Which US states fared best and worst in the pandemic and why

Volume 7, Issue 16 | April 26, 2023

In This Issue 

Lessons learned on testing from the COVID Crisis Group and Dr. Fauci
We need to address the challenges in wastewater surveillance
Follow-up on seed-amplification assay uses beyond Parkinson’s
Why free COVID tests are a have-to-have, not a nice-to-have

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New and Noteworthy

Lessons Learned, Edition Number N+1:
The COVID Crisis Group and Dr. Fauci

The latest publication in the “What went wrong during the pandemic and how can we fix it the next time” genre came out this week, and it’s a biggie. Lessons From the Covid War: An Investigative Report comes from a team of heavy hitters in science and public health called the COVID Crisis Group who, according to STAT News, were originally intended to be an independent commission along the lines of the one created to investigate 9/11, looking into the nation’s pandemic response.

We haven’t had the chance to read all 300-plus pages yet (Mara was interviewed for the book), but one finding caught our attention: Non-pharmaceutical interventions (aka NPIs - things like masks, isolation, quarantine, etc.) failed because testing failed, especially in the early days of the crisis. NPIs work best when deployed strategically, in the populations most likely to spread disease, not wholesale. But with a virus that’s spread by asymptomatic people, the only way you find out who’s most likely to spread disease is to test everyone - or at least as many people as humanly possible. Only then can you know who needs to mask, who needs to quarantine, who needs to isolate. Without that necessarily high level of testing, NPIs were used as a “blunt instrument” (think mask mandates for everybody, not just exposed or infected people) which didn’t work as well as was needed, and backlash resulted.

Coincidentally, the New York Times just published an in-depth interview with Dr. Anthony Fauci on the very same topic. His take on testing during the pandemic’s early days focuses on the federal government’s reliance on the CDC’s COVID test, even after it became clear that the test was faulty: “It was a huge, huge, huge problem. Not only the technical mess-up by the CDC, but then the follow-up of not encouraging the use of other tests from other sources and instead saying: ‘No, wait, wait, we’ll fix it. We’ll fix it.’”

Commentary:  No surprise that we agree with the fundamental premise: Testing was mismanaged at the beginning and underused through most of the pandemic.  We can’t forget this.  Nothing against vaccines and treatments, but testing will always be the first line of knowledge. No one can manage an outbreak or individual patients without knowing who has the ailment.  For COVID in particular, if the US (and other nations) had been able to mount a broad and effective testing effort, we might have learned about asymptomatic spread much earlier.   To have had any hope at containing the virus, we would have needed adequate testing and concomitant isolation.  

We take a lot of solace in the MPox response, which showed that some of the lessons about testing were understood: Public / private partnerships existed from the beginning, and response was focused on communities that had the highest risk.  We also know that “lessons learned from COVID” reports will continue to appear for some time. Let’s hope that we can create a groundswell of attention about the power (and affordability) of testing so that decision makers will remember that lesson, at the very least.  

States’ COVID performance: Hawaii first and Arizona last

This week The Lancet published an in-depth assessment of how US states performed during the first 31 months of the COVID pandemic (January 2020 through July 2022) in terms of infection and death rates. Infections were massively and variably undercounted, so in this brief review we only focus on deaths. Each state was adjusted to the overall US age and comorbidity profile for comparison (see extract reproduced here). During this time, the national average number of deaths was 372 per 100,000 people, or 0.4%. Hawaii was lowest at 147, and Arizona nearly four times worse at 581. 

Interpreting what drives state death rates is tricky for a couple of reasons: 

1. The authors expose correlation, not causation, and 

2. The states have a very wide range of differences (see the supplemental data to dig in further). Take state population, for example: The average is 6.7 million, but only Massachusetts and Indiana are close to that number. Fifteen are bigger and 33 are smaller, some by a lot: California is 67 times bigger than Wyoming. It is much easier for smaller states to have more extreme drivers and outcomes, for better or worse, whereas larger ones will trend toward the average. The authors do what they can to reduce these confounders (e.g., by using logarithmic scales and statistical measures), but if every state counts as an independent and equivalent data point, smaller states inevitably have more influence on the analysis than larger ones do. 

Nevertheless, the analyzed correlations are highly suggestive of underlying drivers of difference at the state level. The authors examine 34 possible factors, which fall into three categories: 

• States’ pre-COVID conditions

• Their COVID-era policies 

• Resulting individual behaviors 

It is perhaps no surprise that behavior influenced deaths the most: Mask mandates had very little impact, but actually using a mask lowered deaths by 34%. Similarly, vaccine mandates decreased deaths by 39%, while being vaccinated reduced deaths by 97%. As might be expected, stay-at-home mandates were highly effective (62% lower deaths), followed by gym and restaurant closures. Interestingly, closing bars or primary schools (but not higher education) both drove deaths higher. (Unfortunately, this study did not examine the important role of testing and isolation.)

Taken together, the policy implications are clear: However achieved, broader adoption of masking, vaccination, and the avoidance of congregate settings would have reduced death rates dramatically nationwide, but the power of mandates alone to achieve these three objectives was mixed. Although there was no difference due to the party affiliation of state governors nor to declared “trust in the federal government,” the higher the percentage of people voting for the 2020 Republican presidential candidate was in a given state, the higher the percentage of people who died there was, too - suggesting that this was a stronger factor driving individual choices than red state/blue state polarization alone.  

Wastewater surveillance: essential, despite the challenges

A CDC/National Academy of Sciences committee reported back in January that the US needs a “truly representative, sustainable, national wastewater surveillance system.” This surveillance modality, now expanded to 1400 sites, was one of the demonstrated successes of the pandemic, but its coverage across the nation is still very spotty. 

Last week’s NEJM perspective highlights some of the challenges. Since wastewater teems with millions of pathogens and not all can be analyzed at any one time, we will need to target an evergreen subset of pathogens which have imminent pandemic potential. Culturally, there is resistance to collection of the human DNA that is also present in these samples, since it would be possible (although expensive) to track specific individuals to specific locations. Commentary: One way or another, we need the pathogen surveillance that systematic wastewater testing provides.

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Food for Thought

Giving people free at-home tests made a difference

A survey-based study led by Emory University and published in MMWR analyzed the ordering and use of free at-home COVID tests supplied by the federal government through COVIDtests.gov. The sampling, done during April and May 2022, showed that 60% of respondents had ordered test kits and 32% of households nationwide used at least one of these tests. The experience was considered acceptable by 95% of households.  Additional interesting statistics showed the impact of the free test program during this time:

• Of those who tested positive, 38% used a COVIDtest.gov test

• 22% of users tested positive during the study 

• 24% of users stated they probably wouldn't have tested without the free tests

Commentary: Policy-makers and decision-makers, are you paying attention to that last line? Because you should be. With the end of the Public Health Emergency, the cost of tests is about to shift back to insurers - which means that people who are un- or under-insured are going to have to pay for tests out of pocket. This study makes the strongest argument we’ve seen against making that shift. If you want people to test, you have to make it possible - and easy - for them to do so.

Footnote to last week’s item on seed amplification assay use for Parkinson’s

Last week, we covered the use of an alpha-synuclein seed amplification assay (SSA) to diagnose early stage Parkinson’s disease. This week, AlzForum published a very thorough deep dive into the potential for the utility of SAA beyond Parkinson’s. The substantial challenges of applying the SAA approach are described towards the end of the review, with further references and industry researcher comments.

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Quick Hits

According to the CDC, the week ending April 19, 2023 saw the fewest deaths across the US (1,160) since the week of March 19, 2020, which saw 169 deaths.