Sunday, July 26, 2020

`Outlier Blindness' & Things To Come


CDC Infographic


#15,384


For many scientists, and a few small subsets of society, the COVID-19 pandemic - and our fumbling global response - comes as little surprise. Preparing for and dealing with the `next' pandemic has been the raison d'ĂȘtre of this blog since 2006, and the prime focus of many others, including CIDRAP, the Johns Hopkins Center For Health Security, Crof's Blog, and the dedicated volunteers at FluTrackers.

Our common message has been that another pandemic is inevitable, and that the world isn't close to being ready. 

That this could be so painfully obvious to so many of us, yet dismissed as a `low probability' threat by (literally) billions of others, speaks to the human tendency to underestimate the magnitude of `outlier events', and our inherent belief that tomorrow will be pretty much like today.   

Even after the COVID-19 virus emerged, and clearly posed a pandemic threat, people (who should have known better) continued to dismiss its importance, and potential impact for months. Even today, millions of people refuse to believe that SARS-CoV-2 is a real pandemic, and a genuine public health threat. 

Ten years ago, in  None So Blind As Those Who Will Not Listen, I wrote about this cognitive dissonance during the backlash over the severity of the 2009 pandemic. 
The popular `lay’ perception of a pandemic – at least in the western world – seems to be based on novels like George R. Stewart's Earth Abides, Stephen King’s The Stand, and the BBC’s production of Survivors. 
George Romero fans would argue that if it doesn’t involve zombies, it doesn’t really qualify as a pandemic.
By those standards, the status of 1918 as a pandemic would be in doubt.
Seven years ago, in The Pandemic Preparedness Messaging Dilemma, we looked (for the umpteenth time) at the resistance to preparing for pandemics and other major disasters by the general public, large corporations, and even governments. 

Even agencies that espoused pandemic preparedness turned out to be spectacularly unprepared for COVID-19.  And this despite yearly warnings from the WHO, The World Bank, and others that the world was not ready for a pandemic. 

Fifteen years ago Dr. Michael Osterholm, director of CIDRAP, presciently likened a severe pandemic to an 18-month global blizzard, where nearly everything is shut down. Many will find themselves without a paycheck, either due to their refusal to work and risk exposure, or because their jobs are simply no longer available (see Baby, it's Cold Outside).
Sound familiar? 
More recently, in his 2017 book Deadliest Enemy (see my Review: Deadliest Enemy: Our War Against Killer Germs), Dr. Osterholm revisits the idea of our JIT economy, and writes:
Ironically, the ways we have organized the modern world for efficiency, economic development, and for enhanced lifestyle -- the largely successful attempts to transform the planet into a global village -- have made us more susceptible to the effects of infectious disease than we were in 1918.
And the more sophisticated, complex, and technologically integrated the world becomes, the more vulnerable we will be to one disastrous element devastating the entire system.
In 2008, in Lloyd's: A Pandemic Is Inevitable and in The Lloyds Report: A Closer Look, we looked at their predictions for the next pandemic. 
EXECUTIVE SUMMARY

1. A PANDEMIC IS INEVITABLE With historic recurrence rates of 30-50 years it is prudent to assume that a pandemic will occur at some point in the future. The severity of such events is highly variable; some estimates suggest the most severe to date, in 1918, killed up to 100m. Many pandemics affect the old and young; but some (including the 1918 event) can, perversely, affect the most healthy.

2. 1918 MAY NOT BE THE WORST CASE It is certainly true that the 1918 event was extreme relative to other pandemics in history. However many published “worst case” scenarios take 1918 as a base. There is a danger that we over optimise to this one scenario. There are other forms of pandemic than influenza, some have higher case mortality. Pandemic preparedness should consider a range of scenarios to ensure plans are appropriately flexible.

3. ECONOMIC IMPACTS MAY BE SIGNIFICANT A repeat of the 1918 event is expected to cause a global recession with estimated impacts ranging from 1% to 10% of global GDP. Most industries will be affected, some more than others. In particular, industries with significant face to face contact will be impacted significantly. Insurers investment assets may be affected depending on the mix held. Wider economic and social effects may lead to secondary forms of loss for insurers.

4. MANY INSURANCE LOSSES ARE POSSIBLE For some classes of business such as, life and health it is clear that the impact will be adverse. For other classes of business it is less clear but many forms of liability covers including general liability, D&O, Medical Malpractice as well as specific products offering business interruption and event cancellation could be triggered. Inner limits for Pandemic losses (vertical and sideways) may help to contain exposure.

