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Behind the model that projected 5,500 deaths in Alabama — and why it changed

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Chip Brownlee | The Trace

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Early last week it said 7,500 would die in Alabama by August.

This modeling from the University of Washington’s Institue for Health Metrics and Evaluation has been cited by the White House’s coronavirus task force.

This modeling — that last week suggested somewhere between 100,000 and 240,000 Americans could die — spurred President Donald Trump’s decision to extend social-distancing guidelines through April and served, at least in part, as a call to action for Alabama to issue its stay-at-home order Friday.

Then it was revised downward again to 5,500. As recently as this weekend, the model projected that Alabama would have the highest per capita death rate in the country and the fourth-highest total death toll.

But by Monday morning, it was adjusted again — this time projecting fewer than 1,000 will die by August from the novel coronavirus that causes COVID-19. Instead of the highest per capita death rate in the country, Alabama is now projected to fall somewhere in the middle — 22 out of 51.

The changing numbers and the shifting projections can tell us many things but one is this: that modeling a pandemic is hard, especially when how it pans out depends heavily upon how state governments and the people adhere to social-distancing guidelines. No one knows how this will end.

I spoke with Dr. Ali Mokdad, one of the senior scientists at IHME and a former official at the Centers for Disease Control and Prevention. He helped develop the model. (We spoke before the model was revised downward for Alabama.)

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IHME’s model is live. It is updated regularly. It was never meant to be interpreted as a comprehensive prediction of the future. It was intended as a planning tool to help policymakers, hospital officials and the public plan ahead. In fact, the people who made the model hope their projections at present are wrong — that they will be revised downward more.

“By reducing the number of people who have infections by staying at home, you can help the medical system,” Mokdad told me. “And when the peak comes, that shortage that we are projecting will not be as big as we are seeing right now because social-distancing is working.”

The updated modeling shows how social-distancing is working, not that it was never possible that 5,000 or 7,000 people could have died. Had we not acted, had people not changed their behavior, had the state not implemented a stay-at-home order, that could have surely been the case — and it still could be.

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State Health Officer Dr. Scott Harris said the model has been helpful in planning for the peak.

“I think the thing that’s been most helpful about that model is really the timelines,” Harris said in an interview with APR.

“The margin of error they have on there is tremendous,” Harris said. “I don’t necessarily think it’s incorrect, but you can almost read what you want to on there. We could have 50,000 deaths or 5,000 deaths or any number. But the timeline makes sense, seeing when we’re expected to have a surge. That was what was most useful to us.”

The shaded area indicates uncertainty in the modeling, ranging from 1 to 247 deaths per day on April 25.

A model is only as good as its inputs. Last week, IHME’s model for Alabama had little data to work off of. The state had only just begun to report deaths. And when the state changed its reporting of deaths, and the death toll spiked as a result, IHME’s model — which is primarily based on deaths per day — adjusted.

“So one day they just kind of flipped the switch, and suddenly our numbers changed dramatically in one day even though the situation on the ground was the same,” Harris said. “I am not saying they are wrong, but the timeline is most useful.”

Even though the number of deaths per day is still increasing, the state hasn’t seen a similar jump since last week. The model, as a result, has stabilized, too.

The shaded area indicates uncertainty in the modeling, ranging from 400 to 2,000 total deaths by August.

As more data becomes available, the model will adjust again. The projections could worsen if deaths begin to spike, or the projections could get better if deaths level off before the projected peak in mid-April.

“People are working tirelessly not only to make sure that we’re going to be able to handle the need for ventilators in the coming weeks but also that we have the surge capacity to figure out if we do exceed the number of beds that we have, how we can deal with that,” Dr. Jeanne Marrazzo, the director of the infectious diseases division at UAB, said last week. Marrazzo is also a member of Gov. Kay Ivey’s coronavirus task force.

There are a number of assumptions in the model, including complete adherence to social-distancing measures through August. If Alabamians flout the stay-at-home order that began Saturday evening, the projections could surely be wrong — the reality could be worse. The death toll could be much higher than nine hundred because Alabama remains particularly susceptible to the virus.

“When you look at Alabama, there are more people who have risk factors in Alabama and the Southeast in general,” Mokdad said. “More obesity, more high blood pressure, more diabetes and more cardiovascular disease, and more cancer there than really anywhere else.”

