Alabama’s and Mississippi’s troubling Covid-19 curves, briefly explained

National Covid-19 cases appear to be plateauing, but new hot spots are emerging.

For the first time in a while, there is a bit of good news to report about America’s coronavirus pandemic: Nationally, cases have plateaued — and in some places, they have begun to decline slightly.

But, as always is the case when looking at the national numbers, the situation is more complicated than it seems.

Over the last two weeks, the average number of new cases reported daily has dipped from more than 66,000 to roughly 60,000, according to the Covid Exit Strategy tracker. The number of people hospitalized with Covid-19 nationwide has also fallen in the last 10 days, which would suggest an ebb in the virus’s spread. The explanation for the drops is pretty simple: Arizona, Florida, California, and Texas — the four states that had driven much of the summer wave — have seen their daily new cases drop by between 11 percent and 28 percent over the last two weeks. Hospitalizations in those states have also tailed off.

Deaths are still at their highest levels since May, however, with the US currently averaging more than 1,000 Covid-19 deaths every day.

Earlier in the summer, there seemed to be a disconnect between case numbers and death counts, with the death count remaining low even as new case counts rose. But this time, the case count is declining and the death count is rising. Because of the lag between when a person’s case is reported and when their death would be reported if they fall victim to the coronavirus — which can sometimes be a month or more — we may not see the drop in cases reflected in the death data for a while.

It’s too soon to say any of those four states are out of the woods entirely. Certain areas, like the Rio Grande Valley in Texas, are still struggling, and experts warn that any progress could be quickly reversed.

“It would not take much — schools reopening in person, or people relaxing precautions a little bit because we’re ‘past the peak’ — for us to have a growing epidemic again,” Tom Hladish, a research scientist at the University of Florida’s Emerging Pathogens Institute, told me.

But if the summer’s hot spots are in fact starting to turn a corner, the worry is new ones will flare up. The US had enjoyed a steady decline in cases and deaths after the New York City region got through the worst of its outbreak in the spring — until Arizona, California, Florida, and Texas began reopening their economies and cases picked up again in June. This was an important reminder that the US does not have one outbreak but many, and any improvements in one place could be quickly offset if new areas experience a spike in cases, hospitalizations, and, eventually, deaths.

With that in mind, I asked public health experts which states show signs of an accelerating outbreak and looked at the data myself.

There are some states that have had worrying trends for a while but flew under the radar while much of the nation’s attention focused on the Big Four. Georgia and Nevada typify that group; their daily new cases, positive test rates, and hospitalizations are stubbornly high. Others are definitely trending in the wrong direction: Missouri and Oklahoma are two states where cases and positive test rates have gone up recently.

But two states stood out from the rest, the unfortunate candidates most likely to become the next US hot spots: Alabama and Mississippi.

Alabama

There are various ways to measure the scale and trajectory of a state’s outbreak — percent of tests coming back positive, number of new cases per million people, number of hospital beds occupied — but by any of these metrics, Alabama is in a bad place.

At the beginning of July, Alabama was averaging fewer than 1,000 new Covid-19 cases every day. Today, the daily average is above 1,600. The percentage of tests that are positive is more than 21 percent and rising, according to Covid Exit Strategy; experts say that the positivity rate should be 5 percent or less in order for a state to feel it is adequately managing its outbreak. According to the Covid Tracking Project, about 800 people were hospitalized with Covid-19 in Alabama on July 1; today, the number is 1,529.

Going by the number of new cases per million people — a good proxy for how saturated a state is with Covid-19 infections — Alabama has the fourth-worst outbreak in the US. It also ranks fifth in the number of people hospitalized per million people. Right now, 72 percent of the state’s hospital beds are occupied, which the public health researchers at Covid Exit Strategy characterize as an “elevated” level of hospitalizations.

Taken together, these are a troubling set of trends. Alabama did issue a statewide mask order in mid-July, which may help to ensure the situation does not spiral out of control, and Gov. Kay Ivey has extended the mandate through August. But the state has been reluctant to order businesses closed again after starting to reopen its economy in late April, and Ivey has been insistent about starting in-person instruction at Alabama schools.

“It is worth watching whether face mask orders in place … help to curtail or prevent widespread outbreaks,” Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, said. It will likely be several weeks before any effect would be seen, given the lags in reporting.

Mississippi

Mississippi is, if anything, even worse off than its neighbor to the east.

The number of daily new cases roughly doubled from 639 on July 1 to 1,178 on August 2. More than 20 percent of tests are positive, and that number has been steadily rising for the last two weeks. A month ago, about 800 people were hospitalized with Covid-19 in Mississippi; today, nearly 1,200 are. It now ranks second in new cases per million people, behind only Florida.

Most troubling is the growing death toll. The state reported 52 new deaths on July 31, a record, and dramatically higher than one month ago, when Mississippi was seeing 10 deaths per day on average. Its large Black population and high poverty levels could make the state particularly vulnerable to the coronavirus, considering being a person of color and of a lower socioeconomic status have been linked to more adverse outcomes.

“Both Alabama and Mississippi have an awful lot of counties that are predicted to be vulnerable on the basis of their population demographics,” William Hanage, a Harvard epidemiologist, told me, “Whether age, race, or socioeconomic status, or some combination of all three.”

The state has so far not reimposed any social distancing restrictions or issued a statewide mask requirement, according to Boston University’s database of state Covid-19 policies, adding to the concern among public health experts. Gov. Tate Reeves did impose a mask mandate for specific counties and warned bars may have to be closed if the virus continues to spread.

But the state has also pushed ahead with opening schools; one of the first school districts to restart classes has already reported that one student has tested positive for the coronavirus. The school district said it has notified people who came into close contact with the student, the public health practice known as contact tracing. But the level of spread in the state and the lack of contact tracing workers could make it difficult to do that work at scale; NPR reported last month that the state had not hired enough people to meet its estimated contact tracing needs.

Given the trend lines in Mississippi, Harvard Global Health Institute director Ashish Jha predicted the state would become first in the nation in the number of new cases as a share of its population.

In other words, Mississippi may soon be the worst Covid-19 hot spot in the country.

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