5. SECONDARY IMPACTS MAY OCCUR Events causing significant global and societal turmoil can give rise to considerable secondary impacts. It is far from clear which of these, if any, would occur; but for resilience planning purposes it is worth considering them. For example the lawlessness experienced in New Orleans after Katrina could be repeated if police services are affected. Traditional claims such as fire loss may be exacerbated if fire emergency services have depleted efficiency and if tradesmen are in short supply.
In December of 2012 the U.S. National Intelligence Council released a report called "Global Trends 2030: Alternative Worlds" that tried to anticipate the global shifts that will likely occur over the next two decades (see Black Swan Events).

Number one on their hit parade?
Global Trends 2030's potential Black Swans
1. Severe Pandemic
"No one can predict which pathogen will be the next to start spreading to humans, or when or where such a development will occur," the report says. "Such an outbreak could result in millions of people suffering and dying in every corner of the world in less than six months."
In 2014, the U.S. Director of National Intelligence declared An Influenza Pandemic As A National Security Threat, writing:  No one can predict which pathogen will be the next to spread to humans, or when or where such a development will occur, but humans will continue to be vulnerable to pandemics, most of which will probably originate in animals.

The following year, in The Blue Ribbon Study Panel Report on Biodefense, we examined an 84 page Bipartisan Report of The Blue Ribbon Study Panel On Biodefense that looked at our nation’s vulnerability to a biological attack, an accidental release, or naturally occurring pandemic with a highly pathogenic biological agent.

I could list hundreds more reports, studies, table top exercises (
 EVENT 201, CLADE X), and clarion calls (WHO/World Bank GPMB Pandemic Report : `A World At Risk) - all warning of our vulnerability to a severe pandemic - and urging greater preparedness.
 
COVID-19, and its inevitable knock-on impacts - many of which are yet to come -  won't be the last major global crises we'll have to deal with in the years ahead.  Another pandemic is inevitable - and may be worse than SARS-CoV-2 - as well as natural disasters like CAT 5 hurricanes, earthquakes, floods, famines, and even severe space weather.  

We either get a lot better at recognizing - and preparing for - these threats, or resign ourselves to suffering even greater economic and societal turmoil in the future.

To that end, researchers at the University of New South Wales in Sydney, Australia have published an interesting study on `Outlier Blindness' ; our tendency to dismiss, or trivialize, obvious threats. 

This 59-page study is heavy on statistics - all of which are well above my pay-grade - but you can get the gist from the press release below. The authors propose a neurobiological basis for our tendency to grossly underestimate `outlier' threats. 

While focused primarily on the investment community, there would seem to be lessons here for all of us. 

How our brains blind us to 'black swan' economic events
21 JUL 2020
VICTORIA TICHA
Neurobiological factors blind people to making sound investment decisions when markets are hit by large macroeconomic shocks, shows UNSW Business School research.

The outbreak of coronavirus was and still is an ‘interesting natural experiment’ illustrating how people, particularly investors, initially misinterpret the nature of major unpredictable events (known as black swan events), says Scientia Fellow Elise Payzan-LeNestour, Associate Professor in the School of Banking and Finance at UNSW Business School.

A/Prof. Payzan-LeNestour says people tend to grossly underestimate their importance before eventually readjusting their view – though by which time it may be too late. “Our brain is deceiving us in a pervasive and systematic fashion,” she says.

Her latest co-authored research paper: “Outlier Blindness”: Efficient Coding Generates an Inability to Represent Extreme Values sheds light on the neurobiological foundations of this bias, which is at odds with behavioural patterns previously described in behavioural science. With her collaborator from Columbia University, she calls this bias “outlier blindness”. 
Insights for business and finance 

During the Great Depression, Australia suffered years of high unemployment poverty, low profits, deflation, and lost opportunities for economic growth. But during this time, the government cut spending drastically. As we now know – thanks to Keynesian economics – fiscal contraction only adds fuel to the fire in times of widespread falls in demand. 
If history is anything to go by, Australia needs more government stimulus – not less, inasmuch as the current downturn is not the sign of a temporary crisis but of a permanent shift. The findings by A/Prof. Payzan-LeNestour’s research suggests people tend to grossly underestimate the sheer significance of events like the Great Depression while they are living it, and as a result, they do not react as quickly as they should. 