If we try to return to normal earlier, then the projections could be worthless because the model assumes social-distancing continues through August. If we stop social distancing, about 97 percent of the population would still be susceptible to the disease. The virus would surge again. Until a vaccine becomes available, the virus and the threat of mass casualties could return.

“Our bodies as a species, we have never seen this virus,” Marrazzo said. “And that’s why so many people are having such a hard time handling it after getting infected.”

That threat could be mitigated by a nationwide mass testing regime, which would enable widespread contact tracing and targeted quarantines. That testing regime would have to include the large number of people who show no symptoms. We are nowhere near the capability of testing the number of people we would need for that to work.

The revision of the death toll from 5,500 down to 900 should not be taken as an all-clear. The modeling is based on the actual death toll, which could change if our behavior changes.


Below is a Q&A of our conversation. It was edited for length and clarity.

Q: Why does the modeling look so bad for Alabama?

Dr. Mokdad: It doesn’t look good, but let me explain why. We are modeling mortality. We take the death rate and model off that. We project the death rate into the future.

Then we back-calculate the number of beds, ICU beds and ventilators that are needed. Because we know from hospitals right now how many people with COVID-19 showed up at the hospital, how many were on a ventilator, how many of them needed to be in an ICU bed, how many died and how many survived. So we can do that by calculation.

The reason we are modeling mortality and not how many cases we have is because we are concerned that we are not testing everybody who needs to be tested. So the number of confirmed cases that we are releasing as a country is not totally reflective of reality. And this is not a criticism of the country; it’s just the reality. But we are reporting as positive the people who came and got tested. And we have still a shortage of tests.

Second, there are people out there who may have COVID-19 but are asymptomatic. We have studies showing that they don’t have any symptoms. We know people who were tested here in our hospital, who were positive, but they never had any symptoms. They were tested and they were found out to be positive. But they can still pass the virus, even though they don’t have any symptoms. We also know that many have mild symptoms and may not require hospitalization. Or some who have symptoms but may think it’s something else, like allergies, especially in a state like Alabama, which is beginning its allergy season.

So we decided to model mortality. We project a peak of demand — demand of the medical system — in mid-April.

The reason why Alabama would be much worse than most other places is a number of factors. When you look at Alabama, there are more people who have risk factors in Alabama and the Southeast in general. More obesity, more high blood pressure, more diabetes and more cardiovascular disease, and more cancer there than anywhere else.

So we would expect people who are high risk to use more resources because they have conditions that would make mortality higher and there will be more demand for resources.

Q: Gov. Kay Ivey just issued a stay-at-home order. A lot of people have said that came too late. How does that play into this model?

Dr. Mokdad: So in our model, we monitor all of these decisions. We know that you closed schools. We know that you closed non-essential businesses and services should be closed. But at this time, we have not added the stay-at-home order. That happened today.

It’s really too late, unfortunately. From our perspective, it should have been done much earlier. We cannot change the past, but we can change the future. So the lesson here is that these orders should have been in place earlier, but from now on, what we really need to stress for people in Alabama, is by staying home and adhering to these social distancing guidelines, you can reduce the number of deaths. The most important part for Alabama is that it could have a shortage of facilities to take care of patients.

By staying at home, you can reduce the burden on the hospital system. You can allow your physicians to have at hand the resources they need to deliver the best medical care for everybody who needs it. By reducing the number of people who have infections by staying at home, you can help the medical system and when April 17 comes, that shortage that we are projecting will not be as big as we are seeing right now because social distancing is working.

Q: Can you talk about the timeline and why this might have come too late for the peak demand?

Dr. Mokdad: I’m not saying it’s too late to do anything. The decision was made too late. It should have been done much earlier. I’m not picking on Alabama. Even in Washington, I would have liked my governor to make that call much earlier.

I and everybody in this country, we saw a pandemic unfolding in China. We saw how aggressive their measures were. We know they suffered. We saw it. So why didn’t we prepare ahead of time for it? We knew this was coming in December or January. We had January and February.

We had over a month and a half to prepare. Let’s be realistic and say a month because the first case was in Seattle. So let’s say we had a month. Why are we having this discussion now about our capacity to produce ventilators? We are the United States of America. We have the best resources. We have the best minds here. We are a resilient population. If you inform the public and give them the right information at the right time, Americans love their country and want to protect each other. So they would have stayed at home. All of us should have made this call much earlier. It’s too bad that Alabama did it on April 4th, when other states started doing it in mid-March. Even those states should have done it earlier.

Q: What should people take away from your modeling?

