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Imperial County Public Health Director Jeanette Angulo reports to the county Board of Supervisors on July 28 about improving numbers related to COVID-19 transmissions. VIDEO SCREEN CAPTURE

Why are COVID deaths rising so rapidly if cases are falling? Timing, Imperial officials say

The number of dead due to COVID in Imperial County took several sizeable daily leaps last week, just as it has numerous times over the past few weeks, despite public health dashboard data showing positive cases of the virus continuing to decline and health officials continuing to say conditions are improving.

Deaths considered COVID-19-related reached 220 as of the morning of Aug. 1, up from 200 on July 30, 188 on July 28, and 181 on July 25. The climb has seemed impossibly steep, impossibly fast: since July 20, the dashboard has gone from 163 total deaths, an increase of 57 deaths in two full weeks of reporting.  

Imperial County Public Health Officer, Dr. Stephen Munday, tells the county board July 28 that he’s “cautiously optimistic” about improving conditions in the county on COVID spread. VIDEO SCREEN CAPTURE

So, what gives with all the deaths? If conditions are improving, why are so many people still dying? Or does it just seem that way?

“The increase in deaths reflect the overall increase in cases. And there’s an expected delay in deaths. With some deaths occurring weeks or up to a month or longer after the individual initially tested positive. There’s also a delay in reporting deaths. We confirm that the deaths are due to COVID-19 by reviewing death certificates,” said Paula Kriner, epidemiology department manager with the Imperial County Public Health Department, during the July 27 weekly press conference on COVID.

Public health officials are cautious to put a more concrete average timeline to the delay in reporting, but between initial sickness and death, compounded by post-mortem investigations and the release of death certificates, there could be anywhere from roughly four to eight weeks lag time between detection of the virus, which shows up in the local data almost immediately, and a death making the dashboard.

That’s a pretty wide swing in time, yet it’s slightly reassuring in that a decrease in the daily leaps and bounds of those dying from COVID-19 complications are actually decreasing, too, and the numbers will likely begin to reflect this once the time it takes to verify the deaths syncs up with the number of decreasing positive cases.

“While receipt of death certificates is a factor in the delay, there are a variety of other factors that contribute to the lag in death reporting as well. Like the Public Health Department, other agencies involved in the death investigation process (i.e. mortuary, coroner, and California Department of Public Health) are being heavily impacted by this pandemic and, as a result, are experiencing lag times,” wrote Andrea Bowers, a spokesperson for county public health, in a July 30 follow-up email attributed to additional information from Kriner.

“The time that it takes for the Public Health Department to receive notifications and follow up on information received from all agencies involved is taking longer than usual. Our department continues to work in collaboration with local and state partners in an effort to provide accurate counts as quickly as possible,” Bowers stated.

When asked to further reconcile the recent decrease in positive testing numbers and the increases in reported deaths, Bowers responded:

“It’s not uncommon that those who pass away from COVID (were) diagnosed much earlier on and have been hospitalized for a lengthy period before succumbing to it. This, along with all the things mentioned (before), factor into the differences you’re seeing in the decreasing positives and the ongoing reporting of deaths,” she stated. 

Simply put, we’re seeing the deaths that are the results of surges in illnesses reported a month to six or more weeks ago, such as the large increases in positive cases that started to be seen after Mother’s Day weekend on May 10 and other holidays.

So, it’s likely the numbers of reported deaths will slow in a similar time frame in the future, reflective of the decreasing positive tests we’re witnessing today.

A significant downward trend in positive cases and hospitalizations is relatively recent for Imperial County. It was just over a full week ago that Dr. Christian Tomaszewski, El Centro Regional Medical Center’s chief medical officer, reported that the curve was flattening at the hospital.

Since then, Imperial County has continued to fall in the rankings in the state for COVID-related hospitalizations and testing positive. What was once No.1 or No. 2 in the state in multiple categories for several weeks in May, June, and parts of July, is down several rungs comparatively.

Janette Angulo.

“We no longer have the highest case rates in the last 14 days per 100,000 (residents),” county Public Health Director Jeanette Angulo told the county Board of Supervisors during a departmental report on COVID on July 28.