The theory proposed by A/Prof. Payzan-LeNestour and colleagues also sheds light on investor risk attitudes in the aftermath of COVID-19, which is quite puzzling at first. Recent research provides evidence that on one hand, COVID-19 made investors more risk-averse for a given level of perceived risk (which is quite intuitive; this probably occurred because of increased fear and panic).

On the other hand, COVID-19 decreased investors’ perception of a given level of risk, which is also quite puzzling and one potential explanation for why the S&P 500 has rebounded 32 per cent since late March. Many market observers are calling this ‘a disconnect from the deteriorating fundamentals’, says A/Prof. Payzan-LeNestour.
Why is this?
The theory she proposes predicts exactly such a pattern, which she recently described in detail with co-authors from UNSW and UTS. “Following the extreme volatility of March, investors subsequently underestimated risk, leading to inflated valuations through downward biased discount rates, leading to a market rebound until such time as perceptions revert towards objective measures of risk,” she explains.

So, what is causing investors’ temporary underestimation of risk following their exposure to extreme volatility? “The brain becomes adapted to very high levels of volatility reasonably quickly – so completely crazy levels of volatility can become the new normal,” which she shows in an experimental study.
Insights for all of us

“Awareness of our own perceptual biases may help us become less susceptible to them, even though they are very ingrained,” says A/Prof. Payzan-LeNestour.

“If you are conscious of them, even if part of your brain is still deceiving you, you may be able to adjust your decision-making,” she explains. 
“Ironically, even I (and I’m supposed to know about outlier blindness) was blind to the importance of COVID-19 for months, in the sense that I grossly underestimated its importance and didn’t realise until a few weeks ago that our world will never go back to what it was before,” confesses A/Prof. Payzan-LeNestour. “I guess this reflects the fact that as any scientist, I try to view my own theories with a healthy degree of scepticism.”
She says, hopefully, the dissemination of her research into the neurobiological foundations of investor decision-making will help people anticipate how they are going to react to the next tragedy and correct their view accordingly. 

Even though I've been writing about pandemics for 15 years, it took me the first half of January before I finally wrapped my head around the idea that we were facing a genuine pandemic.  Like everyone else, I wanted this to be contained in China, and to turn out to be just another `warning shot', not the real thing.

I suppose we all carry a certain degree of `Outlier Blindness'.
 
I can't tell you what the next great crisis will be, how bad it will be, or who it will affect. I simply operate on the assumption that another shoe will drop sooner or later, and that anything that occurs in the next couple of years will probably be made worse by the concurrent COVID-19 pandemic and economic downturn.  

While we may not be able to stop the next global crisis, the better prepared we are going into it, the less damage we will take. 

But for that to happen, we first need to learn how to open our eyes to the threats around us. 
 
Some past preparedness blogs to get you started include:

CDC Upcoming COCA Call (Jul 28th): COVID-19 & Diabetes




#15,383

On Tuesday afternoon (Jul 28th) the CDC will hold their 2nd COCA Webinar of July, this time focusing on the importance of diabetes prevention, management, and support during our ongoing COVID-19 pandemic.
COCA Calls are generally heavily attended and are of greatest interest to clinicians and healthcare providers. If you have trouble getting through - or are unable to attend the live session - the CDC archives these broadcasts for later viewing.
Details on Tuesday's COCA Call follow:

Coronavirus Disease 2019 (COVID-19) and Diabetes: The Importance of Prevention, Management, and Support

Overview

During this COCA Call, presenters will focus on current information about the impact and increased risk for COVID-19 complications in people with diabetes and the importance of diabetes prevention, management, and support.


Presenters

Celeste Philip, MD, MPH
Deputy Incident Manager
COVID-19 Response
Centers for Disease Control and Prevention

Ann Albright, PhD, RD
Director
Division of Diabetes Translation
Centers for Disease Control and Prevention

CDR Sharon Saydah, PhD (USPHS)
Epidemiology Task Force
COVID-19 Response
Centers for Disease Control and Prevention

Call Materials

None at this time
Call Details


When: Tuesday, July 28, 2020,
2:00 p.m. to 3:00 p.m. (Eastern Time)

Webinar Link:
https://www.zoomgov.com/j/1615367357external icon

Dial In:
US: +1 669 254 5252 or +1 646 828 7666

International numbersexternal icon

iPhone one-tap:
US: +16692545252,,1615367357# or +16468287666,,1615367357#

Webinar ID: 161 536 7357

Saturday, July 25, 2020

Hanna Becomes 1st Hurricane Of 2020 Atlantic Season


#15,382


While originally expected to top out as a strong tropical storm, Hanna this morning was upgraded to a minimal hurricane just hours before its expected landfall in southern Texas, making this the first hurricane of 2020.   