Dr. Mokdad: We can still make a difference here by staying at home. We have to be very careful. At this time, especially in a state like Alabama, where I worked a lot with the CDC. I worked a lot in Alabama. We know the state has underserved populations. It has many minorities and vulnerable populations. We need to be compassionate.

It’s time for all of us right now, all of us in other states, to help Alabama. Alabama should not be left alone to deal with this burden. It’s time for us to focus on Alabama. I know New York is in the media, and they deserve that, but we should still not forget Alabama. You should not be left alone to deal with this.

Chip Brownlee is a former political reporter, online content manager and webmaster at the Alabama Political Reporter. He is now a reporter at The Trace, a non-profit newsroom covering guns in America.

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AARP Alabama asks for details on $50 million federal COVID-19 aid to nursing homes

Eddie Burkhalter

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(STOCK PHOTO)

The Alabama chapter of AARP is asking the state to ensure federal coronavirus relief funds are spent wisely and in the open. Gov. Kay Ivey on Friday announced $50 million in grants would go to state nursing homes to aid in the fight against COVID-19.

Candi Williams, AARP’s Alabama state director, told APR on Monday that the organization, which advocates for the elderly, wants a better understanding of how that money will be spent and to ensure some is spent for ongoing COVID-19 testing.

A spokesman for the Alabama Nursing Home Association says details on how the money can be spent is already publicly available, however, and Ivey in early June announced the award of $18.27 million in federal CARES Act funds to be spent toward regular nursing home COVID-19 testing.

“What we’re looking for is specifics on how it will be used, and we want those specifics to be made publicly available,” Williams said.

Ivey on Friday said the money is to be administered by the Alabama Nursing Home Association Education Foundation. The Alabama Hospital Association is to administer up to $50 million in grants to state hospitals through another program.

“This allocation of up to $50 million will be for operational costs that are COVID-19 related, such as PPE, cleaning, personnel costs and other costs incurred related to the pandemic,” Ivey’s office said in a press release Friday.

“In partnership with the state of Alabama, the Alabama Nursing Home Association Education Foundation will administer the funds fairly and impartially on behalf of the people of Alabama, for all of Alabama’s nursing home facilities,” the statement goes on to say.

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Williams said the public deserves to know how the federal funds will be used, and said Ivey’s office hasn’t yet signaled whether those details will be made public.

Ivey’s office, through a spokeswoman, declined to comment, and referred a reporter to the Alabama Nursing Home Association.

John Matson, communications director for the Alabama Nursing Home Association, told APR that AARP Alabama need only read the memorandum of understanding published along with Ivey’s announcement about the grants on Friday to see how the money must be spent.

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According to the memorandum, the Alabama Nursing Home Association Education Foundation can only disburse the funds to nursing homes “for the purposes of responding to or mitigating the COVID-19 public health emergency” and details what facilities must do to receive the money.

Among the requirements, nursing homes in their applications must provide supporting documentation, which can include invoices, purchase orders, payroll records and financial records, according to the memorandum. The foundation must also provide the Alabama Finance Director’s Office with a detailed report on the 15th of each month noting how the money was spent, according to the document.

“I think it would be helpful for them to read that,” Matson said, referring to AARP Alabama and the memorandum of understanding.

AARP Alabama is also asking that the money be used for ongoing and methodical testing of all residents and staff in the state’s long-term care facilities.

“We’ve seen across the country that testing can be hit or miss, and testing frequency can vary,” Williams said. “We’ve seen in other states where that has helped curb the loss of life and helps protect residents.”

Matson noted that Ivey in early June also announced a separate $18.27 million in federal CARES Act funds to be spent toward regular nursing home COVID-19 testing and “proactive surveillance” through the end of the calendar year, which is also being administered by the Alabama Nursing Home Association Education Foundation.

Alabama’s long-term care ombudsmen, who are tasked with protecting residents’ rights and investigating health and safety concerns, have been largely banned from entering Alabama’s long-term care facilities since early on in the pandemic when the facilities ended visitations to help prevent the spread of the virus.

Williams said AARP would also like to see the safe reentry of ombudsmen into state facilities and for those details to be included in a publicly-released plan.

“We also have been advocating for transparency and real-time data about the COVID cases and death in Alabama nursing homes and long-term care facilities. That continues to be a struggle,” Williams said.

The Centers for Medicare and Medicaid Services is collecting that state data, but it’s weeks old by the time it’s published on the federal agency’s website, Williams said.