“There’s actually nine counties above us,” she said. “The same with the testing positivity rate; there are eight other counties that have higher rates than us.”

Covering epidemiological stability in the county, Angulo told the board that the county’s goal for numbers of positive cases is 100 cases per 100,000 residents. In the week prior to July 28, the county was in the 200s to 300s per 100,000 residents, from a high range of 700 to 800 cases per 100,000 residents for several weeks.

In terms of seven-day average percentages — another marker the state wants Imperial County and other California counties to reach — the goal is less than 8 percent testing positive. Angulo said in the week prior to her report, the percentages were between 14 percent to 19 percent, down from the high 20 percents to the low 30 percents four and more weeks ago.

“So, we are making some progress,” Angulo told the board.

What’s more, all of those numbers have continued to decline in the days following her presentation.

The number of total positive cases between July 28 and Aug. 1 only increased by 220 cases, fewer than 100 new positives a day.

With the percentages, on Aug. 1 Imperial County reached a low of 12.02 percent, with the county in the 13 percents on July 30-31.

County Public Health officials have not said the curve has flattened like Dr. Tomaszewski declared, nor have they acknowledged whether the county is on the other side of the peak for good when asked, but all indications are that is the case.

“I am cautiously optimistic,” county Public Health Officer, Dr. Stephen Munday, told the county board.

He said with emergency room visits, intensive-care unit admissions and out-of-county transfers all down, “we hope these are harbingers of better things to come.”

To better explain the large waves and chunks of deaths behind a delay in reporting, though, just look at the death data for yourself on the dashboard.

When the raw data gets updated on that ominous display of numbers, such as the big 220 referenced at the start of this story, the gaps in individual deaths per day and total deaths also get updated in finer detail on the lesser-viewed “deaths timeline” tab. The “deaths timeline” has a line graph charting total deaths on the same grid as a bar graph charting deaths per day.

One can clearly see, when the line graph is removed (try it for yourself on the desktop version), deaths per day have been zero to one or two consistently since mid-July. Larger surges of five or more deaths per day began around mid-May and lasted through mid-July, consistent with positive case surges.

To be certain, the numbers of deaths due to COVID are continuing to have an effect in the county in other ways.

Although the spike in cases might be behind us, those who have died of COVID up to this point have left behind a visible result at Frye Chapel and Mortuary in Brawley, where coroner’s officials and medical examiners do their death investigations and where the county’s COVID dead are stored.

Frye Chapel, for all intents and purposes, functions almost as a county morgue.

Outside the mortuary are four huge refrigerated trailers that hold the dead, many if not all of which, are COVID cases.

Four refrigerated trailers holding the remains of those who have died of COVID-19 stand outside Frye Chapel and Mortuary in Brawley on Aug. 1. CORISSA IBARRA PHOTO

Managing owner Sheila Kruger could not immediately be reached for comment for this story, but she has spoken about the situation at Frye Chapel before with the media.

In mid-June, the mortuary was holding more than double the number of dead it had held the previous year, Kruger told KQED, a public broadcasting news site from the Los Angeles area.

“We are bursting at the seams, literally,” she said at the time.

Understanding the Numbers, or Who is Dying?

The death of Carmen Ortiz Huerta to COVID-19 complications checks all the boxes of just who in the community is dying from COVID.

It’s not even clear whether her death has been reported in the data on the dashboard as of Aug. 1 due to privacy issues, but we do know she had all the factors that made her death seem almost inevitable when her family first heard she had tested positive for the virus.

“We knew she wouldn’t recover. She had everything going against her,” her daughter Gloria Granillo said during an Aug. 2 interview, the same morning her mother’s obituary appeared in a local newspaper for the first time.

She was elderly, at age 88, was a 20-year colon cancer survivor, and had co-morbidities of diabetes and high-blood pressure.

What’s more, she was a resident of Imperial Heights Healthcare & Wellness Centre in Brawley, the site of an outbreak, or cluster, of COVID cases among residents that was first reported to this newspaper by facility medical director Dr. George Fareed on June 19, after he began to see patients test positive starting June 14.