Practically speaking, there's very little difference between a high-end tropical storm and a minimal hurricane, except for making the record books. 

Residents in the affected area should be finishing their preparations for the storm. And those who live outside of Hanna's path should be preparing for what the Atlantic and Caribbean will undoubtedly produce over the next 90-120 days. 




 
As we discussed back in May, in Why Preparing For This Year's Hurricane Season Will Be `Different', our concurrent COVID-19 pandemic will complicate nearly every aspect of hurricane season, including evacuations, staying in shelters, and the time it will take to restore utilities and provide disaster relief after the storm.
With the official forecast calling for an unusually active season (see NOAA's Busy 2020 Atlantic Hurricane Season Outlook), it makes sense to make your plans and lay in your supplies now, before a tangible threat appears on the horizon.
So, if you haven't already done so, plan a visit to NOAA's Weather-Ready Nation  2019's Hurricane Preparedness week web page, and decide what you need to do now to keep you, your family, and your property safe during the coming tropical season.

Seroprevalence of SARS-CoV-2 in Dogs & Cats - Italy















#15,382


Six months into the SARS-CoV-2 (COVID-19)  pandemic and there remain major gaps in our understanding of how this virus spreads, which species (beyond humans) are susceptible, and how that might affect this (and future) pandemics. 

SARS-CoV-2, much like MERS-CoV, appears to have originated from bats, and then jumped - either directly, or more likely via an intermediate host - to humans.  


                  

While the initial damage has all ready been done, should SARS-CoV-2 find other suitable animal reservoirs, it could make it much harder to eradicate, and could conceivably provide the virus with additional evolutionary options. 

An already `humanized' coronavirus circulating, and evolving, in a non-human animal reservoir  would significantly increase the risk of seeing a new and improved `SARS-CoV-3' pandemic emerge down the road. 

Luckily, early research has shown that the virus does not replicate well in pigs and chickens (see Susceptibility of Ferrets, Cats, Dogs & Other Domestic Animals to SARS-CoV-2) by Dr. Hualan Chen et al. 

They wrote: 
We found that SARS-CoV-2 replicates poorly in dogs, pigs, chickens, and ducks, but efficiently in ferrets and cats. We found that the virus transmits in cats via respiratory droplets. Our study provides important insights into the animal reservoirs of SARS-CoV-2 and animal management for COVID-19 control.
While encouraging news, SARS-CoV-2 continues to evolve, and what we can say about its transmissibility and replication today many not hold tomorrow. And we've seen at least one farmed animal - mink - are highly susceptible to infection and may even have infected humans in the Netherlands (see COVID-19: Back To The Mink Farm).
Since then nearly a million mink have been culled in the Netherlands, and recently Spain ordered the culling of close to 100,000 after an outbreak at a mink farm in Teruel  (see CNN Spain orders cull of nearly 100,000 farmed mink after animals test positive for Covid-19). 

Wageningen Bioveterinary Research (WBVR) maintains a summary page on the outbreak in the Netherlands (below).
COVID-19 detected on multiple Dutch mink farms
          (Excerpt) 
Risk analysis 20 July

In a letter to parliament dated 20 July, the OMT-Z recommends expanding existing measures for persons who are in contact with mink. If new infections are still being detected on Dutch mink farms after mid-August, it is advised to cull all mink farms to prevent them from becoming a reservoir for the coronavirus.

Spread of the virus between mink

Previous research has shown that ferrets are susceptible to SARS-CoV2. Therefore it was already assumed that mink might be susceptible too. Pneumonia was seen in sections on mink and SARS-CoV-2 was detected in organs and throat swabs. Based on the variations in the genetic codes of the virus, it could be concluded that mink farms have transmitted the virus to each other.