“Having that information would help us protect the residents, staff and surrounding communities, but also making sure families have that information,” Williams said.

The Alabama Department of Public Health has declined to release county-level or facility-level details on coronavirus in long-term care facilities and nursing homes, citing privacy concerns. Many other states do release that information, however.

According to CMS, there have been 3,841 confirmed COVID-19 cases and 562 deaths among residents in Alabama nursing homes as of July 26. AARP Alabama said COVID-19 deaths of nursing home residents make up approximately 42 percent of the state’s total coronavirus deaths.

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Gov. Kay Ivey awards $100 million to state nursing homes, hospitals in fight against coronavirus

Eddie Burkhalter

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Gov. Kay Ivey held an Coronavirus update Press conference Wednesday, July 29, 2020 in Montgomery, Ala. (Governor's Office/Hal Yeager)

Gov. Kay Ivey on Friday announced the award of $100 million in coronavirus relief funds for grants to state nursing homes and hospitals to aid in the fight against COVID-19. 

“While there are many aspects of COVID-19 that we still don’t know, one thing that isn’t in dispute is our seniors and those with preexisting health conditions fair the worst when contracting the virus,” Ivey said in a statement. “Protecting our most vulnerable citizens remains a priority for my administration, and it is incumbent to ensure that our nursing homes and hospitals have every tool possible to mitigate the spread of COVID-19 as well as keep their staff and health care professionals safe as they offer exceptional care to those who are ill.”

One of the two grant programs will provide up to $50 million to be used by Alabama nursing homes for personal protective equipment, cleaning, personnel costs and “other costs incurred related to the pandemic,” according to a press release from Ivey’s office. 

The Alabama Nursing Home Association Education Foundation will administer the funds, according to Ivey’s office. The non-profit previously received $18.27 million in federal coronavirus relief aid to pay for testing and proactive surveillance of COVID-19 for health care workers and nursing home residents. 

“On behalf of Alabama’s nursing homes, I thank Governor Ivey for her continued commitment to assisting the residents and staff in our facilities,” said Brandon Farmer, president of the Alabama Nursing Home Association, in a statement. “Our nursing homes continue to provide high quality, compassionate care despite the challenges posed by COVID-19. These funds will help cover the unexpected and ongoing costs we incur during this pandemic and allow us to focus on caring for those most vulnerable to this virus.”

The Alabama Hospital Association will administer up to $50 million through the other grant program to state hospitals, according to the release. 

“Despite unprecedented challenges and financial strains as a result of the pandemic, Alabama’s hospitals have continued to rise to the occasion in meeting the health care needs of our citizens,” said Dr. Don Williamson, president of the Alabama Hospital Association, in a statement. “Our hospitals thank Governor Ivey and her administration for the continued support and financial assistance. This will go a long way to ensure hospitals are able to care for all patients who need hospital services and protect their employees while doing so.”  

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The two grant programs were funded from the approximately $1.9 billion the state received through the CARES Act. Up to $250 million of that money has been earmarked for the delivery of health care in the state’s battle with coronavirus.

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Judge dismisses lawsuit asking court to loosen voting restrictions amid COVID-19 pandemic

Eddie Burkhalter

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A Montgomery Circuit Court judge on Wednesday dismissed a lawsuit against Gov. Kay Ivey, Secretary of State John Merrill and several Montgomery County election officials that asked the court to expand Alabama’s absentee voting and relax other voting measures amid the COVID-19 pandemic. 

Montgomery Circuit Judge J.R. Gains in his order dismissing the suit wrote that the court lacked jurisdiction to rule on the plaintiff’s complaint because “Plaintiffs present a non-justiciable political question, Plaintiffs lack standing to sue Defendants, and the claims against Defendants are barred by sovereign immunity.” 

The League of Women Voters’ lawsuit asked Gains to order Ivey and Merrill to exercise emergency powers to waive the notary or witness requirement, the requirement to supply a copy of a photo ID and to extend no-excuse absentee voting into the fall. 

“COVID 19 is a very real threat, not only to voters’ physical health but also to the health of Alabama’s electoral process.  We are profoundly disappointed by the judge’s decision, which allows elections to proceed in their current state,” said League President Barbara Caddell in a statement Friday. 

