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July 23, 2020

Track these 15 metrics to beat the coronavirus, according to Tom Frieden

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    According to Tom Frieden, a former CDC director and current president and CEO of Resolve to Save Lives, the United States lacks the national strategy and data necessary to track and stop the country's coronavirus epidemic. To address the issue, Frieden and several public health experts have compiled a list of 15 key metrics the country would need to track to stop the coronavirus' spread.

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    Frieden says US lacks 'essential' Covid-19 indicators

    Researchers from Resolve to Save Lives, part of global public health organization Vital Strategies, sifted through public coronavirus data from all 50 states and Washington, D.C. According to the Washington Post, Frieden and his colleagues' research 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."

    The researchers found that the data often was "inconsistent, incomplete, and inaccessible," Frieden and Cyrus Shahpar—former director of the Global Rapid Response Team at CDC and current director of the Prevent Epidemics team at Resolve to Save Lives—explain in an New York Times opinion piece.

    For instance, they write, "[n]ot a single state published turnaround time for testing, nor how promptly patients are isolated, nor the proportion of cases diagnosed among people who had contact with a Covid-19 patient"—even though those indicators "are essential to know how well we are fighting the virus."

    To get states on the "same page," Resolve to Save Lives, in collaboration with a group of organizations including the American Public Health Association and the Johns Hopkins Center for Health Security, created a list of 15 Covid-19 indicators for states to track and publicly report. The organizations compiled the list with input from states and public health organizations, and they modeled the list after international best practices.

    The list is divided into two categories: nine essential indicators that "every state and county should be able to collect and publish … immediately," and six more indicators that they should be able to publish "within a few weeks," according to Frieden and Shahpar.

    The health experts also included a suggested target for each indicator, which they said should be tracked and reported by each state.

    The 15 indicators

    According to Frieden and colleagues, the essential indicators that states should be able to track and report immediately are:

    1. New confirmed and probable cases of Covid-19, as well as per capita rates by date, with a seven-day moving average (target: decreasing over a 14-day period or at a low level);
    2. Percentage of new Covid-19 cases linked to at least one other case (target: greater than 80%);
    3. Screening and diagnostic testing per-capita rates by date, with seven-day moving average (target: 1.5 tests per 1,000 people per day);
    4. Percentage of positive screening and diagnostic tests by date, with threshold and seven-day moving average (target: less than 3% positivity);
    5. Covid-like illness (CLI) and Influenza-like illness (ILI) trends from EDs (target: at or below adjusted baseline, declining);
    6. Covid-19 daily hospitalization per capita rates, with seven-day moving average (target: decreasing or low level);
    7. Percentage of beds occupied by confirmed and suspected Covid-19 patients (target: low proportion, ie: less than 10%);
    8. List of outbreaks with Covid-19 cases and deaths among residents and staff at long-term care facilities, congregate facilities–such as homeless shelters and correctional facilities—and essential workplaces (target: low level of cases and outbreaks, if occurring, quickly spotted and stopped); and
    9. Confirmed and probable Covid-19 deaths and per-capita rates with seven-day moving average (target: decreasing over 14 days or at a low level).

    The essential indicators that states should be able to track and report "within a few weeks," according to Frieden and colleagues, are:

    1. Weekly reports on diagnostic test turnaround time from specimen collection to test report (target: a median of less than or equal to 48 hours, and an increasing proportion of less than 24 hours);
    2. Weekly reports on time from specimen collection to isolation of cases (target: more than 80% within 48 hours);
    3. Weekly reports on the percentage of cases interviewed for contact tracing within 48 hours of testing (target: more than 80%);
    4. Weekly reports on the percentage of new cases among quarantined contacts (target: more than 50%);
    5. Weekly reports on new infections among health care workers that are not confirmed to be contracted outside the health facility (target: zero); and
    6. Weekly reports on the percentage of people wearing face masks or coverings correctly in public indoor settings based on direct observation or security camera analysis (target: more than 80%).


    Frieden on Tuesday said, "States around the country have done good work. They've been doing the challenging, hard, meticulous job of collecting, analyzing, and presenting crucial information."

    However, he said that "because of the lack of national leadership, we don't have common standards, definitions, targets, or accountability"—and as a result, despite a "tsunami of data points," America is "flying blind on the actual risk and the effectiveness of the response." For instance Frieden contended that it's more important to track the number of coronavirus tests processed within 48 hours than it is to track the overall number of tests conducted, since delayed results can't be used as a reliable indicator of someone's current infection status. "If we can get states to report this, then we're going to be in much better shape," he said.

    Frieden explained that making the recommended information public would help the country come together to develop a national strategy for managing the epidemic. Ultimately, he said, "What gets measured can get managed. And what gets measured and reported publicly, can absolutely get better."


    According to the Post, entities representing state public health officials expressed support for the recommendations.

    Michael Fraser, CEO of the Association of State and Territorial Health Officials, said, "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."

    Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, said employing consistent metrics can provide people with the data necessary to change behavior. In addition, she said it was significant that Frieden in the list recognized the relative importance of each metric, and that "the optimal target may change based on the local status of the [epidemic]."

    However, some public health experts expressed concern that state and local health agencies are too overwhelmed to provide the recommended data. For instance, Jeanne Marrazzo, director of the Division of Infectious Diseases at the University of Alabama at Birmingham School of Medicine, said, "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."

    CDC in a statement said it has been working with states and other entities since the epidemic's start "to collect, analyze, and report out data critical to formulate the nation's response to this unprecedented public health crisis." According to CDC, the agency currently monitors, or intends to monitor with states, 14 of the 15 indicators, some of which are available on CDC's website or individual states' websites.

    Michael Caputo, assistant secretary for public affairs at HHS, criticized the recommendations. "[U]nder [CDC Director Robert] Redfield's leadership, [CDC] has already accomplished the very things Frieden calls for," Caputo said (Frieden/Shahpar, New York Times, 7/21; Branswell, STAT News, 7/21; Sun, Washington Post, 7/21).

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