Possible spread from mink to employee

Minister Schouten of Agriculture, Nature and Food Quality (LNV) reports in a letter to parliament dated 19 May that it is plausible that one of the employees was infected with the coronavirus by mink. In a second letter dated 25 May, she announced that it is plausible another infection of an employee via mink took place.
          (Continue . . . )

Admittedly, farmed mink being susceptible to SARS-CoV-2 poses far less of a concern than if the virus had an affinity for pigs or poultry - but it is important to monitor other potential hosts for the virus - as they could provide additional opportunities for the virus to adapt and evolve outside of our view.

As far as felines are concerned, over the past couple of months we've looked at a small  number of field reports, and some limited research, on the susceptibility of cats to the COVID-19 pandemic and their potential for transmitting the SARS-CoV-2 virus to others.
CDC: Pets & Other Animals and COVID-19
NEJM: Transmission of SARS-CoV-2 in Domestic Cats
APHIS: Confirmation of COVID-19 in Two Pet Cats in New York
The evidence thus far suggests your cat is far more likely to contract the SARS-CoV-2 virus from you, or another human, than to spread it to humans   What is known as Reverse Zoonosis. 


Today, however, we have a new (pre-print) study from Italy which suggests both dogs and cats may be more susceptible to SARS-CoV-2 than previously believed, although they rarely show symptoms or test positive by RT-PRC. 

Evidence of exposure to SARS-CoV-2 in cats and dogs from households in Italy

Edward Ian Patterson, Gabriella Elia, Andrea Grassi, Alessia Giordano, Costantina Desario, Marta Medardo, Shirley L. Smith, Enyia R Anderson, Tessa Prince, Grace T. Patterson, Eleonora Lorusso, Maria Stella Lucente, Gianvito Lanave, Stefania Lauzi, Ugo Bonfanti, Angelica Stranieri, Vito Martella, Fabrizio Solari Basano, Vanessa R Barrs, Alan D Radford, Umberto Agrimi,Grant L Hughes, Saverio Paltrinieri, Nicola Decaro
doi: https://doi.org/10.1101/2020.07.21.214346

This article is a preprint and has not been certified by peer review [what does this mean?].
 
Abstract

SARS-CoV-2 originated in animals and is now easily transmitted between people. Sporadic detection of natural cases in animals alongside successful experimental infections of pets, such as cats, ferrets and dogs, raises questions about the susceptibility of animals under natural conditions of pet ownership. 

Here we report a large-scale study to assess SARS-CoV-2 infection in 817 companion animals living in northern Italy, sampled at a time of frequent human infection. No animals tested PCR positive. 

However, 3.4% of dogs and 3.9% of cats had measurable SARS-CoV-2 neutralizing antibody titers, with dogs from COVID-19 positive households being significantly more likely to test positive than those from COVID-19 negative households. Understanding risk factors associated with this and their potential to infect other species requires urgent investigation.

The surprise here isn't that nearly 4% of cats tested showed antibodies to SARS-CoV-2, but rather that dogs lagged behind by only .5%.   Earlier studies had suggested that dogs are far less susceptible to infection than cats. 

In the study's conclusion, the authors wrote:
In this extensive epidemiological survey of SARS-CoV-2, we found that companion animals living in areas of high human infection can become infected. Our results suggest that dogs warrant further investigation regarding SARS-CoV-2 susceptibility in contrast to experimental studies which suggested cats were most susceptible (9).
We also observed seropositivity rates in animals comparable to those of humans via community sampling at a similar time in European countries (19-21). This suggests that infection in companion animals is not unusual. Based on current knowledge, it is unlikely that infected pets play an active role in SARS-CoV-2 transmission to humans.
However, animal-to-human transmission may be more likely under certain environmental conditions, such as the high animal population densities encountered on infected mink farms (22). As and when human transmission becomes rarer and contact tracing becomes more accessible, serological surveillance of pets may be advocated to develop a wholistic picture of community disease dynamics and ensure that all transmission opportunities are terminated.

While there is limited evidence of animal-to-human transmission of SARS-CoV-2 from companion animals, the CDC does maintain a web page with advice for pet owners. 

Updated June 28, 2020
 
What you need to know
  • A small number of pets worldwide, including cats and dogs, have been reported  to be infected with the virus that causes COVID-19, mostly after close contact with people with COVID-19.
  • Based on the limited information available to date, the risk of animals spreading COVID-19 to people is considered to be low.
  • It appears that the virus that causes COVID-19 can spread from people to animals in some situations.
  • Treat pets as you would other human family members – do not let pets interact with people outside the household.
  • If a person inside the household becomes sick, isolate that person from everyone else, including pets.
  • This is a rapidly evolving situation and information will be updated as it becomes available.
(SNIP)

What to do if you own pets
 
Until we learn more about how this virus affects animals, treat pets as you would other human family members to protect them from a possible infection.