“The League of Women Voters is a non-partisan organization whose mission is to empower voters and defend democracy. This case was filed to do just that. It was filed in the Alabama court system based on the Alabama Constitution and the Alabama Emergency Management Act which protect the right to vote in times of ‘tumult’ and give the Governor and the Secretary of State emergency power to protect citizens during emergencies. This pandemic certainly qualifies as ‘tumult’ requiring additional emergency assistance,” Caddell continued.

Caddell said that since the judge ruled he didn’t have the authority to require Ivey and Merrill to use their emergency powers, the league is appealing to Ivey for help, and detailed eight requests:

  • Suspend the requirement that a copy of the voter’s photo ID be included with the voter’s application for an absentee ballot
  • Suspend the requirement that the absentee ballot be notarized or signed by two witnesses;
  •  Provide adequate personal protective equipment for clerks and poll workers and disinfecting polling equipment;
  • Require in-person voters to wear masks and maintain social distancing;
  • Authorize local election officials to provide early voting at least fourteen days before each election day;
  • Authorize local election officials to provide drive-through or curbside voting where practicable, to establish vote centers and relax restrictions on wrong-precinct voting;
  • Provide local election officials the financial resources to implement these emergency measures; and
  • Adequately notify all Alabama voters of these emergency measures.  This includes either notifying voters that no box need be checked to vote absentee or modifying the absentee application and ballot forms to inform voters explicitly which boxes to check.

“In the past, Governor Ivey has demonstrated her concern for Alabamians in a variety of ways, and we encourage her to address our concerns for election safety by using her emergency power to order such common-sense voter protections,” the league said in their statement.

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Alabama coronavirus cases more than doubled in the last 30 days

The state has averaged 1,605 cases per day in the last 30 days. Thursday’s increase of 1,626 exceeded that average.

Brandon Moseley

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(STOCK PHOTO)

The Alabama Department of Public Health reported an additional 1,626 coronavirus cases on Thursday after several days when new cases increased by less than 1,000 per day.

Through July 7, at least 45,263 Alabamians had contracted the coronavirus, but in the 30 days since, 48,139 more Alabamians have tested positive for the virus and more deaths have followed. The state has averaged 1,605 cases per day in the last 30 days. Thursday’s increase of 1,626 exceeded that average.

The state now has 93,402 confirmed cases of the coronavirus and that number is sure to rise as schools begin to reopen next week and children and teachers begin intermingling for the first time in 117 days.

Through July 7, at least 1,007 Alabamians died from COVID-19. In the last 30 days, another 647 Alabamians have died. That is an average of nearly 22 deaths per day. The Department of Public Health confirmed an additional 15 COVID-19 deaths on Thursday. The state’s death toll now stands at 1,654.

As of Wednesday, at least 1,575 people who have tested positive for COVID-19 were being treated in hospitals statewide. Many hospitals have recently been or are currently near ICU bed capacity. Making matters worse for health care workers, 5,575 Alabama health care workers have tested positive for the coronavirus.

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At least 1,576 of those health care worker cases have come in just the last 30 days.

By Thursday, the state reported 736,594 tests, and 93,402 have been positive. That is nearly a 12.7 percent rate of positive tests since March. Public health officials say anything over 5 percent is bad and an indicator that there are many more people out there with the coronavirus that are not being detected.

In the last two weeks, though, at least 17.5 percent of tests have come back positive, based on 14-day averages of daily case and test increases. In the last week, that positivity rate has been nearly 17 percent.

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At least 37,923 Alabamians are presumed to have recovered.

Some states, including New York, are asking that visitors from Alabama quarantine themselves for 14 days upon arrival. GOP Senate candidate Tommy Tuberville was recently criticized in The Washington Post for defying Washington D.C.’s 14-day quarantine request for visitors from Alabama.

Not all of the news is bad. The seven and 14-day averages of daily case increases in the state have both been dropping since peaking around July 25. The cases, while dropping, are still well above what they were prior to July 13, and the positivity rate remains high.

The state remains under a “safer-at-home” order through the end of August, issued by Gov. Kay Ivey and State Health Officer Dr. Scott Harris. If you do not have to leave your home, then do not leave your home. You are safer there.

If you are going to be around other people not in your household, you are required to wear a mask or cloth face covering. This includes school children returning to classes this month.

Remember to always socially distance. Stay six feet away from other people as much as possible. Don’t shake hands or hug people not actually living in your household.

If someone in your household is sick, isolate them from the rest of the family. If you or someone in your family have any sort of symptoms, get tested for the coronavirus. Remember to wash your hands frequently.

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