The analysis is the first comprehensive review of covid-19 data that all 50 states and Washington, D.C., are using to make decisions about policies on mask-wearing and opening schools and businesses. In the absence of a national strategy to fight the pandemic, states have had to develop their own metrics for tracking and controlling covid-19. But with few common standards, the data are inconsistent and incomplete, according to the report released by Resolve to Save Lives, a New York nonprofit led by former Centers for Disease Control and Prevention director Tom Frieden and part of the global health organization Vital Strategies.
Some essential information that would show response effectiveness is not being reported at all. Only two states report data on how quickly contact tracers were able to interview people who test positive to learn about potential contacts. Not a single state reports on the turnaround time of diagnostic tests, the analysis found. Week-long waits for results hobble efforts to track real-time virus spread and make contact tracing almost irrelevant.
“States around the country have done good work. They’ve been doing the challenging, hard, meticulous job of collecting, analyzing and presenting crucial information," Frieden said during a news briefing Tuesday. “But because of the lack of national leadership, we don’t have common standards, definitions, targets or accountability.” As a result, despite a “tsunami of data points,” the United States is “flying blind on the actual risk and the effectiveness of the response.”
Frieden noted that Monday’s case total in the United States exceeded that of all cases in Europe, all in Asia and all in Africa. “With 4 percent of the world’s population, we have one-quarter of covid-reported deaths,” he said. “And during the 45 minutes of this briefing, more than 20 people will die from covid in the U.S. and thousands more will become infected.”
His team and other public health leaders are recommending that states and counties report 15 indicators they say are essential for an effective response. The metrics were drafted with input from states and public health organizations and modeled after practices from around the world, Frieden said. States should be able to report on nine of the metrics now and the other six within several weeks.
The nine include information about confirmed and probable cases, rates of hospitalization per capita, and emergency department trends showing people who have symptoms of influenza-like illness and covid-19-like illness.
Frieden said “the obsession” with total number of tests conducted is “close to irrelevant" and may do more harm than good. If more than 800,000 diagnostic tests are done, and only one-fifth of the results are returned in a day or two, and few of those testing positive are rapidly isolated and quarantined and their contacts warned, “we really have done very little good.”
He called on the federal government to release turnaround testing times by state.
Frieden’s team highlighted Ohio and Utah as states that are enhancing high-quality dashboards and risk-alert systems. Several others, including Arizona, Michigan, Minnesota, North Carolina, Oregon, Tennessee and Virginia, have data that give an overall look at the spread of covid-19. Others have told the group they will publish more essential metrics soon, Frieden said.
Some information exists at the federal level but is not shared publicly, he said, noting that what gets measured publicly is what gets managed.
Georges C. Benjamin, executive director of the American Public Health Association, said states have been slow to release the data because “there aren’t expectations from the White House or the CDC to do it,” and they are concerned doing so will make states “look bad.”
CDC, in a statement, said it has been working since the beginning of the outbreak with states and other partners “to collect, analyze and report out data critical to formulate the nation’s response to this unprecedented public health crisis.”
CDC is already tracking, or has plans with states to track, 14 of the 15 indicators, the agency said. The data is posted on the CDC website and many states are also tracking some indicators on their websites. The statement added: “CDC is always looking at best practices for ways to enhance, consolidate and report data, to make it easier for states and the public to access.”
Michael R. Caputo, assistant secretary for public affairs at the Department of Health and Human Services, criticized Frieden and the report.
“While Frieden scrambles for relevance, the team at CDC under Dr. [Robert] Redfield’s leadership has already accomplished the very things Frieden calls for. We’re providing open and transparent data to scientists, researchers, and the public on a level Frieden never accomplished gathering data by fax,” Caputo said.
Public health experts say consensus from governors on common metrics and a regular system for reporting data and triggers for implementing social distancing policies will be vital to suppress and eventually recover from covid-19.
“This report rightly reinforces the need for standard indicators, transparently reported across all states, and lays additional groundwork for a national consensus on unified measures to control spread,” said Beth Cameron, vice president for global biological policy and programs at the Nuclear Threat Initiative. She was the senior director for global health security and biodefense on the White House National Security Council.
If states can quickly identify where people are getting infected and how that is changing over time, “we should be able to identify when things are headed in the wrong direction more quickly than we have done so to date,” said Caitlin Rivers, an epidemiologist and senior scholar at the Johns Hopkins Center for Health Security, who spoke at the briefing on the report.
If there are common targets, the public will also better understand what it will take to bring the pandemic under control. If the benchmark for a state’s diagnostic test positivity rate should be below 5 percent, for example, a state reporting a 20 percent positivity rate is headed in the wrong direction.
Similarly, if a state is reporting that only a small fraction of new covid-19 cases can be linked to prior cases, “things are not going well no matter what a national or local leader might say,” said Tom Inglesby, director at the Hopkins health security center.
The D.C. health department published that key metric for the first time Monday. It said the percentage of new coronavirus cases linked to already known cases is just 2.8 percent — meaning most people contracting the virus aren’t aware of who might have exposed them. The city’s goal is 60 percent.
Groups representing state public health officials support the measures.
“Having some standard metrics to compare across the country will make a big difference in identifying where things are going well and where there is need for additional resources and improvements,” said Michael Fraser, chief executive of the Association of State and Territorial Health Officials.
Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, said using consistent indicators gives people information that can help change behavior.
It’s also important, she said, that Frieden’s team recognized the relative importance of each metric and that “the optimal target may change based on the local status of the pandemic.”
Still, public health experts are also concerned that overwhelmed state and local health departments don’t have the resources to report some of the information at a time when states are experiencing record numbers of infections and hospitalizations.
“Some of these data are going to be very, very hard to get without a workforce dedicated to just charting these metrics week by week,” said Jeanne Marrazzo, director of the Division of Infectious Diseases at the University of Alabama at Birmingham School of Medicine.
“If we had this as a road map at the start in confronting the pandemic, that would have been the bomb,” she said.