Because there is a small risk that people with COVID-19 could spread the virus to animals, CDC recommends that pet owners limit their pet’s interaction with people outside their household.
  • Keep cats indoors when possible and do not let them roam freely outside.
  • Walk dogs on a leash at least 6 feet (2 meters) away from others.
  • Avoid public places where a large number of people gather.
  • Do not put face coverings on pets. Covering a pet’s face could harm them.
There is no evidence that the virus can spread to people from the skin, fur, or hair of pets. Do not wipe or bathe your pet with chemical disinfectants, alcohol, hydrogen peroxide, or any other products not approved for animal use.

Talk to your veterinarian if your pet gets sick or if you have any concerns about your pet’s health. 
          (Continue . . . )
 
 

Friday, July 24, 2020

CDC Updated (July 23rd) COVID-19 Forecasts: Cumulative Deaths & Hospitalizations


#15,380

The CDC has updated its weekly (4 week) forecast for COVID-19 deaths and hospitalizations, and while their remains a high degree of variance between the individual models, they continue to show an upward trend across both key metrics over the next month.

All of these models are based on various assumptions about social distancing, disease transmission rates, and local compliance with recommended control measures, and should therefore be taken with a hefty grain of salt.

First stop, forecasts for national and state numbers of COVID-19 hospitalizations per day for the next 4 weeks, based on 7 national and 8 state models. Last week's forecast had estimates of daily hospitalizations (4,500 to 13,000) by August 10th. 

This week's forecast drops the lower bounds to 2,000 but keeps the 13,000 upper limit. 
Updated July 23, 2020
 
Interpretation of Forecasts of New Hospitalizations
  • This week, five national forecasts suggest an increase in the number of new hospitalizations per day over the next four weeks, while two other forecasts predict stable numbers or slight declines. On August 17, the forecasts estimate 2,000 to 13,000 new COVID-19 hospitalizations per day.
  • State-level forecasts also show a high degree of variability, which results from multiple factors.  Hospitalization forecasts use different sources of data for COVID-19 cases or deaths, with different limitations, and make different assumptions about social distancing.
National Forecasts


 







 
  • The seven national forecasts show the predicted number of new COVID-19 hospitalizations per day for the next four weeks in the United States.
  • The forecasts make different assumptions about hospitalization rates and levels of social distancing and other interventions and use different methods to estimate the number of new hospitalizations. See models below for details.
State Forecasts

Eight state-level models predicting the number of new hospitalizations were submitted this week. These forecasts show the predicted number of new COVID-19 hospitalizations per day for the next four weeks in each state. Each state forecast uses a different scale, due to differences in the number of new COVID-19 cases occurring per day in each state.

Download state forecasts pdf icon[1 MB, 7 pages]1

Download forecast data excel icon[2 MB]
         (Continue . . . .)
 
Next up, the expected number of cumulative National and state COVID-19 deaths over the next 4 weeks, based on 26 individual national forecasts. Last week's estimate, by August 8th, was 150,000 to 170,000 deaths.

Updated July 23, 2020
 
Observed and forecasted cumulative reported COVID-19 deaths as of July 20, 2020.
 
Interpretation of Cumulative Death Forecasts
  • This week CDC received 26 individual national forecasts.
  • This week’s national ensemble forecast predicts there will likely be between 160,000 and 175,000 total reported COVID-19 deaths by August 15th.
  • National and state-level ensemble forecasts suggest that the number of new deaths over the next 4 weeks will likely exceed the number reported over the last 4 weeks for the US overall, as well as in 25 states and 1 territory. The jurisdictions with the greatest likelihood of a larger number of deaths include Alabama, Florida, Georgia, Idaho, Nevada, Oklahoma, South Carolina, Texas, and Utah.
National Forecast

  • The figure shows cumulative reported COVID-19 deaths and forecasted deaths for the next four weeks in the United States.
  • Models make various assumptions about the levels of social distancing and other interventions, which may not reflect recent changes in behavior.  See model descriptions below for details.
State Forecasts

State-level forecasts figures show observed and forecasted state-level cumulative COVID-19 deaths in the US. Each state forecast uses a different scale, due to differences in the numbers of COVID-19 deaths occurring in each state.

