key: cord-0923440-5wxzlh9a
authors: Sen-Crowe, Brendon; Sutherland, Mason; McKenney, Mark; Elkbuli, Adel
title: The Florida COVID-19 mystery: Lessons to be learned
date: 2020-08-16
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.08.009
sha: be997963c2262cfe9abadbdf63d584770d918355
doc_id: 923440
cord_uid: 5wxzlh9a

nan

WHO has released a series of governmental guidelines that should be met before reopening for normal operations, to minimize the risk from COVID-19. One recommendation detailed that COVID-19 positive testing rates <5% should be achieved prior to reopening. However, many US states, including Florida, have reopened with positive testing rates >5%. 1 Florida has become an epicenter of COVID-19 cases. As of July 29, 2020, Florida has 441,977 confirmed cases and 6,117 deaths due to COVID-19. 2 A concerning feature is the timing. Within the past month, 300,902 confirmed cases and 2,698 deaths due to COVID-19 were reported, comprising 68.1% of cases and 44.1% of deaths since the onset. 2 Florida has performed 3,526,765 COVID-19 tests since the pandemic onset, with 1,614,022 (45.8%) completed in the last month. The positive testing rates is 12.8% since the onset of the pandemic but recently increased to 18.9% (Figure 1 ). 2 However, the overall and previous month's case-fatality ratios (CFRs) remain low at 1.4% and 0.90%, respectively. Florida's COVID-19 fatality statistics are in contrast to other states experiencing a heavy second wave such as California, which reports a CFR of 1.8% since the onset of the pandemic and 1.1% in the past month, despite having reduced positive testing rates of 6.32% overall and 7.41% in the past month. 2 In addition, the state of Texas reports an CFR of 1.4% overall and in the past month, despite lower positive testing rates of 11.39% and 14.55%, respectively. 2 A Potential contributing factor is the possible overestimation of COVID-19 cases in Florida. According to the daily COVID-19 update published by Florida's DOH, "People tested on multiple days will be included for each day a new result was received.", meaning individuals who have previously tested positive may contribute to more than one positive test result reported. 4 In contrast to other states, Florida does not have a policy in place to ensure one positive test from a single individual is counted. 3 Another potential factor to a low CFR is a possible delay in the reporting of COVID-19 deaths. The National Center for Health Statistics (NCHS) utilizes death certificates to report COVID-19 deaths. 4 However, death certificates take time to complete and could add to the differing reporting rates between states. As COVID-19 cases have surged, it possible that states fall behind in their reporting. A delay in reporting of COVID-19 deaths could contribute to a paradoxically low CFR in the context of rising positive testing rates.

On the other hand, the low CFR observed may be due to early interventions and prevention strategies enacted by Florida. Early in the pandemic course, AARP Florida urged for increased testing, particularly in vulnerable elderly populations in nursing homes and long-term care facilities where the risk of death is much higher. 5 In addition, restrictions prohibiting visitation to senior living facilities were put into effect when Florida began to reopen to decrease the risk of transmission to the elderly. 6 These interventions could have a more significant effect in Florida compared to other states, as Florida reports the highest percentage of individuals >65 years of age (20.9%). 7 Moreover, the state of Florida swiftly attempted to flatten the COVID-19 growth curve by initiating executive orders mandating the closure of beaches, large-scale community areas, bars, and in-house dining, as well as requiring expansion of hospital capacity. 8 As of July 29, J o u r n a l P r e -p r o o f 2020, Florida reports 16.2% of adult ICU beds and 21.4% of hospital beds are available despite reaching all-time highs in new COVID-19 cases. 9 The relative preparedness likely plays a significant role in the maintenance of low CFRs.

Florida continues to take actions by providing public health advisories to educate Floridians about measures that can be taken to protect against COVID-19. 10 In addition, the Florida DOH released an interactive map displaying testing sites and the types of tests throughout the state to provide a means for the community to get tested. 10 Furthermore, the state expanded self-swab lanes in multiple counties and the creation of additional COVID-19 testing sites. 10 Finally, over 75 million PPEs have been delivered to Florida and disbursed over $318 million to 55 counties via the CARES Act to combat the COVID-19 outbreak. 10 Their efforts have displayed quantifiable improvements as evidenced by the decreasing hospitalization rate and CFR in the face of rising positive testing rates, number of hospitalizations, and deaths due to COVID-19 (Figure 2) .

Taken together, Florida's cumulative efforts to increase public health awareness, testing opportunities and resources, and upkeep of critical hospital resources provided a tremendous benefit that has likely facilitated Florida's low CFR. Rapid identification of the most informative parameters and effective interventions may help Florida provide valuable lessons which can be acutely utilized in other states to manage future resurgences. 

Public health criteria to adjust public health and social measures in the context of COVID-19. World Health Organization

Johns Hopkins University & Medicine Coronavirus Resource Center

COVID-19: summary of persons being monitored, persons tested, and cases. Florida Department of Health

COVID-19 Death Data and Resources

Provisional Death Counts for Coronavirus Disease 2019 (COVID-19)

Plan for Florida's Recovery. Florida Department of Health

Persons 65 and over, percent. United States Census Bureau

COVID-19 Executive Orders. Office of the Governor

Hospital ICU Beds Census and Staffed Availability as reported by ESS. Agency for Healthcare Administration -Florida

The State of Florida Issues COVID-19 Updates. Florida Department of Health