleagues, but we’re not magicians. There’s a limit to what we can do … if there’s not enough beds,” he said. “The hospitals are very full.”
The best way to continue any positive trends and slow the spread is a combination of personal action and public health intervention like expanded testing and faster results.
“We’ve got a long way to go,” Gerald said. “This will continue to evolve over months, not weeks.”
Reach the reporter at Alison.Steinbach@arizonarepublic.com or at 602-444-4282. Follow her on Twitter @alisteinbach.
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