Forecasts fall into one of two categories:
  • The Columbia-UNC, COVID19Sim, ERDC, Geneva, GT-DeepCOVID, ISU, LANL, LSHTM, MIT-CovAlliance, MIT-ORC, MOBS, Oliver Wyman, NotreDame-Mobility, QJHong, STH, UA, UM, UMass-MB, USC, and UT forecasts assume that existing control measures will remain in place during the prediction period.
  • The Columbia, GT-CHHS, IHME, JHU, NotreDame-FRED, PSI, UCLA, and YYG forecasts make different assumptions about how levels of social distancing will change in the future.
Download state forecasts pdf icon[12 pages]

Download forecast data excel icon[1 sheet]


WHO: Plague – Democratic Republic of the Congo

Plague signs
Three Types of Plague -   Credit CDC
 










#15,379

Last summer, in WHO WER: Plague Around The World, we looked at a WHO WER (Epidemiological Weekly Record) review of the 2017 Madagascar Plague outbreak which saw hundreds of confirmed and probable cases.

Globally, a couple of thousand plague cases are reported each year, mostly in rural areas of Africa, Asia, and South America, with Madagascar the hardest, and most consistently hit region.

Bubonic Plague (Yersinia Pestis) - carried by rats, squirrels, and other small rodents, and transmitted by fleas - sets up in the lymphatic system, resulting in the tell-tale buboes, or swollen lymph glands in the the groin, armpits, and neck. 

Less commonly Pneumonic Plague may develop, when the infected individual develops a severe pneumonia, with coughing and hemoptysis (expectoration of blood), which may spread the disease by droplets from human-to-human.

Modern medicine, particularly the advent of effective antibiotics, makes plague far less fearsome than it once was, but Madagascar's recent epidemics, and a large 1994 India outbreak that infected more than 5,000 people (see WHO Summary), show that large urban outbreaks are still possible.
 
The US reports an average of seven human plague cases each year (range: 1–17 cases per year) - mostly bubonic - and almost always in the Western states. The last major urban outbreak of plague in the United States occurred in 1924-25 in Los Angeles.

https://www.cdc.gov/plague/maps/index.html
CREDIT CDC


Overnight the World Health Organization is reporting on a new outbreak of plague in the Democratic Republic of Congo which began in June.  This outbreak is just the latest challenge for the DRC, and comes on top of COVID-19, an ongoing Monkeypox epidemic, and recurrent outbreaks of Measles and Ebola. 


Disease outbreak news
23 July 2020

The health zone of Rethy in Ituri province, the Democratic Republic of the Congo, has seen an upsurge of plague cases since June 2020. The first case, a 12-year-old girl, reported to a local health centre on 12 June experiencing a headache, fever, cough, and an enlarged lymph node. She died on the same day and further deaths from the community due to suspected cases of plague were subsequently reported.

From 11 June though 15 July, six out of 22 health areas have been affected within Rethy health zone (11 villages), with a total of 45 cases including nine deaths (case fatality rate: 20%). All nine (9) cases who died presented with signs of headache, high fever, and painful nodes; four (4) out of the nine (9) cases had cough.
The health zone team carried out an investigation resulting in five positive rapid diagnostic tests (RDTs). Nine additional samples were taken and shipped to the Institut National de Recherche Biomédicale (INRB) laboratory in Kinshasa. Of the 45 cases reported, two showed signs of septicemic plague; all the other cases were diagnosed as having bubonic plague. According to the available information, it is likely that all three types of plague clinical presentation (bubonic, septicemic and pneumonic) are present.

The distribution by sex shows 58% (26/45) are male and 93% (42/45) are greater than five years old. Of the 45 cases reported, nine including four who died, had cough among the symptoms - a sign indicating a potential progression from bubonic plague to pulmonary plague. This was specifically noticed among the deceased.

Plague is endemic in Ituri province. Since the beginning of 2020, Ituri Province has reported a total of 64 plague cases and 14 deaths (CFR:21.8%) in five health zones, namely Aungba, Linga, Rethy, Aru and Kambala health zones. This compares against 10 cases and 5 deaths (lethality 50.0%) during the same period in 2019, all in a single zone.