Carmen Ortiz Huerta, age 88, is shown in her room at Imperial Heights Healthcare & Wellness Centre in Brawley in May. Huerta, who died in a San Diego hospital on July 15 from COVID-related complications, was caught up in the outbreak, or cluster, of cases at Imperial Heights in June. She died after a three-week battle with the illness. PHOTO COURTESY OF GLORIA GRANILLO

From there, in the ensuing days, it was revealed that at least 90 positive COVID cases were tied to the county’s three skilled nursing facilities, Imperial Heights, Imperial Manor in the city of Imperial, and Valley Convalescent Center in El Centro, combining both positives of residents/patients and staff members working at the facilities.

Huerta tested positive for COVID-19 on June 23 and was taken to Pioneers Memorial Hospital on June 24 and transported to Scripps Mercy Hospital in San Diego on June 25, where she remained for three weeks before she died there July 15, Granillo said.

As of July 27, some 29 deaths had been reported out the skilled nursing facilities, according to county Public Health Department Nursing Manager Steven Solis.

“Last week (prior to July 27), two facilities reported zero COVID-19 residents from our weekly testing. So yes, it has been improving. And the challenges remain with all skilled nursing facility staff being compliant to test on a weekly basis at testing sites and reporting the results to their supervisor,” Solis said.

Cumulatively since July 31, there have been 17 deaths reported from Valley Convalescent, zero from Imperial Manor and 12 from Brawley’s Imperial Heights, according to the state Public Health Department website, which tracks data from skilled nursing facilities. There have been 96 total staff members infected and at least 67 residents/patients infected, also as of July 31.

Yet old folks in old folks’ homes are not the only ones dying, clearly. Who exactly is dying, by and large?

“About 60 percent of all deaths are in individuals who are 70 years of age or older. And many have pre-existing conditions such as diabetes, hypertension, or asthma. And some immunocompromised, which puts them at great risk. Older individuals, of course are more vulnerable,” Kriner said July 27.

“Most of the deaths occur in hospitals, both in county and out of county. Some of the cases are among residents of skilled nursing facilities. And we’ve had a couple of recent cases who have died in their homes,” she added.

On further analysis, the lion’s share of those who are dying, as of Aug. 1, were Imperial County residents between the ages of 60 and 89, right in Carmen Huerta’s age range.

Some 73.18 percent — nearly three-quarters — of all deaths are in that range (161 of 220), with 53 deaths between age 60-69, 54 between age 70-79, and 54 between age 80-89.

Although Granillo’s mother was in that age range, so is Granillo, and she has certain pre-existing conditions herself that makes her susceptible.

“It’s scary. … I’m scared of it and I’m sick of it,” said Granillo, who is 65 years old and is a cancer survivor who works in a facility that has also seen more than its fair share of COVID cases.

Granillo works in administration at Centinela State Prison, where she said a correctional officer recently died from COVID-19.

“We’re tested every two weeks and we wear masks every day, all day long,” she explained.

It isn’t known how many more deaths might be attributed to the local state prisons, but Centinela is certainly a hotspot for cases among staff and inmates. As of Aug. 2, according to the California Department of Corrections and Rehabilitation website, Centinela has had 74 employees test positive and 23 return to work. A total of 39 inmates have tested positive, 21 considered active cases and 18 resolved.

For Calipatria State Prison, 55 staff members have tested positive and 25 have returned to work. For inmates, 25 total positive cases have been recorded: 13 active, five resolved, and seven positive inmates released from custody.

Where is Mexico in the Mix?

During the July 28 county board meeting, as public health was wrapping up its presentation and everyone was cautiously celebrating the improved numbers locally, Dr. Munday did mention Mexico.

“I hear through the grapevine that the numbers in Mexicali are improving as well,” he told the board.

Although it’s been difficult to find an accurate dashboard model for Mexicali and Baja California numbers, the state’s website does keep running totals.

As of Aug. 2, Mexicali has reported 1,230 deaths, 6,928 positive confirmed cases, with 181 active cases and 497 suspected positive cases. For Baja California altogether, there have been 2,628 deaths reported, 13,384 positive confirmed cases, with 468 active cases and 1,043 suspected positive cases.

