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We have learned that there likely were many cases of COVID-19 spreading undetected in major cities before we were even aware of the crisis. The upper circle indicates the number of COVID-19 cases that had been detected in the US by March 1st.  Northeastern University estimates that the median number of actual cases on March 1st  resembles the lower blob, with yellow for Boston (2,300), brown for Seattle (2,300), maroon for Chicago (3,300), purple for San Francisco (9,300), and blue for New York City (10,700). If we do not improve our testing capability, then this sort of hidden spread will occur again as our country re-opens.

 

Image showing spread in major cities as represented by dots.

Source: https://www.nytimes.com/2020/04/23/us/coronavirus-early-outbreaks-cities.html

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In addition to hidden cases, we are also learning about uncounted deaths. These countries has significant numbers of excess mortality that are unaccounted for by known COVID-19 deaths.

 

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Six charts showing uncounted deaths in England & Wales, France, Spain, Ecuador, Netherlands, Belgium, Jakarta and Instanbul.

Source: https://www.nytimes.com/interactive/2020/04/21/world/coronavirus-missing-deaths.html

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These excess deaths have occurred in the United States as well. New York City alone has experienced almost 4,000 excess deaths that have not been attributed to the novel coronavirus. It is likely that a significant portion of these deaths are due to people with undiagnosed COVID-19.  How could this happen?

 

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Excess deaths in New York City.
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We are starting to understand the timing of COVID-19 symptoms. Studies clarify that fever is only an initial symptom and that most serious complications occur after the fever breaks (upper chart). Importantly, we are learning that COVID-19 provokes blood clots in some people--who may or may not have cardiovascular disease--which can lead to fatal heart attacks or strokes (lower chart; D-dimer is a measure of a protein fragment that is produced when a blood clot dissolves in the body).

 

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Symptoms of survivors and nonsurvivors.

Source: DOI: 10.1016/S0140-6736(20)30566-3

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Chart of protein fragment that is produced when a blood clot dissolves in the body.

Source: DOI: 10.1016/S0140-6736(20)30566-3

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In a study done in Holland, researcher estimated that over 30% of ICU patients with COVID-19 infections have complications from blood clots, an astonishingly high percentage.

 

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Youth are not immune from this complication either. Early data strongly indicate that, while outcomes are worse as patient age increases, young and middle-aged adults also have severe cases with poor outcomes. About a fifth of those hospitalized are under the age of 45. We don’t yet understand why otherwise some healthy people fare poorly with COVID-19.

 

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While some parts of the country have passed the peak of their surge, much of the country still has not – including Kentucky.

 

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These data suggest that Kentucky is not yet fully on the other side of its surge. The mortality curve should lag the new cases curve by about 2 weeks.  The map indicates that the counties in Kentucky whose case count in increasing the fastest are areas that have the least access to emergency services.

 

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Map of confirmed cases in Kentucky

 

Another way to see this same conclusion is by noting the states in which the percentage of positives tests for the coronavirus continues to climb. Kentucky is on that list.

 

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Predicted positive peaks
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Forecasting models for COVID-19 impacts are still widely divergent. The top two models for the United States show the same information in two different formats. Both of these models assume that current social distancing measures continue through the projected time period.  And, as you can see, in the third model, the shaded range of possible number of deaths is additionally quite large for Kentucky, but none of the forecasts predict that Kentucky has crested its surge.

 

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