The current COVID-19 epidemic affects seven out of 26 provinces in the country. Ituri has also reported cases of COVID-191 that may further interrupt response activities due to lockdown. These are in addition to long standing public health response challenges identified in the region, including a lack of resources and insecurity. Although it has been reported that there is no significant impact of the COVID-19 context on activities taking place in this area, there is limited information available on the current access to health care. This includes whether or not there is a need for the population of Ituri to seek care in Uganda, as well as the availability of human resources, drugs, and personal protective equipment (PPE). Furthermore, the reference laboratory in Bunia, Ituri province is currently not functional, which might delay the confirmation of suspected cases and response efforts.
Public health response
  • A national rapid response team (RRT) has been deployed to the affected health zone to conduct an outbreak investigation and implement initial response activities.
  • UNICEF is on the ground responding to the humanitarian situation at Bunia, working on community engagement and safe and dignified burial practices.
  • The WHO guideline for plague, including case definitions, has been disseminated to health facilities to improve the detection of cases.
  • The WHO is supporting plague endemic areas with surveillance, investigation of cases, and training of health workers and community relays in the prevention, early detection and case management of plague.
  • Doxycycline prophylaxis has been administrated to the listed contacts.
  • Intra-household spraying with deltamethrin has been used in some villages.
  • Safe and dignified burials (SDB) have been performed by the health district team.
  • Sensitization of the population on plague prevention measures in the affected villages through local radio.
WHO risk assessment

Infection with plague can cause severe disease resulting in high mortality in humans, particularly if not identified early. Plague can exhibit in three forms: bubonic, septicemic and pneumonic. If untreated, bubonic plague can evolve to pneumonic plague. Early diagnosis and treatment are essential for survival and reduction of complications.

Rethy health zone is endemic for plague and regularly registers cases of enzootic variants of Yersinia pestis, in much of the wild rodent population. Its first outbreak was reported in February 2020 with cases imported from Linga health zone, based in the Godjoka health area.

On the security level, there are reports of atrocities and violence linked to the militia CODECO which continues to impact the population of this territory (Djugu and its surroundings). There have been mass population displacements within Djugu and Mahagi Territories. Currently, the Rethy Health Zone has received approximately 112 714 internally displaced persons (IDPs), most of whom have come from the Jiba and Linga Health Zone. The growing insecurity impacts traffic flow between the villages and the willingness of the population to either stay or work in that area. There has also been a deterioration of water, hygiene and sanitation conditions in the reception areas and in the IDP sites.

The early detection and reporting of the current outbreak by healthcare workers demonstrate that a functioning surveillance system is in place. Ituri province had a reference laboratory in Bunia which is no longer functional. The Institut National de la Recherce Biomedicale (INRB) laboratory based in Kinshasa/DRC has the ability to conduct laboratory testing for suspected cases. However, delays in shipping samples from Rethy to Bunia and then to Kinshasa, and delays in testing in Kinshasa INRB due to high workload and backload related to COVID-19 samples to be tested, might jeopardize the surveillance and response. Ongoing efforts are required to ensure that any other cases are promptly detected, isolated, and investigated to avoid the establishment of local transmission.

The risk at national level is considered to be moderate given: the evolution of the current situation is in danger of deteriorating rapidly (case fatality rate: 20%), the notification of cases of pulmonary plague, the challenges with the surveillance system and delays between sample collection and laboratory confirmation, and the volatile security situation and the existence of other epidemics in progress in the country which prevents the setting up of a more comprehensive response. Furthermore, the health zone currently does not have enough PPE, body bags and materials needed for decontamination. Malteser International, an NGO that supplies the health zone with drugs, has had difficulty getting the products into the zone because of insecurity on the RN27 road.

The principles of control are known and have been implemented (early treatment with the recommended antibiotics, isolation of the pneumonic cases, chemoprophylaxis given to the close contacts of the latest ones, rodent and flea control, safe and dignified burials, and the prevention of nosocomial transmission) but the means are limited and the health system is unable to manage the cases in the most appropriate way. The antibiotics used for the treatment of the cases are Doxycycline, Ciprofloxacin and Cotrimoxazole. For the pulmonary or septicemic form case, Gentamycin was administrated. The lack of laboratory confirmation is worrying but the use of rapid diagnostic tests (RDT) on the field ensures a minimum of confirmation among the suspected cases. The RDTs are especially reliable to confirm bubonic plague suspected forms.

The risk at regional level is considered low since the epidemic seems to be contained in the Rethy health zone and that it is an isolated region. The risk is considered low globally.
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