The number of active cases does seem to be down substantially for Mexicali.

On July 24, Mexicali had reported some 1,170 deaths and 6,628 confirmed total positive COVID cases. That’s a change of 60 deaths over a little more than a week and 300 total positive cases.

For the entire state of Baja California, some 2,480 deaths and 12,649 COVID-positive cases were reported as of July 24. That’s a change of 148 deaths over a little more than a week and 735 total positive cases.

Bloomberg News Service reported some weeks back that more than 43 percent of all hospitalized COVID cases in Baja California had resulted in death.

It couldn’t immediately be determined whether Mexicali and Baja California’s cumulative numbers indicate improvement or not.

U.S. Death Data and What People Believe

Social media is aflame with incendiary comments questioning what constitutes a COVID death and whether the numbers are fudged. The comments have appeared on local COVID pages and on any variety of local publications’ stories or updates on COVID data.

Many people in this country don’t trust the death numbers and think the data is being doctored to some degree. As of Aug. 1, the Centers for Disease Control and Prevention reported 152,970 deaths in the United States attributed to COVID-19.

An Axios/Ipsos poll from July 21 found that 31 percent of Americans believe the COVID death toll is less than what’s being reported, while 34 percent believe the actual death toll is higher than the official number. A lot of what people think is being filtered through political affiliation and where they get their news, according to the poll.

Simply put, people who think the numbers are inflated tend to get their information from conservative media, the poll states.

Actually, a study published July 1 by Virginia Commonwealth University and Yale University researchers in the Journal of the American Medical Association found that coronavirus deaths are being undercounted, “reflecting a common view held by public health experts and epidemiologists,” according to an article in Forbes.

It’s hard to know the truth when everyone, even medical professionals, seem to have an opinion.

A local woman, who asked that her name not be used, works at an Imperial County golf course where she comes in contact with any number of people who chat her up after a round or two.

Recently, in the last two or three weeks, she said she was speaking with a physician from San Diego who does work in the Imperial Valley a couple days a week.

As they chatted about COVID, the woman said the doctor told her not to be too concerned about coronavirus cases in the Valley, that the number of positive cases and especially deaths were being over reported, especially at hospitals across the country due to federal reimbursements.

“He said, ‘I’m a doctor and I know a lot of the deaths that are being added as COVID are not COVID,’” the woman explained. “He said, ‘The hospital gets federal funds for every COVID patient whether they live or die.’”

That’s an opinion or idea that has been going around for some time, and Adolphe Edward said he’s been hearing these false perceptions and assumptions for months.

As chief executive officer of El Centro Regional Medical Center, Edward knows all about how expensive it is to treat COVID patients and what lies ahead for his hospital when he reports a death or the treatment of a COVID patient.

COVID is costly, and over a 13-week period, ECRMC had increased expenses of $2.5 million tied to treating COVID patients. Much of that comes from the fact that patients are hospitalized longer and require significant amounts of additional staffing, from extra ICU nurses to additional respiratory therapists because the virus often comes with intubation and ventilator usage.

In fact, Edward said, ECRMC will report monetary losses for July and August, and likely in September, due to COVID.

But it isn’t simply a matter of telling the government you have COVID patients and/or deaths and the waiting for the federal dollars to roll in.

“Hospitals cannot inflate our death rates and anything that is COVID,” Edward said during a brief interview Aug. 2.

He said the federal government made it known months ago that any expense related to COVID or any patient or death related to COVID would be under intense scrutiny by the federal government. He said all receipts, for all expenses, would be required to be kept by hospitals all over the country.

“We were notified that for all hospitals that receive a penny from the federal government, audit is automatic, and it begins this fiscal year,” Edward said.

El Centro Regional Medical Center Chief Executive Officer Adolphe Edward (left) gives the thumbs up as Dr. Christian Tomaszewski, ECRMC chief medical officer, thanks Imperial County residents for helping to “flatten the curve” on COVID cases in the region during a July 24 daily report. VIDEO SCREEN CAPTURE
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