COVID-19 in the United States: Where Are We Now? Where Have we Been?

By: Dr. Zachary Bloomgarden

COVID-19 in the United States: Where are we now? Where have we been? Coronavirus infectious disease 2019 (COVID-19) was identified in Wuhan, China, in late 2019, and the first case in the United States, a traveler who had returned from Wuhan, was confirmed in late January 2020. The US restricted air travel and declared a public health emergency in the beginning of February, terming this a national emergency in March, allowing federal funding, which was rapidly increased by the end of March, along with offering telemedicine for healthcare.1

Tallies of case numbers tell the story: rapid increase to about 30 000 cases per day from the end of March to early April, stabilizing at this level until mid-June, then increasing to more than 60 000 cases per day by July, dipping back to 40 000 at the end of August, but then again increasing to the current level of more than 120 000 cases per day.2

Individual states showed different patterns: In New York and New Jersey, peaks of 10 000 and 4000 per day in April, decreasing to below 1000 at the end of the month, while in Florida, Texas, and California peaks of 10 000 to 15 000 per day were seen towards the end of July, only decreasing by September, and still remaining at 3000 to 5000 per day. As of this writing, there have been nearly 10 000,000 cases in the US, and nearly 240 000 deaths.3

Death rates tell the story of the toll of the disease. By tracking weekly death rates in the US over past years, the number of excess deaths with COVID-19 can be calculated. Deaths involving COVID-19 began to increase in the beginning of April, peaking over 16 000 per week at the end of April, decreasing at the end of June, then peaking at 8000 deaths per week at the end of July, with levels decreasing again but still remaining at 4000 per week.4

The difference of progressively increasing numbers of reported cases but decreasing death rates, although still terribly high, appears to be explained in part by different age distribution of COVID-19 cases over the months. In May the greatest numbers of cases were the very old, age 80 and over, but progressively in June, July, and August, the peak of cases was among those age 20 to 29.5 From the beginning of February through the end of October, under 100 deaths occurred in those below age 25 (Figure 1).

After age 25, the percentage of COVID-19 deaths increased progressively. About 3% of deaths were in those age 25 to 34, 6% at age 35 to 44, and 8% to 10% in every decade thereafter—although the population size decreases as age goes up. Altogether, nearly one of every one hundred Americans age 85 and over died of COVID19 or its complications during the past 9 months (Table 1).6

There were similar numbers of deaths among non-Hispanic whites, non-Hispanic blacks, and people of Hispanic ethnicity, but, calculated as percentages, minority populations showed double, triple, or even greater multiples in relative death rates, suggesting that these groups were adversely affected to a much greater extent. Similarly, deaths occurred to much greater extent among people with a history of coronary disease and among those with stroke, among those with hypertension, with diabetes, and, strikingly, among those with Alzheimer’s disease, perhaps reflecting the tremendous excess of deaths occurring in residents of nursing homes and similar residential facilities.

Deaths occurred to a much greater extent in the early period of the epidemic, with more than 33 000 deaths among residents of New York and 16 000 among residents of New Jersey, particularly occurring during the period through April and early May, while a total of more than 17 000 residents of Florida, nearly 18 000 of California, and more than 19 000 of Texas died because of COVID-19, mostly occurring during later months.

The decrease in New York from more than 700 to less than 20 deaths per day from April to the end of July was almost certainly brought about by “lockdown,” closing nonessential businesses, with many working from home, and with vigilance of wearing masks, maintaining physical distance, remaining in well-ventilated areas, as much as possible outdoors, and not gathering in large groups.7

The longest periods of lockdown, over 200 days, were in California, Nevada, Oregon, and Wisconsin, while New York and Illinois had 60- to 80-day periods, and Connecticut, Kansas, Massachusetts, and Michigan had lockdown periods of 20 to 40 days.8

COVID-19 has led to drastic changes in healthcare in the US. During the peak initial COVID period, visits to emergency rooms decreased 42%—and although some unnecessary visits were avoided, it cannot be a good thing that emergency rooms for myocardial infarction and for stroke decreased 23% and 20%, and those for diabetes decreased 10%.9

Outpatient visits decreased more than 20% from average levels in 2018 and 2019, with office visits to physicians from April through June decreasing by just over half, in part replaced by telemedicine visits—which increased from 1% in 2018 and 2019 to more than one third of outpatient visits in 2020.10 So, COVID 19 occurred in multiple “waves” with varying time course in different states, with lockdown appearing to offer a major initial approach to preventing the surge in deaths that has occurred in areas experiencing peaks in infection.

The dramatic effect of age in increasing COVID-19 mortality is evident from the analysis. In addition to its myriad economic and social effects, lockdown led to a reduction in non-COVID emergency care, in part undesirable, but with a rapid growth in telemedicine to offset some of the decrease in outpatient care. We face important challenges going forward. We must sustain behavior changes, helping people to take appropriate precautions, perhaps instituting “micro-lockdowns” in small areas seeing resurgence of infection. We need to increase testing availability and make sure that results are rapidly available.

Eventually, vaccine rollout will be crucial in establishing a “new normal.”

(This article originally appeared in the Journal of Diabetes)

Zachary T. Bloomgarden, MD, MACE, FASPC is a Clinical Professor at the Department of Medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York City

REFERENCES

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